A 35-year-old, previously healthy woman comes to the emergency department due to eye injury. She was cleaning her bathroom with industrial-strength bleach 30 minutes ago when some of the chemical splashed into her left eye. The patient immediately washed the eye with tap water for several minutes. She now has a gritty sensation in the eye and difficulty opening it. Physical examination reveals blepharospasm and conjunctival erythema of the left eye. Urgent ophthalmology consultation is requested. Which of the following is the best immediate step in management of this patient?

Question

A 35-year-old, previously healthy woman comes to the emergency department due to eye injury.  She was cleaning her bathroom with industrial-strength bleach 30 minutes ago when some of the chemical splashed into her left eye.  The patient immediately washed the eye with tap water for several minutes.  She now has a gritty sensation in the eye and difficulty opening it.  Physical examination reveals blepharospasm and conjunctival erythema of the left eye.  Urgent ophthalmology consultation is requested.  Which of the following is the best immediate step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d1c2_bd1a_bc81_eb0c9b089887_MD0003_00 This patient has a vision-threatening ocular chemical burn. Typical symptoms include eye pain, blepharospasm (eg, inability to open the eyelid), a gritty sensation, and eye erythema; severe cases may lead to ischemia of the conjunctiva, and the eye may appear white. As in other parts of the body, chemical burns are categorized as follows: Acid burns: cause coagulation necrosis (eg, protein denaturation) that results in an eschar, thereby preventing further acid penetration and injury Alkali burns (eg, bleach): cause liquefactive necrosis (eg, cell membrane dissolution), which leads to deeper penetration of tissues and therefore more severe injuries In either case, the most important (and urgent) step in management is to restore a neutral pH by flushing the eye copiously with water or saline. Normalization of pH typically takes 30-60 minutes but may take greater than >2 hours for alkali burns. In ideal circumstances, a provider continuously flushes the eye, but eye-wash devices (eg, Morgan lens) can be used. Topical anesthesia can be administered to improve patient comfort and tolerance of irrigation. After cessation of irrigation, the eye's pH should be remeasured with litmus paper to confirm that it remains neutral. (Choice A) Cycloplegics (parasympatholytic agents that prevent light-induced miosis) may be prescribed for long-term management of pain caused by photophobia resulting from large corneal abrasions. They are not indicated for acute ocular burns. (Choice C) Topical antibiotics may be used in the management of ocular chemical burns but not before normalization of the eye's pH is achieved through copious irrigation. (Choice D) Eye patch application was once a commonly used treatment for corneal abrasions because it was thought to promote epithelial proliferation and encourage healing. It is used much less frequently now because it does not seem to provide much benefit. Patching is not appropriate for the treatment of chemical burns. (Choice E) Although neutralization of pH is of the utmost importance, it should be achieved with pH-neutral saline irrigation rather than a neutralizing agent (eg, acetic acid for alkali burns) because acid-base neutralization reactions are exothermic and therefore can cause further injury. Acetic acid is sometimes used for alkali burns on skin, but evidence regarding its efficacy is limited. Educational objective: Chemical burns to the eye are vision-threatening emergencies. The most important and urgent step in management is copious irrigation to normalize the pH. References: Treatment of acute ocular chemical burns. (http://www.ncbi.nlm.nih.gov/pubmed/28935121)

A 35-Year-Old, Previously Healthy Woman Comes to the Emergency Department