Ocular Chemical Burns in the Dermatology Office: A Practical Approach to Managing Safety Precautions

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Ocular Chemical Burns in the Dermatology Office: A Practical Approach to Managing Safety Precautions
Author(s)
Deborah J. Moon, MD
Shawna Langley, MD

Many dermatologic procedures are performed on the face, such as skin biopsies, surgical excisions, and cosmetic procedures, which can increase the risk for accidental ocular injuries.1,2 Ocular chemical burns have been reported to account for approximately 3% to 20% of ocular injuries3,4 and are one of the few ocular emergencies dermatologists may encounter in practice. Given the potentially severe consequences of permanent vision changes or loss, it is important to take precautionary steps in preventing chemical exposures and know how to appropriately manage ophthalmic emergencies when they occur.1,5-8 In this article, we describe a patient with a transient ocular chemical injury from exposure to aluminum chloride hexahydrate that completely resolved with immediate care. We also offer practical guidance for the general dermatologist in the acute management of acidic chemical burns to the eye, highlighting immediate copious irrigation as the most important step in preventing severe permanent damage. Given that aluminum chloride hexahydrate is an acidic solution, we focus predominantly on the approach to acidic chemical exposures to the eye.

Case Report

A 61-year-old woman was seen in the dermatology outpatient clinic for a shave biopsy on the left cheek followed by aluminum chloride application for hemostasis. Following the biopsy, the patient stated she felt the sensation that something had dripped into the left eye and she felt a burning pain. There was a 30- to 60-second delay in irrigation of the eye, as it was at first unclear what had occurred. The patient reported an increased burning sensation, and at that point she was instructed to begin flushing the eye with tap water from the examination room sink for 15 to 20 minutes; she wanted to stop irrigation after a few minutes, and convincing her to continue thorough irrigation was somewhat challenging. It was determined that aluminum chloride hexahydrate had dripped from an oversaturated cotton swab in transit from the tray to the biopsy site.

The patient was urgently directed to the ophthalmology clinic and evaluated by an ophthalmologist within 1 to 2 hours of chemical exposure. Visual acuity of the affected left eye was noted to be 20/30 -2 with correctional glasses, and slit lamp examination revealed moderate injection of the conjunctiva and sclera, and at least 3 punctate epithelial erosions and punctate staining of the inferior aspects of the cornea, consistent with a chemical injury. The remaining ocular examination was normal for both eyes. She was diagnosed with keratitis of the left eye from chemical exposure to aluminum chloride and was prescribed loteprednol etabonate ophthalmic suspension 0.5% and tobramycin ophthalmic solution 0.3% to be applied to the left eye 4 times daily, with follow-up 4 days later.

At follow-up, the patient denied any pain, though she was not using the prescribed eye drops consistently. On examination, the patient showed improvement in visual acuity to 20/20 -2 and complete resolution of the keratitis, with slit lamp examination showing clear conjunctiva, sclera, and cornea. Given complete resolution, the eye drops were discontinued.

Comment

Factors Contributing to Ocular Chemical Injuries
Chemical burns to the eyes during cosmetic or surgical procedures are one of the few acute ocular emergencies dermatologists may encounter in practice. If not managed properly, the eye may be permanently damaged. Therefore, dermatologists must be confident in the initial management of ocular chemical burns (Table 1; Figure).

A, When using aluminum chloride hexahydrate (AlCl3H12O6), ensure eye safety precautions. B, Irrigate the affected eye(s) for at least 15 to 30 minutes. Remove contact lenses as soon as practical or after several seconds of immediate irrigation.6,8 Patients should keep eyes wide open and rotate their eyes in all directions. C, Identify and verify the chemical and, if possible,
obtain the material safety data sheet. D, Refer the patient urgently to ophthalmology for a visual acuity test and treatment. Images courtesy of Deborah J. Moon, MD (Los Angeles, California). 

Mechanism of Ocular Chemical Burns
The extent of injury is predominantly determined by 2 factors: (1) the chemical properties of the substance, and (2) the length of exposure.5,9,10 Potential chemical exposures and their reported ocular effects are listed in Table 2.11-21 Alkaline chemical burns often have the gravest outcome, as they can rapidly penetrate into the internal ocular structures, potentially leading to cataracts and glaucoma.9 Hydroxyl ions, often found in alkaline chemicals, are capable of rapidly denaturing the corneal matrix and triggering release of proteolytic enzymes through a series of inflammatory responses. Conversely, ocular damage from most acidic chemicals often is limited to the more superficial structures, such as the cornea and conjunctiva, given that acids may cause corneal proteins to coagulate, thus forming a barrier that slows further penetration into deeper structures.9 Nonetheless, corneal damage can still have a devastating impact on visual acuity, as the cornea provides 65% to 75% of the eye’s total focusing power.22 For both alkaline and acidic chemicals, immediate profuse irrigation is most critical in determining the clinical course.23-26 To provide perspective, potent alkaline chemicals may penetrate into the anterior chamber of the eye within 15 seconds,9 and delayed initiation of irrigation by even 5 to 15 minutes may lead to irreversible intraocular damage.27


 

 


Symptoms of Ocular Chemical Exposure
Signs and symptoms associated with ocular chemical exposures include erythema, pain, tearing, photosensitivity, eyelid swelling, foreign body sensation, changes in vision, and corneal clouding.3,5,9,28 Specifically, aluminum chloride hexahydrate, a hemostatic agent commonly used by dermatologists, has potentially caused eye irritation and conjunctivitis, according to its material safety data sheet,29 as well as blepharospasms, transient disturbances in corneal epithelium, and a persistent faint nebula in the corneal stroma.30 Similar antiperspirants also showed damaging effects to bovine lenses, ocular irritation, and subjective reports of burning and watery eyes.31-33

Immediate Management
If potential chemical exposure to the eye is suspected either by the health care provider or patient, immediately irrigate the affected eye(s) for at least 15 to 30 minutes (longer for alkaline burns) with at least 1 to 2 L of irrigation fluid until the pH is between 7 and 7.2.3-5,9,27,34,35 Irrigation fluids reported to be used include normal saline, Ringer lactate solution, normal saline with sodium bicarbonate, and balanced salt solution.5 If no solutions are readily available, immediate irrigation with tap water is sufficient for diluting and washing away the chemical and has been reported to have better clinical outcomes than delaying irrigation.5,24-26 Studies have shown that prolonged irrigation corresponded with reduced severity, shortened healing time, shorter in-hospital treatment duration, and quicker return to work.5,26

