Ocular injuries from fireworks: the 11-year experience of a US level I trauma center.

PurposeCharacterize ocular trauma and visual outcomes from firework injuries at a level I trauma center.MethodsRetrospective review of all firework injuries at Harborview Medical Center between 2003 and 2013.ResultsThree hundred and twenty-seven patients sustained firework injuries, of which 100 (31%) sustained ocular injuries. The average age of all patients who sustained fireworks injuries was 24.2 years, 89% were male and 54% of injuries occurred within 48 h of 4 July. Ocular injuries were most commonly caused by mortars (24%) and rockets (22%). Rockets were associated with four times the frequency of ocular injuries as compared with non-ocular injuries (P<0.001). Spectators were more likely to sustain ocular injuries than non-ocular injuries (P=0.001). The most common injuries sustained were corneal abrasions (67%), hyphemas (42%), eyelid injuries (39%), and ruptured globes (17%). Twenty-eight percent of patients with ocular injuries required surgical intervention. Ruptured globes occurred in 17% of patients, with the majority being complex corneoscleral lacerations. Fifty-eight percent of patients who sustained ruptured globes were left with no light perception in the affected eye. Average follow-up was 188 days. Average visual acuity significantly improved from logMAR 1.8±1.6 at presentation to logMAR 1.3±1.8 at last follow-up.ConclusionsFirework-related ocular trauma frequently results in vision-threatening pathology. Prompt referral to and treatment by ophthalmologists is critical. This study documents the dangers inherent in the personal use of fireworks and provides data that may help guide public policy to decrease the frequency of these devastating injuries.

Crash and Burn: Ocular Injuries due to Fireworks.

PURPOSE: To identify the patterns of ocular injury and to determine ocular morbidity resulting from the use of firecrackers. METHODS: A prospective observational study of all patients presenting with ocular trauma consequent to fireworks usage in a tertiary eye care center in South India over a one-month period around the autumn festival of Diwali. We also reviewed the published literature from around the world reporting ocular injuries due to firecrackers. RESULT: 49 patients were included in the study, out of which the vast majority (40/81%) were males. The mean age was 17 years. Almost an equal number of bystanders (24/48.9%) was affected as compared to people handling the fireworks (25/51%). 13 (26.53%) patients had open-globe injury whereas 33 (67.34%) patients had closed-globe injury. Twenty-two (44.8%) patients underwent surgical intervention. Eighteen (36.7%) patients had final vision less then 20/40 (range = 20/50 to No Perception of Light) with eight patients having no perception of light in the affected eye. CONCLUSION: Unregulated use of firecrackers can lead to significant ocular morbidity, mainly involving children, young males, and even innocent bystanders. A combination of public awareness and appropriate legislative laws should be formulated regarding the use of fireworks to decrease the load of needless blindness on society.

Topical autologous platelet-rich plasma eyedrops for acute corneal chemical injury.

PURPOSE: Evaluation of efficacy of autologous platelet-rich plasma eyedrops as an adjunct to standard medical treatment as compared with standard medical treatment with artificial tears in acute ocular chemical injury. METHODS: Twenty eyes with grade III to grade V chemical injury were randomly assigned to 2 groups. Group I (10 eyes) received autologous platelet-rich plasma eyedrops along with standard medical treatment, and group II (10 eyes) received standard medical treatment alone. Follow-up was on days 3, 7, 14, 21, 30, 60, and 90. Chi-square test for categorical variables and Mann-Whitney test for quantitative variables were applied for statistical analysis. RESULTS: The mean time between exposure and presentation was 2.15 ± 0.93 days (group I, 2.2 ± 0.73 days; group II, 2.1 ± 0.98 days; P = 0.81). Complete epithelialization was achieved in all the eyes. The mean ± SD and median (range) time to complete epithelialization were 40 ± 31.57 days and 25.5 (7-90) days in group I and 47 ± 26.15 days and 30.0 (21-90) days in group II (P = 0.29). For grade III injuries, mean ± SD and median (range) time to complete epithelialization were 14 ± 7 days and 14 (7-21) days in group I and 28.5 ± 3.67 days and 28.5 (21-30) days in group II (P = 0.006) [Wilcoxon rank sum (Mann-Whitney) test]. At 3 months, corneal clarity showed significant improvement in grade I compared with grade II (P = 0.048). Similarly, the percentage improvement in best-corrected visual acuity was 63.64 ± 55.75 and 37.74 ± 9.66 for grades I and II, respectively (P = 0.082). CONCLUSIONS: Topical autologous platelet-rich plasma therapy is safe and effective, and it promotes rapid reepithelialization of ocular surface and can be administered along with standard medical therapy.

