Treatment of Alkaline Eye Burns

Immediate Emergency Management

• The American College of Cardiology is not applicable here, however, immediate copious irrigation with large volumes of clean water is the single most critical intervention and must begin at the scene of injury without delay, continuing until pH normalization is confirmed by a healthcare professional 1
• Begin continuous irrigation immediately with tap water or any available clean water source for at least 15 minutes minimum 1
• Use large, continuous volumes—the endpoint is pH normalization (normal ocular pH ~7.4), not a fixed time duration 1, 2
• If immediately available, normal saline or Ringer's lactate may be used, but do not delay irrigation to obtain these solutions 1
• Continue irrigation during transport to medical facility—delays worsen outcomes significantly 1
• Avoid contaminating the unaffected eye during irrigation 1
• The definitive endpoint for irrigation is when a healthcare professional confirms the pH of the eye has returned to normal (pH ~7.4) 1

Ophthalmologic Assessment and Ongoing Management

• Examine with fluorescein staining using cobalt blue light to assess corneal epithelial defects 3
• Daily ophthalmologic review is mandatory during the acute phase 3
• Apply preservative-free artificial tears (hyaluronate or carmellose) every 2 hours throughout the acute illness 3, 4
• For severe corneal epithelial defects, use only preservative-free formulations 4
• Consider overnight ointment or moisture chamber devices 4
• Broad-spectrum topical antibiotics are mandatory when corneal epithelial defects are present 3, 4, 5
• In the UK, moxifloxacin or levofloxacin (quinolones) four times daily is recommended for broad Gram-positive and Gram-negative coverage 5
• Continue until epithelial defect heals 4
• Topical corticosteroids (e.g., preservative-free dexamethasone 0.1%) supervised by ophthalmology may reduce ocular surface damage in acute phase 5
• Important caveat: Corticosteroids can mask signs of corneal infection and should be used with extreme caution in the presence of corneal epithelial defects 3, 5
• Monitor closely for infection if steroids are used 5
• Daily removal of inflammatory debris and lysis of conjunctival adhesions by ophthalmologist or trained nurse using saline irrigation, squint hook, and forceps 3, 6
• Apply topical anesthetic (proparacaine or tetracaine) before this procedure 3
• Avoid blind sweeping of fornices with cotton swabs—this causes additional damage 3
• If patient has significant chemosis or lid involvement preventing complete closure, establish moisture chamber with polyethylene film to prevent corneal exposure and ulceration 3, 7
• Watch for signs of infection: increased pain, purulent discharge, worsening infiltrate, stromal loss 5
• If infection suspected, obtain cultures (bacterial and fungal—Candida keratitis is common in surface disease) and initiate hourly broad-spectrum antibiotics 5

Common Pitfalls to Avoid

• Delaying irrigation to seek "better" solutions—tap water immediately is superior to delayed saline 1
• Stopping irrigation too early—continue until pH confirmed normal, not just for 15 minutes 1
• Using preserved artificial tears with severe epithelial defects—these worsen surface damage 4
• Aggressive fornix sweeping without proper technique—causes additional trauma 3
• Using topical steroids without close monitoring—can mask infection in compromised corneas 3, 5