If an eye wash station is not available, the patient can gently flush the eye under a sink faucet set to a gentle stream of lukewarm water.6,7 The health care provider also may manually irrigate the eye. Necessary equipment includes a large syringe or clean eyecup, irrigating fluid, local anesthetic drops for comfort, a towel to soak up excessive fluid, and a bowl or kidney dish to collect the irrigated fluid.34 Providers should first wash their hands. If necessary, anesthetic eye drops may be added for comfort. Lay a towel over the patient’s neck and shoulders and position the patient at a comfortable angle. Place a bowl adjacent to the patient’s cheek to collect the irrigating fluid and have the patient tilt his/her head such that the irrigated fluid would flow into the bowl. Pour a steady stream of the irrigating fluid over the eye from a height of no more than 5 cm.6,7,34

During irrigation, ensure that the patient’s eye(s) is wide open and that all ocular surfaces, including the area underneath the eyelids, are thoroughly washed; everting the eyelids may be beneficial. Ask the patient to move his/her eye(s) in all directions while irrigating. If available, place a litmus strip in the conjunctival fornix to ensure that the goal pH of 7 to 7.2 is reached.9 The pH should be rechecked every 15 to 30 minutes to ensure there has been no change, as hidden crystalized chemical particles may continue to elute chemicals, causing further injury.3 Contact lenses, if present, should be removed as soon as practical, as lenses can trap chemicals; however, immediate initiation of irrigation should not be delayed8 (Table 1).

Identify and verify the chemical suspected to have been exposed to the patient’s eye. The material safety data sheet, which may often be found online if a hard copy is not available, may provide valuable information for the ophthalmologist.36 After thorough irrigation, refer the patient urgently to ophthalmology or the emergency department for prompt evaluation. The emergency department is frequently equipped with polymethylmethacrylate scleral lenses, also called Morgan Lens, which consist of a plastic lens connected via tubing to a bag of irrigation fluid (eg, Ringer lactate solution), allowing for prolonged continuous irrigation of the conjunctiva and cornea. The ophthalmologist will conduct a visual acuity test and complete a thorough eye examination to assess the extent of ischemic injury to the conjunctiva or sclera and damage to the corneal epithelium and internal ocular structures.9



Generally, topical antibiotics, artificial tears, and topical steroids may be provided to patients with mild injury with close follow-up.9,37 For higher-grade injuries, broad-spectrum topical antibiotics, oral antibiotics, topical corticosteroids, vitamin C, and surgical treatments may be additionally recommended (Table 3). Long-term follow-up may be recommended by the ophthalmologist to monitor for potential late complications, such as glaucoma from damage to the trabecular meshwork, corneal abnormalities and limbal stem cell deficiency, symblepharon formation, or eyelid abnormalities.9

Conclusion

We report a case of a transient chemical burn to the eye secondary to exposure to aluminum chloride hexahydrate. Complete resolution of the injury was achieved with prompt irrigation and urgent medical management by ophthalmology. This case emphasizes the potential for ocular emergencies in the dermatology setting and highlights the steps for appropriate management should a chemical burn to the eye occur. We emphasize the importance of immediate profuse irrigation for 15 to 30 minutes and urgent evaluation by an ophthalmologist. Dermatologists should be cognizant of potential hazards to the eye during facial procedures and always take proper precautions to decrease the risk for ocular injuries.