Glaucoma in patients with ocular chemical burns.

PURPOSE: To examine the development and management of glaucoma in patients with ocular chemical burns. DESIGN: Retrospective, observational case series. METHODS: setting: University of Washington Eye Clinics. patient population: Twenty-nine eyes (18 patients) with ocular chemical burns seen between 1997 and 2010 with a minimum of 3 months of follow-up. observation procedure: Eyes were graded using the Roper-Hall scale. main outcome measures: Long-term use of glaucoma medications (3 months or more) and need for glaucoma surgery. RESULTS: The mean age was 45 ± 17 years, with a mean follow-up of 75 ± 47 months (median, 66 months). Roper-Hall grade III or IV eyes (n = 20) had significantly higher intraocular pressure at presentation (35.9 vs 16.4 mm Hg; P = .001) and over follow-up were more likely to require long-term glaucoma medications (P = .003) or to undergo glaucoma surgery (P = .016) than Roper-Hall grade I or II eyes. Thirteen eyes (12 Roper-Hall grade III or IV) underwent glaucoma surgery. Eight eyes underwent glaucoma tube implant surgery; 4 required at least 1 revision. Seven eyes underwent diode laser cyclophotocoagulation; 4 required repeat treatment. Most (89%) eyes had controlled intraocular pressure at the last follow-up. However, 76% of eyes with visual acuity of 20/200 or worse at initial evaluation did not have improved vision at the last follow-up. CONCLUSIONS: Eyes with Roper-Hall grade III or IV ocular chemical burns were more likely to have glaucoma and to require surgery for it. Outcomes of glaucoma management generally were good, although tube implant surgeries often had complications requiring revision.

Comparison of prognostic value of Roper Hall and Dua classification systems in acute ocular burns.

AIM: To compare the predictive outcome of ocular burns using two different prognostic classification systems, that is, Dua and Roper Hall classification. PATIENTS AND METHODS: In a prospective, randomised, controlled clinical trial, the extent of acute ocular burns in 100 patients was graded by Roper Hall and Dua classifications. Patients were randomised in two groups of 50 each to receive conventional medical therapy alone or additional amniotic membrane transplantation (AMT). Moderate burns were graded similarly (grade II and III) under both systems, while severe burns were classified differently and compared further. Baseline parameters (size of epithelial defect, corneal haze, limbal ischaemia, conjunctival involvement and visual acuity) and outcome variables (healing of epithelial defect, corneal clarity, corneal vascularisation, visual outcome and symblepharon) after 1 year were noted and compared. RESULTS: There was no difference in terms of time taken and rate of healing of epithelial defect, but there was a significant difference in extent of corneal vascularisation between grades IV, V and VI (p<0.05). In patients who received AMT in addition to medical therapy, the degree of corneal clarity achieved was significantly better in patients with grade IV burns than either grade V (p=0.045) or grade VI (p=0.024) burns, and final visual acuity was significantly better in these patients (p=0.043). On comparison of patients with grade IV burns (with and without AMT), the outcome in terms of extent of corneal vascularisation was significantly better (p=0.0124) in patients who received AMT. CONCLUSIONS: Dua classification by providing further subclassification of grade IV ocular burns by Roper Hall into three separate grades has a superior prognostic predictive value in severe ocular burns.

Subconjunctival application of regenerative factor-rich plasma for the treatment of ocular alkali burns.

