Chemical Burns of the Eye

First aid for a chemical splash in the eye

What you do in the first minute matters more than anything a doctor does later. Damage continues for as long as the chemical stays on the eye.

1. Flush immediately. Use the nearest source of clean, lukewarm water: a sink, shower, hose, eyewash station or bottled water. Do not wait to find saline or to read the product label.
2. Hold the eyelids open. Pain makes the lids clamp shut, so use your fingers, or have someone help. Roll the eye up, down and side to side so water reaches every part.
3. Keep going for at least 15 minutes. For alkalis or an unknown chemical, rinse for 20 to 30 minutes, or continuously on the way to the ER if someone else is driving.
4. Remove contact lenses if they do not come out with the water. Do not delay flushing to do this.
5. Direct the water away from the other eye. Tilt the head so runoff does not spill into the unaffected eye.
6. Do not try to neutralize an acid with an alkali or vice versa. The reaction gives off heat and makes the injury worse.
7. Do not rub the eye or cover it with a tight patch.
8. Bring the container or its name to the ER, or photograph the label.

Call Poison Control (1-800-222-1222 in the US) if you are unsure whether a product is harmful, but do this while flushing or after, not instead.

Why alkali burns are worse than acid burns

Alkali injuries are more common, especially at work and with household cleaners. Hydrofluoric acid, used in rust removers and glass etching, is an exception among acids because it penetrates like an alkali.

Irritants such as pepper spray, soap and alcohol-based gel change the eye's pH very little. They sting intensely but usually do not burn the tissue.

Symptoms

• Severe burning or stinging pain
• Redness, tearing and swollen eyelids
• Blurred vision or a white haze over the eye
• Light sensitivity
• A feeling that something is stuck in the eye

A worrying sign is an eye that looks white rather than red in places. That paleness means blood vessels around the cornea have been destroyed (limbal ischemia), which predicts a worse injury.

What happens in the ER

Treatment starts with more rinsing, often before any history is taken.

• Numbing drops let you keep the eye open.
• Irrigation continues with liters of saline, sometimes through a contact-lens-shaped device (a Morgan lens).
• pH testing: a strip of litmus paper is touched to the eye. Rinsing goes on until the pH is back to about 7.0 to 7.5 and stays there after a short wait.
• Removing particles: the doctor flips the eyelids and sweeps under them with a moist swab to clear trapped cement or lime.
• Slit-lamp examination with fluorescein dye shows how much of the surface has been stripped and whether the cornea is cloudy.
• Eye pressure is measured, because burns can raise it.

Grading the injury

Ophthalmologists grade chemical burns by how clear the cornea is and how much of the limbus (the ring where the cornea meets the white of the eye) has lost its blood supply. The limbus holds the stem cells that regrow the corneal surface. Grade I burns heal well. Grade IV burns, with an opaque cornea and most of the limbus damaged, carry a high risk of permanent vision loss.

Treatment after irrigation

Mild burns are treated with lubricating drops, antibiotic drops or ointment to prevent infection, and pain relief. They usually heal in a few days.

Moderate and severe burns are managed by an ophthalmologist and may include:

• Steroid drops in the first week or so to control inflammation, then tapered to avoid slowing healing
• Dilating (cycloplegic) drops to relax the eye's focusing muscle and ease pain
• Pressure-lowering drops if eye pressure rises
• Vitamin C (ascorbate) and doxycycline by mouth and as drops, which can help collagen repair and limit corneal melting after alkali burns
• Amniotic membrane graft: a thin biological dressing placed over the eye to calm inflammation and promote healing
• Later surgery: limbal stem cell transplant, corneal transplant or an artificial cornea when scarring is severe

Complications

• Corneal scarring and permanent blurred vision (see corneal scarring)
• Limbal stem cell deficiency, where the cornea is overgrown by cloudy conjunctival tissue
• Raised eye pressure and secondary glaucoma
• Cataract
• Dry eye and scarred eyelids that stick to the eyeball (symblepharon)
• Corneal ulcers or perforation

Outlook

Most chemical splashes, especially from mild household products, heal completely within a week when flushed quickly. Outcome depends mainly on the type of chemical, how long it stayed in contact and how fast irrigation began. Severe alkali burns can take months to settle and may need several operations.

Preventing chemical eye injuries

• Wear wraparound safety goggles when using cement, plaster, drain cleaners, oven cleaners, pool chemicals or car batteries.
• Never mix cleaning products. Bleach plus ammonia or acid releases toxic gas.
• Store chemicals in their original labeled containers, out of children's reach. Laundry and dishwasher pods are a common cause of eye burns in toddlers.
• Know where the nearest eyewash station is at work.

For other eye emergencies, see eye injuries, foreign body in the eye and corneal abrasion. Chemical burns to the skin are covered under chemical burns.

Frequently asked questions

How long should you flush your eye after a chemical splash?

Flush for at least 15 minutes with clean running water, and for 20 to 30 minutes if the chemical was an alkali such as cement, lime, drain cleaner or ammonia, or if you do not know what it was. In the ER, rinsing continues until a pH strip shows the eye is back to neutral.

Is it better to use water or saline?

Use whatever is closest. Tap water, a shower or bottled water is fine and should never be delayed while you look for saline. Every second of contact adds damage. Hospitals use sterile saline or balanced salt solution once you arrive.

Can a chemical burn to the eye heal on its own?

Mild burns, with only surface irritation, usually heal fully within a few days after thorough rinsing. Any burn from a strong alkali or acid, or any burn that leaves blurred vision, needs an eye examination because damage can be hidden and can get worse over hours.

Why is my eye still blurry after a chemical splash?

Blurring can come from loss of the clear surface layer of the cornea, swelling of the cornea, or residual chemical. It needs prompt examination by an eye doctor, especially if the cornea looks hazy or white, or if blurring has not cleared within an hour.

Is pepper spray a chemical burn?

Pepper spray is an irritant rather than a corrosive. It causes intense burning, tearing and lid spasm but rarely damages the eye permanently. Rinse with cool water, remove contact lenses and see a doctor if pain or blurring lasts more than an hour or two.