References
  1. Ricci LH, Navajas SV, Carneiro PR, et al. Ocular adverse effects after facial cosmetic procedures: a review of case reports. J Cosmet Dermatol. 2015;14:145-151.
  2. Boonsiri M, Marks KC, Ditre CM. Benzocaine/lidocaine/tetracainecream: report of corneal damage and review. J Clin Aesthet Dermatol. 2016;9:48-50.
  3. Gelston CD. Common eye emergencies. Am Fam Physician. 2013;88:515-519.
  4. Sharma N, Kaur M, Agarwal T, et al. Treatment of acute ocular chemical burns. Surv Ophthalmol. 2018;63:214-235.
  5. Chau JP, Lee DT, Lo SH. A systematic review of methods of eye irrigation for adults and children with ocular chemical burns. Worldviews Evid Based Nurs. 2012;9:129-138.
  6. Sears W, Sears M, Sears R, et al. The Portable Pediatrician: Everything You Need to Know About Your Child’s Health. New York, NY: Little, Brown and Company; 2011.
  7. Kuckelkorn R, Schrage N, Keller G, et al. Emergency treatment of chemical and thermal eye burns. Acta Ophthalmol Scand. 2002;80:4-10.
  8. Schulte PA, Ahlers HW, Jackson LL, et al. Contact Lens Use in a Chemical Environment. Cincinnati, OH: National Institute for Occupational Safety and Health, US Department of Health and Human Services; 2005. NIOSH publication 2005-139.
  9. Hemmati HD, Colby KA. Treating acute chemical injuries of the cornea. Eyenet. October 2012. https://www.aao.org/eyenet/article/treating-acute-chemical-injuries-of-cornea. Accessed May 28, 2019.
  10. Schrage NF, Langefeld S, Zschocke J, et al. Eye burns: an emergency and continuing problem. Burns. 2000;26:689-699.
  11. Gattey D. Chemical-induced ocular side effects. In: Fraunfelder FT, Fraunfelder FW, Chambers WA, eds. Clinical Ocular Toxicology. Edinburgh, Scotland: W.B. Saunders; 2008:289-306.
  12. Apt L, Isenberg SJ. Hibiclens keratitis. Am J Ophthalmol. 1987;104:670-671.
  13. Tabor E, Bostwick DC, Evans C. Corneal damage due to eye contact with chlorhexidine gluconate. JAMA. 1989;261:557-558.
  14. Galor A, Jeng BH, Lowder CY. A curious case of corneal edema. Eyenet. January 2007. https://www.aao.org/eyenet/article/curious-case-of-corneal-edema. Accessed May 28, 2019.
  15. Hamed LM, Ellis FD, Boudreault G, et al. Hibiclens keratitis. Am J Ophthalmol. 1987;104:50-56.
  16. Haring R, Sheffield ID, Channa R, et al. Epidemiologic trends of chemical ocular burns in the United States. JAMA Ophthalmol. 2016;134:1119-1124.
  17. Racioppi F, Daskaleros PA, Besbelli N, et al. Household bleaches based on sodium hypochlorite: review of acute toxicology and poison control center experience. Food Chem Toxicol. 1994;32:845-861.
  18. Shazly TA. Ocular acid burn due to 20% concentrated salicylic acid. Cutan Ocul Toxicol. 2011;30:84-86.
  19. Speaker MG, Menikoff JA. Prophylaxis of endophthalmitis with topical povidone-iodine. Ophthalmology. 1991;98:1769-1775.
  20. Apt L, Isenberg S, Yoshimori R, et al. Chemical preparation of the eye in ophthalmic surgery: III. effect of povidone-iodine on the conjunctiva. Arch Ophthalmol. 1984;102:728-729.
  21. Stroman DW, Mintun K, Epstein AB, et al. Reduction in bacterial load using hypochlorous acid hygiene solution on ocular skin. Clin Ophthalmol. 2017;11:707-714.
  22. Paul M, Sieving A. Facts about the cornea and corneal disease. National Eye Institute, National Institutes of Health website. https://nei.nih.gov/health/cornealdisease. Accessed May 20, 2019.
  23. Khaw P, Shah P, Elkington A. Injury to the eye. BMJ. 2004;328:36-38.
  24. Duffy B. Managing chemical eye injuries: Bernice Duffy says initial management of potentially devastating chemical eye injuries by emergency nurses can affect patients’ future prognosis as much as subsequent ophthalmic treatment. Emerg Nurse. 2008;16:25-30.
  25. Burns F, Paterson C. Prompt irrigation of chemical eye injuries may avert severe damage. Occup Health Saf. 1989;58:33-36.
  26. Ikeda N, Hayasaka S, Hayasaka Y, et al. Alkali burns of the eye: effect of immediate copious irrigation with tap water on their severity. Ophthalmologica. 2006;220:225-228.
  27. Eslani M, Baradaran-Rafii A, Movahedan A, et al. The ocular surface chemical burns. J Ophthalmol. 2014;2014:196827.
  28. Pokhrel PK, Loftus SA. Ocular emergencies. Am Fam Physician. 2007;76:829-836.
  29. Drysol. MSDS No. BLVCL; Glendale, CA: Person & Covey Inc; March 9, 1991. http://msdsreport.com/msds/blvcl. Accessed May 20, 2019.
  30. Grant WM, Schuman JS. Toxicology of the Eye: Effects on the Eyes and Visual System From Chemicals, Drugs, Metals and Minerals, Plants, Toxins and Venoms: Also Systemic Side Effects From Eye Medications. Vol 1. Springfield, IL: Charles C. Thomas Publisher; 1993.
  31. Wong W, Sivak JG, Moran KL. Optical response of the cultured bovine lens; testing opaque or partially transparent semi-solid/solid common consumer hygiene products. Toxicol In Vitro. 2003;17:785-790.
  32. Donahue DA, Kaufman LE, Avalos J, et al. Survey of ocular irritation predictive capacity using chorioallantoic membrane vascular assay (CAMVA) and bovine corneal opacity and permeability (BCOP) test historical data for 319 personal care products over fourteen years. Toxicol In Vitro. 2011;25:563-572.
  33. Groot AC, Nater JP, Lender R, et al. Adverse effects of cosmetics and toiletries: a retrospective study in the general population. Int J Cosmet Sci. 1987;9:255-259.
  34. Stevens S. Ophthalmic practice. Community Eye Health. 2005;18:109-110.
  35. Hoyt KS, Haley RJ. Innovations in advanced practice: assessment and management of eye emergencies. Adv Emerg Nurs J. 2005;27:101-117.
  36. LaDou J, Harrison RJ, eds. CURRENT Diagnosis & Treatment: Occupational & Environmental Medicine. 5th ed. New York, NY: McGraw-Hill Education; 2013.
  37. Roper-Hall M. Thermal and chemical burns. Trans Ophthalmol Soc U K. 1965;85:631-653.
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Author and Disclosure Information

Dr. Moon is from David Geffen School of Medicine at UCLA, Los Angeles, California. Dr. Langley is from the Department of Dermatology, Loma Linda University Medical Center, California.

The authors report no conflict of interest.

Correspondence: Deborah J. Moon, MD, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Los Angeles, CA 90095 ([email protected]).

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Deborah J. Moon, MD
Shawna Langley, MD
Author(s)
Deborah J. Moon, MD
Shawna Langley, MD
Author and Disclosure Information

Dr. Moon is from David Geffen School of Medicine at UCLA, Los Angeles, California. Dr. Langley is from the Department of Dermatology, Loma Linda University Medical Center, California.

The authors report no conflict of interest.

Correspondence: Deborah J. Moon, MD, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Los Angeles, CA 90095 ([email protected]).

Author and Disclosure Information

Dr. Moon is from David Geffen School of Medicine at UCLA, Los Angeles, California. Dr. Langley is from the Department of Dermatology, Loma Linda University Medical Center, California.

The authors report no conflict of interest.

Correspondence: Deborah J. Moon, MD, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Los Angeles, CA 90095 ([email protected]).

Article PDF
CT103006346.PDF
Article PDF
CT103006346.PDF

Many dermatologic procedures are performed on the face, such as skin biopsies, surgical excisions, and cosmetic procedures, which can increase the risk for accidental ocular injuries.1,2 Ocular chemical burns have been reported to account for approximately 3% to 20% of ocular injuries3,4 and are one of the few ocular emergencies dermatologists may encounter in practice. Given the potentially severe consequences of permanent vision changes or loss, it is important to take precautionary steps in preventing chemical exposures and know how to appropriately manage ophthalmic emergencies when they occur.1,5-8 In this article, we describe a patient with a transient ocular chemical injury from exposure to aluminum chloride hexahydrate that completely resolved with immediate care. We also offer practical guidance for the general dermatologist in the acute management of acidic chemical burns to the eye, highlighting immediate copious irrigation as the most important step in preventing severe permanent damage. Given that aluminum chloride hexahydrate is an acidic solution, we focus predominantly on the approach to acidic chemical exposures to the eye.

Case Report

A 61-year-old woman was seen in the dermatology outpatient clinic for a shave biopsy on the left cheek followed by aluminum chloride application for hemostasis. Following the biopsy, the patient stated she felt the sensation that something had dripped into the left eye and she felt a burning pain. There was a 30- to 60-second delay in irrigation of the eye, as it was at first unclear what had occurred. The patient reported an increased burning sensation, and at that point she was instructed to begin flushing the eye with tap water from the examination room sink for 15 to 20 minutes; she wanted to stop irrigation after a few minutes, and convincing her to continue thorough irrigation was somewhat challenging. It was determined that aluminum chloride hexahydrate had dripped from an oversaturated cotton swab in transit from the tray to the biopsy site.