PURPOSE: To study the efficiency of the subconjunctival application of autologous regenerative factor-rich plasma (RFRP) in patients with different degrees of ocular alkali burns. METHODS: Thirty-five eyes of 35 patients with ocular alkali burns were analyzed. They were classified into moderate and relevance groups according to the severity of the burn. A control group was established for each with conventional topical medical treatment; subconjunctival regenerative factor rich plasma (RFRP) was applied to the other groups. A further group was added to the severe chemical burn group, which received autohemotherapy. The clinical evolution of the lesions and the period in which the pathology prevented the patient from working were studied; monitoring was carried out until the patient had healed. RESULTS: In the moderate chemical burns, there was a significant reduction in corneal and conjunctival epithelization times, sick leave duration, and healing time when the patients were treated with RFRP in comparison to the control group. With regard to the severe burns, significant reduction in time to corneal scarring in those treated with RFRP in comparison to traditional treatment was reported. RFRP showed, at least as effective and less side effects than the autohemotherapy. CONCLUSIONS: Subconjunctival infiltration with autologous RFRP can be considered an effective, straightforward, and economical form of treatment for burns of the ocular surface.

[Ocular burns]. / Brûlures oculaires.

Ocular or thermal burns account for 7.7%-18% of ocular trauma. The majority of victims are young. The burns occur in the setting of accidents at work or in the home, or during a physical attack. Chemical burns by strong acids or bases are responsible for the most serious injuries. Associated with the destruction of limbal stem cells, they present as recurrent epithelial ulcerations, chronic stromal ulcers, deep stromal revascularization, conjunctival overlap, or even corneal perforation. The initial clinical exam is sometimes difficult to perform in the presence of burning symptoms. Nevertheless, it enables the physician to classify the injury, establish a prognosis, and most importantly, guide the therapeutic management. The Roper-Hall modification of the Hughes classification system is the most widely utilized, broken down into stages based on the size of the stromal opacity and the extent of possible limbal ischemia. This classification is now favorably supplemented by those proposed by Dua and Wagoner, which are based on the extent of the limbal stem cell deficiency. The prognosis of the more serious forms of ocular burns has markedly improved over the last decade because of a better understanding of the physiology of the corneal epithelium. Surgical techniques aimed at restoring the destroyed limbal stem cells have altered the prognosis of severe corneal burns. In order to decrease the incidence of burns, prevention, particularly in industry, is essential.

Evaluation of therapeutic deep anterior lamellar keratoplasty in acute ocular chemical burns.

PURPOSE: To evaluate the role of deep anterior lamellar keratoplasty (DALK) in acute ocular chemical burns. METHODS: The study was conducted in 50 eyes of 50 patients (24 male, 26 female) with average age of 38.3+/-14.3 years. DALK in 5 eyes (10%), DALK with quadrant conjunctivo-limbal graft in 25 eyes (50%), and DALK with amniotic membrane in 20 eyes (40%) were performed along with conventional medical therapy. Controls who were matched in all respects (50 eyes) were given medical therapy only as they refused surgical intervention. RESULTS: Follow-up of cases ranged from 6 to 48 months (mean 21.5+/-14.18 months). Forty-three eyes (86%) could be restored with clear cornea as compared to 6% in control group. The visual acuity improvement was seen in 100% with good score (0.49+/-1.46) in DALK group as compared to 18% with low score (0.03+/-0.01) in control group (p<0.0001). Visual acuity improvement in DALK was 6/12 in 19 eyes (38%), 6/24 in 28 eyes (56%), and 6/36 in 3 eyes (6%) but was 3/60-6/60 in 6 eyes (12%) and finger counting only in 3 eyes (6%) in control group. Eyes with advanced grade II and grade III showed better improvement than those with burns of grade IV (p<0.05). The discomfort was relieved and epithelial healing was achieved immediately in DALK as compared to a prolonged course in control group (p<0.0001). Vascularization presented in 38% in DALK with least score (0.13+0.15) as compared to 100% in control group with high score (2.8+/-0.30). Perforation of cornea was seen only in 2 cases (4%) in DALK with low score (0.03+/-0.10) as compared to 88% in control group (1.33+/-0.20). Symblepharon was seen in 2% in DALK group as compared to 62% in control group. CONCLUSIONS: DALK with and without conjunctival or amniotic membrane transplantation is an effective technique in restoring the integrity of the eye with an excellent graft transparency in 86% and improvement in visual acuity in 100% of the acute chemical burns.