The patient was urgently directed to the ophthalmology clinic and evaluated by an ophthalmologist within 1 to 2 hours of chemical exposure. Visual acuity of the affected left eye was noted to be 20/30 -2 with correctional glasses, and slit lamp examination revealed moderate injection of the conjunctiva and sclera, and at least 3 punctate epithelial erosions and punctate staining of the inferior aspects of the cornea, consistent with a chemical injury. The remaining ocular examination was normal for both eyes. She was diagnosed with keratitis of the left eye from chemical exposure to aluminum chloride and was prescribed loteprednol etabonate ophthalmic suspension 0.5% and tobramycin ophthalmic solution 0.3% to be applied to the left eye 4 times daily, with follow-up 4 days later.

At follow-up, the patient denied any pain, though she was not using the prescribed eye drops consistently. On examination, the patient showed improvement in visual acuity to 20/20 -2 and complete resolution of the keratitis, with slit lamp examination showing clear conjunctiva, sclera, and cornea. Given complete resolution, the eye drops were discontinued.

Comment

Factors Contributing to Ocular Chemical Injuries
Chemical burns to the eyes during cosmetic or surgical procedures are one of the few acute ocular emergencies dermatologists may encounter in practice. If not managed properly, the eye may be permanently damaged. Therefore, dermatologists must be confident in the initial management of ocular chemical burns (Table 1; Figure).

A, When using aluminum chloride hexahydrate (AlCl3H12O6), ensure eye safety precautions. B, Irrigate the affected eye(s) for at least 15 to 30 minutes. Remove contact lenses as soon as practical or after several seconds of immediate irrigation.6,8 Patients should keep eyes wide open and rotate their eyes in all directions. C, Identify and verify the chemical and, if possible,
obtain the material safety data sheet. D, Refer the patient urgently to ophthalmology for a visual acuity test and treatment. Images courtesy of Deborah J. Moon, MD (Los Angeles, California). 

Mechanism of Ocular Chemical Burns
The extent of injury is predominantly determined by 2 factors: (1) the chemical properties of the substance, and (2) the length of exposure.5,9,10 Potential chemical exposures and their reported ocular effects are listed in Table 2.11-21 Alkaline chemical burns often have the gravest outcome, as they can rapidly penetrate into the internal ocular structures, potentially leading to cataracts and glaucoma.9 Hydroxyl ions, often found in alkaline chemicals, are capable of rapidly denaturing the corneal matrix and triggering release of proteolytic enzymes through a series of inflammatory responses. Conversely, ocular damage from most acidic chemicals often is limited to the more superficial structures, such as the cornea and conjunctiva, given that acids may cause corneal proteins to coagulate, thus forming a barrier that slows further penetration into deeper structures.9 Nonetheless, corneal damage can still have a devastating impact on visual acuity, as the cornea provides 65% to 75% of the eye’s total focusing power.22 For both alkaline and acidic chemicals, immediate profuse irrigation is most critical in determining the clinical course.23-26 To provide perspective, potent alkaline chemicals may penetrate into the anterior chamber of the eye within 15 seconds,9 and delayed initiation of irrigation by even 5 to 15 minutes may lead to irreversible intraocular damage.27


 

 


Symptoms of Ocular Chemical Exposure
Signs and symptoms associated with ocular chemical exposures include erythema, pain, tearing, photosensitivity, eyelid swelling, foreign body sensation, changes in vision, and corneal clouding.3,5,9,28 Specifically, aluminum chloride hexahydrate, a hemostatic agent commonly used by dermatologists, has potentially caused eye irritation and conjunctivitis, according to its material safety data sheet,29 as well as blepharospasms, transient disturbances in corneal epithelium, and a persistent faint nebula in the corneal stroma.30 Similar antiperspirants also showed damaging effects to bovine lenses, ocular irritation, and subjective reports of burning and watery eyes.31-33

Immediate Management
If potential chemical exposure to the eye is suspected either by the health care provider or patient, immediately irrigate the affected eye(s) for at least 15 to 30 minutes (longer for alkaline burns) with at least 1 to 2 L of irrigation fluid until the pH is between 7 and 7.2.3-5,9,27,34,35 Irrigation fluids reported to be used include normal saline, Ringer lactate solution, normal saline with sodium bicarbonate, and balanced salt solution.5 If no solutions are readily available, immediate irrigation with tap water is sufficient for diluting and washing away the chemical and has been reported to have better clinical outcomes than delaying irrigation.5,24-26 Studies have shown that prolonged irrigation corresponded with reduced severity, shortened healing time, shorter in-hospital treatment duration, and quicker return to work.5,26

If an eye wash station is not available, the patient can gently flush the eye under a sink faucet set to a gentle stream of lukewarm water.6,7 The health care provider also may manually irrigate the eye. Necessary equipment includes a large syringe or clean eyecup, irrigating fluid, local anesthetic drops for comfort, a towel to soak up excessive fluid, and a bowl or kidney dish to collect the irrigated fluid.34 Providers should first wash their hands. If necessary, anesthetic eye drops may be added for comfort. Lay a towel over the patient’s neck and shoulders and position the patient at a comfortable angle. Place a bowl adjacent to the patient’s cheek to collect the irrigating fluid and have the patient tilt his/her head such that the irrigated fluid would flow into the bowl. Pour a steady stream of the irrigating fluid over the eye from a height of no more than 5 cm.6,7,34

During irrigation, ensure that the patient’s eye(s) is wide open and that all ocular surfaces, including the area underneath the eyelids, are thoroughly washed; everting the eyelids may be beneficial. Ask the patient to move his/her eye(s) in all directions while irrigating. If available, place a litmus strip in the conjunctival fornix to ensure that the goal pH of 7 to 7.2 is reached.9 The pH should be rechecked every 15 to 30 minutes to ensure there has been no change, as hidden crystalized chemical particles may continue to elute chemicals, causing further injury.3 Contact lenses, if present, should be removed as soon as practical, as lenses can trap chemicals; however, immediate initiation of irrigation should not be delayed8 (Table 1).

Identify and verify the chemical suspected to have been exposed to the patient’s eye. The material safety data sheet, which may often be found online if a hard copy is not available, may provide valuable information for the ophthalmologist.36 After thorough irrigation, refer the patient urgently to ophthalmology or the emergency department for prompt evaluation. The emergency department is frequently equipped with polymethylmethacrylate scleral lenses, also called Morgan Lens, which consist of a plastic lens connected via tubing to a bag of irrigation fluid (eg, Ringer lactate solution), allowing for prolonged continuous irrigation of the conjunctiva and cornea. The ophthalmologist will conduct a visual acuity test and complete a thorough eye examination to assess the extent of ischemic injury to the conjunctiva or sclera and damage to the corneal epithelium and internal ocular structures.9



Generally, topical antibiotics, artificial tears, and topical steroids may be provided to patients with mild injury with close follow-up.9,37 For higher-grade injuries, broad-spectrum topical antibiotics, oral antibiotics, topical corticosteroids, vitamin C, and surgical treatments may be additionally recommended (Table 3). Long-term follow-up may be recommended by the ophthalmologist to monitor for potential late complications, such as glaucoma from damage to the trabecular meshwork, corneal abnormalities and limbal stem cell deficiency, symblepharon formation, or eyelid abnormalities.9

Conclusion

We report a case of a transient chemical burn to the eye secondary to exposure to aluminum chloride hexahydrate. Complete resolution of the injury was achieved with prompt irrigation and urgent medical management by ophthalmology. This case emphasizes the potential for ocular emergencies in the dermatology setting and highlights the steps for appropriate management should a chemical burn to the eye occur. We emphasize the importance of immediate profuse irrigation for 15 to 30 minutes and urgent evaluation by an ophthalmologist. Dermatologists should be cognizant of potential hazards to the eye during facial procedures and always take proper precautions to decrease the risk for ocular injuries.

Many dermatologic procedures are performed on the face, such as skin biopsies, surgical excisions, and cosmetic procedures, which can increase the risk for accidental ocular injuries.1,2 Ocular chemical burns have been reported to account for approximately 3% to 20% of ocular injuries3,4 and are one of the few ocular emergencies dermatologists may encounter in practice. Given the potentially severe consequences of permanent vision changes or loss, it is important to take precautionary steps in preventing chemical exposures and know how to appropriately manage ophthalmic emergencies when they occur.1,5-8 In this article, we describe a patient with a transient ocular chemical injury from exposure to aluminum chloride hexahydrate that completely resolved with immediate care. We also offer practical guidance for the general dermatologist in the acute management of acidic chemical burns to the eye, highlighting immediate copious irrigation as the most important step in preventing severe permanent damage. Given that aluminum chloride hexahydrate is an acidic solution, we focus predominantly on the approach to acidic chemical exposures to the eye.

Case Report

A 61-year-old woman was seen in the dermatology outpatient clinic for a shave biopsy on the left cheek followed by aluminum chloride application for hemostasis. Following the biopsy, the patient stated she felt the sensation that something had dripped into the left eye and she felt a burning pain. There was a 30- to 60-second delay in irrigation of the eye, as it was at first unclear what had occurred. The patient reported an increased burning sensation, and at that point she was instructed to begin flushing the eye with tap water from the examination room sink for 15 to 20 minutes; she wanted to stop irrigation after a few minutes, and convincing her to continue thorough irrigation was somewhat challenging. It was determined that aluminum chloride hexahydrate had dripped from an oversaturated cotton swab in transit from the tray to the biopsy site.

The patient was urgently directed to the ophthalmology clinic and evaluated by an ophthalmologist within 1 to 2 hours of chemical exposure. Visual acuity of the affected left eye was noted to be 20/30 -2 with correctional glasses, and slit lamp examination revealed moderate injection of the conjunctiva and sclera, and at least 3 punctate epithelial erosions and punctate staining of the inferior aspects of the cornea, consistent with a chemical injury. The remaining ocular examination was normal for both eyes. She was diagnosed with keratitis of the left eye from chemical exposure to aluminum chloride and was prescribed loteprednol etabonate ophthalmic suspension 0.5% and tobramycin ophthalmic solution 0.3% to be applied to the left eye 4 times daily, with follow-up 4 days later.

At follow-up, the patient denied any pain, though she was not using the prescribed eye drops consistently. On examination, the patient showed improvement in visual acuity to 20/20 -2 and complete resolution of the keratitis, with slit lamp examination showing clear conjunctiva, sclera, and cornea. Given complete resolution, the eye drops were discontinued.

Comment

Factors Contributing to Ocular Chemical Injuries
Chemical burns to the eyes during cosmetic or surgical procedures are one of the few acute ocular emergencies dermatologists may encounter in practice. If not managed properly, the eye may be permanently damaged. Therefore, dermatologists must be confident in the initial management of ocular chemical burns (Table 1; Figure).

A, When using aluminum chloride hexahydrate (AlCl3H12O6), ensure eye safety precautions. B, Irrigate the affected eye(s) for at least 15 to 30 minutes. Remove contact lenses as soon as practical or after several seconds of immediate irrigation.6,8 Patients should keep eyes wide open and rotate their eyes in all directions. C, Identify and verify the chemical and, if possible,
obtain the material safety data sheet. D, Refer the patient urgently to ophthalmology for a visual acuity test and treatment. Images courtesy of Deborah J. Moon, MD (Los Angeles, California). 

Mechanism of Ocular Chemical Burns
The extent of injury is predominantly determined by 2 factors: (1) the chemical properties of the substance, and (2) the length of exposure.5,9,10 Potential chemical exposures and their reported ocular effects are listed in Table 2.11-21 Alkaline chemical burns often have the gravest outcome, as they can rapidly penetrate into the internal ocular structures, potentially leading to cataracts and glaucoma.9 Hydroxyl ions, often found in alkaline chemicals, are capable of rapidly denaturing the corneal matrix and triggering release of proteolytic enzymes through a series of inflammatory responses. Conversely, ocular damage from most acidic chemicals often is limited to the more superficial structures, such as the cornea and conjunctiva, given that acids may cause corneal proteins to coagulate, thus forming a barrier that slows further penetration into deeper structures.9 Nonetheless, corneal damage can still have a devastating impact on visual acuity, as the cornea provides 65% to 75% of the eye’s total focusing power.22 For both alkaline and acidic chemicals, immediate profuse irrigation is most critical in determining the clinical course.23-26 To provide perspective, potent alkaline chemicals may penetrate into the anterior chamber of the eye within 15 seconds,9 and delayed initiation of irrigation by even 5 to 15 minutes may lead to irreversible intraocular damage.27