Chemical, thermal, and biological ocular exposures.

Chemical or radiant energy injuries to the eyes are considered ocular burns. The majority of these injuries are occupation-related. Chemical burns are by far more common and represent a true emergency. Thermal and UV injuries are associated with severe pain, but often result in less long-term sequelae than chemical injuries do. The term "biologic exposure" refers to an exposure to human blood or other body fluid. This article describes patterns of these injuries and exposures, with particular emphasis on emergent management and including acute diagnostic and treatment considerations.

Histopathologic limbus evolution after alkaline burns.

PURPOSE: To study the histopathologic evolution of the corneal limbus after alkaline burns according to the clinical severity and therapy used. METHODS: A prospective study of 15 eyes from 12 patients (9 men and 3 women) with moderate and severe alkaline burns was performed. All patients were divided into 2 groups in accordance with the clinical ocular severity and the therapy that was used: medical therapy, amniotic membrane transplantation (AMT), autologous limbal transplantation (ALT), and ALT combined with AMT (ALT + AMT). Biopsies were obtained from affected limbal areas immediately after the ocular burn and 9 months later. RESULTS: Limbal regeneration was limited to small areas in patients with moderate burns treated with medical therapy; in contrast, the limbal structure showed significant stromal and epithelial regeneration in patients with moderate burns treated with AMT. There was an important stromal regeneration with an incomplete reepithelialization in patients with severe burns treated with AMT. Patients treated with ALT showed a good reepithelialization with a defective stromal regeneration. Epithelial and stromal regeneration was notable in patients with severe burns treated with ALT + AMT. CONCLUSIONS: In patients with moderate alkaline burns, AMT improved both limbal stromal and epithelial regeneration more effectively than medical therapy. In patients with severe burns, the best reepithelialization and stromal regeneration were obtained with ALT + AMT.

Severe ocular injury resulting from chuna packets.

OBJECTIVE: To describe a mechanism of severe ocular alkali burns occurring as a result of bursting of chuna packets (edible calcium hydroxide paste), a popular additive to chewing tobacco in India. DESIGN: Retrospective case series. PARTICIPANTS: Twenty-one patients (25 eyes) who experienced ocular burns as a result of bursting of chuna packets. INTERVENTION: Patients were treated medically or with 1 or more of the following surgeries: symblepharon release, amniotic membrane grafting, allograft or autograft stem cell transplantation, or both, and large diameter lamellar keratoplasty. MAIN OUTCOME MEASURES: The main outcome measures were time interval between the injury and presentation, presenting visual acuity, grade of injury, management (medical therapy or surgical intervention), and final visual outcome at the last follow-up. RESULTS: The average age at time of injury was 8.4+/-5.5 years. The median visual acuity at presentation was light perception with projection. The ocular burns were grade 4 in 23 eyes. Eight of 25 eyes were treated medically, and the rest underwent 1 or more surgeries in the form of symblepharon release (n = 6), amniotic membrane grafting (n = 3), allograft or autograft stem cell transplantation (n = 6), and large diameter lamellar keratoplasty (n = 6). At the final follow-up (mean, 637+/-592 days), median visual acuity was 1/60. CONCLUSIONS: Bursting of chuna packets can cause severe ocular alkali burns in children. These patients carry a poor visual prognosis with both medical and surgical therapy.

[Acute therapy for eye burns]. / Akuttherapie von Augenverätzungen.