 

 


Symptoms of Ocular Chemical Exposure
Signs and symptoms associated with ocular chemical exposures include erythema, pain, tearing, photosensitivity, eyelid swelling, foreign body sensation, changes in vision, and corneal clouding.3,5,9,28 Specifically, aluminum chloride hexahydrate, a hemostatic agent commonly used by dermatologists, has potentially caused eye irritation and conjunctivitis, according to its material safety data sheet,29 as well as blepharospasms, transient disturbances in corneal epithelium, and a persistent faint nebula in the corneal stroma.30 Similar antiperspirants also showed damaging effects to bovine lenses, ocular irritation, and subjective reports of burning and watery eyes.31-33

Immediate Management
If potential chemical exposure to the eye is suspected either by the health care provider or patient, immediately irrigate the affected eye(s) for at least 15 to 30 minutes (longer for alkaline burns) with at least 1 to 2 L of irrigation fluid until the pH is between 7 and 7.2.3-5,9,27,34,35 Irrigation fluids reported to be used include normal saline, Ringer lactate solution, normal saline with sodium bicarbonate, and balanced salt solution.5 If no solutions are readily available, immediate irrigation with tap water is sufficient for diluting and washing away the chemical and has been reported to have better clinical outcomes than delaying irrigation.5,24-26 Studies have shown that prolonged irrigation corresponded with reduced severity, shortened healing time, shorter in-hospital treatment duration, and quicker return to work.5,26

If an eye wash station is not available, the patient can gently flush the eye under a sink faucet set to a gentle stream of lukewarm water.6,7 The health care provider also may manually irrigate the eye. Necessary equipment includes a large syringe or clean eyecup, irrigating fluid, local anesthetic drops for comfort, a towel to soak up excessive fluid, and a bowl or kidney dish to collect the irrigated fluid.34 Providers should first wash their hands. If necessary, anesthetic eye drops may be added for comfort. Lay a towel over the patient’s neck and shoulders and position the patient at a comfortable angle. Place a bowl adjacent to the patient’s cheek to collect the irrigating fluid and have the patient tilt his/her head such that the irrigated fluid would flow into the bowl. Pour a steady stream of the irrigating fluid over the eye from a height of no more than 5 cm.6,7,34

During irrigation, ensure that the patient’s eye(s) is wide open and that all ocular surfaces, including the area underneath the eyelids, are thoroughly washed; everting the eyelids may be beneficial. Ask the patient to move his/her eye(s) in all directions while irrigating. If available, place a litmus strip in the conjunctival fornix to ensure that the goal pH of 7 to 7.2 is reached.9 The pH should be rechecked every 15 to 30 minutes to ensure there has been no change, as hidden crystalized chemical particles may continue to elute chemicals, causing further injury.3 Contact lenses, if present, should be removed as soon as practical, as lenses can trap chemicals; however, immediate initiation of irrigation should not be delayed8 (Table 1).

Identify and verify the chemical suspected to have been exposed to the patient’s eye. The material safety data sheet, which may often be found online if a hard copy is not available, may provide valuable information for the ophthalmologist.36 After thorough irrigation, refer the patient urgently to ophthalmology or the emergency department for prompt evaluation. The emergency department is frequently equipped with polymethylmethacrylate scleral lenses, also called Morgan Lens, which consist of a plastic lens connected via tubing to a bag of irrigation fluid (eg, Ringer lactate solution), allowing for prolonged continuous irrigation of the conjunctiva and cornea. The ophthalmologist will conduct a visual acuity test and complete a thorough eye examination to assess the extent of ischemic injury to the conjunctiva or sclera and damage to the corneal epithelium and internal ocular structures.9



Generally, topical antibiotics, artificial tears, and topical steroids may be provided to patients with mild injury with close follow-up.9,37 For higher-grade injuries, broad-spectrum topical antibiotics, oral antibiotics, topical corticosteroids, vitamin C, and surgical treatments may be additionally recommended (Table 3). Long-term follow-up may be recommended by the ophthalmologist to monitor for potential late complications, such as glaucoma from damage to the trabecular meshwork, corneal abnormalities and limbal stem cell deficiency, symblepharon formation, or eyelid abnormalities.9

Conclusion

We report a case of a transient chemical burn to the eye secondary to exposure to aluminum chloride hexahydrate. Complete resolution of the injury was achieved with prompt irrigation and urgent medical management by ophthalmology. This case emphasizes the potential for ocular emergencies in the dermatology setting and highlights the steps for appropriate management should a chemical burn to the eye occur. We emphasize the importance of immediate profuse irrigation for 15 to 30 minutes and urgent evaluation by an ophthalmologist. Dermatologists should be cognizant of potential hazards to the eye during facial procedures and always take proper precautions to decrease the risk for ocular injuries.

References
  1. Ricci LH, Navajas SV, Carneiro PR, et al. Ocular adverse effects after facial cosmetic procedures: a review of case reports. J Cosmet Dermatol. 2015;14:145-151.
  2. Boonsiri M, Marks KC, Ditre CM. Benzocaine/lidocaine/tetracainecream: report of corneal damage and review. J Clin Aesthet Dermatol. 2016;9:48-50.
  3. Gelston CD. Common eye emergencies. Am Fam Physician. 2013;88:515-519.
  4. Sharma N, Kaur M, Agarwal T, et al. Treatment of acute ocular chemical burns. Surv Ophthalmol. 2018;63:214-235.
  5. Chau JP, Lee DT, Lo SH. A systematic review of methods of eye irrigation for adults and children with ocular chemical burns. Worldviews Evid Based Nurs. 2012;9:129-138.
  6. Sears W, Sears M, Sears R, et al. The Portable Pediatrician: Everything You Need to Know About Your Child’s Health. New York, NY: Little, Brown and Company; 2011.
  7. Kuckelkorn R, Schrage N, Keller G, et al. Emergency treatment of chemical and thermal eye burns. Acta Ophthalmol Scand. 2002;80:4-10.
  8. Schulte PA, Ahlers HW, Jackson LL, et al. Contact Lens Use in a Chemical Environment. Cincinnati, OH: National Institute for Occupational Safety and Health, US Department of Health and Human Services; 2005. NIOSH publication 2005-139.
  9. Hemmati HD, Colby KA. Treating acute chemical injuries of the cornea. Eyenet. October 2012. https://www.aao.org/eyenet/article/treating-acute-chemical-injuries-of-cornea. Accessed May 28, 2019.
  10. Schrage NF, Langefeld S, Zschocke J, et al. Eye burns: an emergency and continuing problem. Burns. 2000;26:689-699.
  11. Gattey D. Chemical-induced ocular side effects. In: Fraunfelder FT, Fraunfelder FW, Chambers WA, eds. Clinical Ocular Toxicology. Edinburgh, Scotland: W.B. Saunders; 2008:289-306.
  12. Apt L, Isenberg SJ. Hibiclens keratitis. Am J Ophthalmol. 1987;104:670-671.
  13. Tabor E, Bostwick DC, Evans C. Corneal damage due to eye contact with chlorhexidine gluconate. JAMA. 1989;261:557-558.
  14. Galor A, Jeng BH, Lowder CY. A curious case of corneal edema. Eyenet. January 2007. https://www.aao.org/eyenet/article/curious-case-of-corneal-edema. Accessed May 28, 2019.
  15. Hamed LM, Ellis FD, Boudreault G, et al. Hibiclens keratitis. Am J Ophthalmol. 1987;104:50-56.
  16. Haring R, Sheffield ID, Channa R, et al. Epidemiologic trends of chemical ocular burns in the United States. JAMA Ophthalmol. 2016;134:1119-1124.
  17. Racioppi F, Daskaleros PA, Besbelli N, et al. Household bleaches based on sodium hypochlorite: review of acute toxicology and poison control center experience. Food Chem Toxicol. 1994;32:845-861.
  18. Shazly TA. Ocular acid burn due to 20% concentrated salicylic acid. Cutan Ocul Toxicol. 2011;30:84-86.
  19. Speaker MG, Menikoff JA. Prophylaxis of endophthalmitis with topical povidone-iodine. Ophthalmology. 1991;98:1769-1775.
  20. Apt L, Isenberg S, Yoshimori R, et al. Chemical preparation of the eye in ophthalmic surgery: III. effect of povidone-iodine on the conjunctiva. Arch Ophthalmol. 1984;102:728-729.
  21. Stroman DW, Mintun K, Epstein AB, et al. Reduction in bacterial load using hypochlorous acid hygiene solution on ocular skin. Clin Ophthalmol. 2017;11:707-714.
  22. Paul M, Sieving A. Facts about the cornea and corneal disease. National Eye Institute, National Institutes of Health website. https://nei.nih.gov/health/cornealdisease. Accessed May 20, 2019.
  23. Khaw P, Shah P, Elkington A. Injury to the eye. BMJ. 2004;328:36-38.
  24. Duffy B. Managing chemical eye injuries: Bernice Duffy says initial management of potentially devastating chemical eye injuries by emergency nurses can affect patients’ future prognosis as much as subsequent ophthalmic treatment. Emerg Nurse. 2008;16:25-30.
  25. Burns F, Paterson C. Prompt irrigation of chemical eye injuries may avert severe damage. Occup Health Saf. 1989;58:33-36.
  26. Ikeda N, Hayasaka S, Hayasaka Y, et al. Alkali burns of the eye: effect of immediate copious irrigation with tap water on their severity. Ophthalmologica. 2006;220:225-228.
  27. Eslani M, Baradaran-Rafii A, Movahedan A, et al. The ocular surface chemical burns. J Ophthalmol. 2014;2014:196827.
  28. Pokhrel PK, Loftus SA. Ocular emergencies. Am Fam Physician. 2007;76:829-836.
  29. Drysol. MSDS No. BLVCL; Glendale, CA: Person & Covey Inc; March 9, 1991. http://msdsreport.com/msds/blvcl. Accessed May 20, 2019.
  30. Grant WM, Schuman JS. Toxicology of the Eye: Effects on the Eyes and Visual System From Chemicals, Drugs, Metals and Minerals, Plants, Toxins and Venoms: Also Systemic Side Effects From Eye Medications. Vol 1. Springfield, IL: Charles C. Thomas Publisher; 1993.
  31. Wong W, Sivak JG, Moran KL. Optical response of the cultured bovine lens; testing opaque or partially transparent semi-solid/solid common consumer hygiene products. Toxicol In Vitro. 2003;17:785-790.
  32. Donahue DA, Kaufman LE, Avalos J, et al. Survey of ocular irritation predictive capacity using chorioallantoic membrane vascular assay (CAMVA) and bovine corneal opacity and permeability (BCOP) test historical data for 319 personal care products over fourteen years. Toxicol In Vitro. 2011;25:563-572.
  33. Groot AC, Nater JP, Lender R, et al. Adverse effects of cosmetics and toiletries: a retrospective study in the general population. Int J Cosmet Sci. 1987;9:255-259.
  34. Stevens S. Ophthalmic practice. Community Eye Health. 2005;18:109-110.
  35. Hoyt KS, Haley RJ. Innovations in advanced practice: assessment and management of eye emergencies. Adv Emerg Nurs J. 2005;27:101-117.
  36. LaDou J, Harrison RJ, eds. CURRENT Diagnosis & Treatment: Occupational & Environmental Medicine. 5th ed. New York, NY: McGraw-Hill Education; 2013.
  37. Roper-Hall M. Thermal and chemical burns. Trans Ophthalmol Soc U K. 1965;85:631-653.
References
  1. Ricci LH, Navajas SV, Carneiro PR, et al. Ocular adverse effects after facial cosmetic procedures: a review of case reports. J Cosmet Dermatol. 2015;14:145-151.
  2. Boonsiri M, Marks KC, Ditre CM. Benzocaine/lidocaine/tetracainecream: report of corneal damage and review. J Clin Aesthet Dermatol. 2016;9:48-50.
  3. Gelston CD. Common eye emergencies. Am Fam Physician. 2013;88:515-519.
  4. Sharma N, Kaur M, Agarwal T, et al. Treatment of acute ocular chemical burns. Surv Ophthalmol. 2018;63:214-235.
  5. Chau JP, Lee DT, Lo SH. A systematic review of methods of eye irrigation for adults and children with ocular chemical burns. Worldviews Evid Based Nurs. 2012;9:129-138.
  6. Sears W, Sears M, Sears R, et al. The Portable Pediatrician: Everything You Need to Know About Your Child’s Health. New York, NY: Little, Brown and Company; 2011.
  7. Kuckelkorn R, Schrage N, Keller G, et al. Emergency treatment of chemical and thermal eye burns. Acta Ophthalmol Scand. 2002;80:4-10.
  8. Schulte PA, Ahlers HW, Jackson LL, et al. Contact Lens Use in a Chemical Environment. Cincinnati, OH: National Institute for Occupational Safety and Health, US Department of Health and Human Services; 2005. NIOSH publication 2005-139.
  9. Hemmati HD, Colby KA. Treating acute chemical injuries of the cornea. Eyenet. October 2012. https://www.aao.org/eyenet/article/treating-acute-chemical-injuries-of-cornea. Accessed May 28, 2019.
  10. Schrage NF, Langefeld S, Zschocke J, et al. Eye burns: an emergency and continuing problem. Burns. 2000;26:689-699.
  11. Gattey D. Chemical-induced ocular side effects. In: Fraunfelder FT, Fraunfelder FW, Chambers WA, eds. Clinical Ocular Toxicology. Edinburgh, Scotland: W.B. Saunders; 2008:289-306.
  12. Apt L, Isenberg SJ. Hibiclens keratitis. Am J Ophthalmol. 1987;104:670-671.
  13. Tabor E, Bostwick DC, Evans C. Corneal damage due to eye contact with chlorhexidine gluconate. JAMA. 1989;261:557-558.
  14. Galor A, Jeng BH, Lowder CY. A curious case of corneal edema. Eyenet. January 2007. https://www.aao.org/eyenet/article/curious-case-of-corneal-edema. Accessed May 28, 2019.
  15. Hamed LM, Ellis FD, Boudreault G, et al. Hibiclens keratitis. Am J Ophthalmol. 1987;104:50-56.
  16. Haring R, Sheffield ID, Channa R, et al. Epidemiologic trends of chemical ocular burns in the United States. JAMA Ophthalmol. 2016;134:1119-1124.
  17. Racioppi F, Daskaleros PA, Besbelli N, et al. Household bleaches based on sodium hypochlorite: review of acute toxicology and poison control center experience. Food Chem Toxicol. 1994;32:845-861.
  18. Shazly TA. Ocular acid burn due to 20% concentrated salicylic acid. Cutan Ocul Toxicol. 2011;30:84-86.
  19. Speaker MG, Menikoff JA. Prophylaxis of endophthalmitis with topical povidone-iodine. Ophthalmology. 1991;98:1769-1775.
  20. Apt L, Isenberg S, Yoshimori R, et al. Chemical preparation of the eye in ophthalmic surgery: III. effect of povidone-iodine on the conjunctiva. Arch Ophthalmol. 1984;102:728-729.
  21. Stroman DW, Mintun K, Epstein AB, et al. Reduction in bacterial load using hypochlorous acid hygiene solution on ocular skin. Clin Ophthalmol. 2017;11:707-714.
  22. Paul M, Sieving A. Facts about the cornea and corneal disease. National Eye Institute, National Institutes of Health website. https://nei.nih.gov/health/cornealdisease. Accessed May 20, 2019.
  23. Khaw P, Shah P, Elkington A. Injury to the eye. BMJ. 2004;328:36-38.
  24. Duffy B. Managing chemical eye injuries: Bernice Duffy says initial management of potentially devastating chemical eye injuries by emergency nurses can affect patients’ future prognosis as much as subsequent ophthalmic treatment. Emerg Nurse. 2008;16:25-30.
  25. Burns F, Paterson C. Prompt irrigation of chemical eye injuries may avert severe damage. Occup Health Saf. 1989;58:33-36.
  26. Ikeda N, Hayasaka S, Hayasaka Y, et al. Alkali burns of the eye: effect of immediate copious irrigation with tap water on their severity. Ophthalmologica. 2006;220:225-228.
  27. Eslani M, Baradaran-Rafii A, Movahedan A, et al. The ocular surface chemical burns. J Ophthalmol. 2014;2014:196827.
  28. Pokhrel PK, Loftus SA. Ocular emergencies. Am Fam Physician. 2007;76:829-836.
  29. Drysol. MSDS No. BLVCL; Glendale, CA: Person & Covey Inc; March 9, 1991. http://msdsreport.com/msds/blvcl. Accessed May 20, 2019.
  30. Grant WM, Schuman JS. Toxicology of the Eye: Effects on the Eyes and Visual System From Chemicals, Drugs, Metals and Minerals, Plants, Toxins and Venoms: Also Systemic Side Effects From Eye Medications. Vol 1. Springfield, IL: Charles C. Thomas Publisher; 1993.
  31. Wong W, Sivak JG, Moran KL. Optical response of the cultured bovine lens; testing opaque or partially transparent semi-solid/solid common consumer hygiene products. Toxicol In Vitro. 2003;17:785-790.
  32. Donahue DA, Kaufman LE, Avalos J, et al. Survey of ocular irritation predictive capacity using chorioallantoic membrane vascular assay (CAMVA) and bovine corneal opacity and permeability (BCOP) test historical data for 319 personal care products over fourteen years. Toxicol In Vitro. 2011;25:563-572.
  33. Groot AC, Nater JP, Lender R, et al. Adverse effects of cosmetics and toiletries: a retrospective study in the general population. Int J Cosmet Sci. 1987;9:255-259.
  34. Stevens S. Ophthalmic practice. Community Eye Health. 2005;18:109-110.
  35. Hoyt KS, Haley RJ. Innovations in advanced practice: assessment and management of eye emergencies. Adv Emerg Nurs J. 2005;27:101-117.
  36. LaDou J, Harrison RJ, eds. CURRENT Diagnosis & Treatment: Occupational & Environmental Medicine. 5th ed. New York, NY: McGraw-Hill Education; 2013.
  37. Roper-Hall M. Thermal and chemical burns. Trans Ophthalmol Soc U K. 1965;85:631-653.
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Ocular Chemical Burns in the Dermatology Office: A Practical Approach to Managing Safety Precautions
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Practice Points

  • Dermatologists should be cognizant of potential hazards to the eyes during facial procedures and always take proper precautions to decrease the risk for ocular injuries.
  • If a patient’s eye(s) becomes exposed to a chemical during a dermatologic procedure, immediate copious irrigation for at least 15 to 30 minutes (longer for alkaline burns) is crucial, followed by prompt evaluation by an ophthalmologist.
  • The patient should be instructed to manually hold open the eye and move the eyeball in all directions to achieve the most effective irrigation of the chemical.
  • If the patient is wearing contact lenses, they should be removed promptly, but do not delay the irrigation to do so. Lenses should be removed once irrigation is underway.
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