BACKGROUND: Eye rinsing is the major therapeutic measure with a decisive impact on prognosis after chemical or thermal eye irritation. Several different major targets are addressed by this measure. AIM OF THE STUDY: Up to now emphasis in research was placed mostly on the neutralisation of chemical products. Newer experimental results on the basis of biological experiments interpreted against the background of basic chemical reactions may enhance clinical treatment by introducing new mechanisms of intervention. MATERIALS AND METHODS: Experiments on the modification of osmolarity, buffering capacity and solubility products show new possibilities of therapy in eye rinsing after eye irritation. These mechanisms are demonstrated by means of key experiments. RESULTS: The official recommendation of rinsing a burnt eye with water seems to be insufficient against the background of actual experimental data. Measurements of pH after eye burns indicate no buffering effects for water, or aqueous saline solution. There was weak buffering for phosphate buffer in alkali burns and a high capacity for neutralisation for diphoterine in alkali and acid burns. Ionic contents and osmolarities of the rinsing solutions have a decisive influence on the ionic composition and osmolarity of the burnt cornea after rinsing. Cellular damage is enhanced in unaffected healthy cell cultures by hyposomolar rinsing. CONCLUSION: We recommend buffered solutions with high buffer capacities for initial eye rinsing. The advantage or disadvantage of the elevated concentration of ions in the buffered rinsing solutions determining osmolarity cannot be confirmed or refuted up to now. It seems to us to be certain that osmolarity is a decisive future factor in initial rinsing.

[Surgical strategy in the treatment of severe and extremely severe eye burns. 2]. / K khirurgicheskoi taktike lecheniia tiazheloi i osobo tiazheloi ozhogovoi travmy glaz (soobshchenie 2).

The author presents the results of using his own surgical strategy in multiple-modality treatment of 76 patients with severe and extremely severe burns of the eyes. He proves that active surgical strategy during the early period of burn process notably decreased the incidence of complications, preserved the eyeball for further reconstructive operations, and thus improved the functional outcomes of severe burns of the eyes.

Ophthalmologic sequelae of thermal burns over ten years at the Alfred Hospital.

PURPOSE: To study the ocular outcomes of facial burns over a 10-year period at the Alfred Hospital; in particular, to investigate the impact of 3 variables (grading of burn, use of prophylactic ocular surface lubrication, and timing of ophthalmologic referral) on the requirements for eyelid surgery. METHODS: A retrospective review of patients admitted to the Alfred Hospital (from October 1990 to October 2000) after thermal burns with facial, eyelid, and ocular involvement. RESULTS: Sixty-six patients were identified with facial burns involving the lids or eyes, having been admitted over a 10-year period. Of these 66, 7 died of complications of the burns and 12 required eye or eyelid surgery. Of those patients treated with prophylactic ocular surface lubrication, the rate of ocular surgery was 18.4% as opposed to 30% when no prophylaxis was used. The higher the percentage of total burn, the later the referral was made. Of those with severe eyelid burns, 100% had eyelid surgery and 50% of moderate burns had eyelid surgery. Sixty percent of moderate eyelid burns that required surgery did not receive prophylaxis. Thirty-four of 66 patients had acute corneal involvement, but only 3 eyes of 118 had long-term corneal morbidity. CONCLUSIONS: The requirement for eyelid surgery was closely related to the severity of the eyelid burn. The presence of an acute corneal burn with epithelial loss was not a poor prognosticator. The use of prophylactic ocular surface lubrication may provide early corneal protection, thereby minimizing ulceration in patients who may otherwise have required surgery, especially in those with mild to moderate exposure. Prompt ophthalmologic examination and the early use of prophylactic ocular surface lubrication for the cornea are associated with less need for eyelid surgery in patients with moderate eyelid burns.

Biocompatibility of electrochemically activated aqueous solutions: an animal study.

The purpose of the study was to evaluate the biocompatibility of electrochemically activated aqueous solutions on experimental animals. Nine rabbits were subjected to acute eye irritation/corrosion tests, nine rabbits to acute dermal irritation/corrosion and 30 rats to acute oral toxicity (LD50) tests. No significant negative effects were noted. Considering the relatively high levels of exposure of the animals to the solutions and the low levels in the anticipated real clinical situation it is argued that these solutions are indeed biocompatible.

Management of alkali burns : an 11-year retrospective review.

OBJECTIVE: To review the spectrum of patients with alkali burns admitted over an 11-year period and to assess the clinical outcomes after the introduction of a standard alkali burn treatment protocol. DESIGN: Retrospective nonrandomized comparative study. PATIENTS AND INTERVENTIONS: A total of 121 patient records with alkali burns (n = 177 eyes) admitted to a tertiary hospital between 1987 and 1998 were reviewed. Eyes treated with a standard alkali burn treatment protocol, which included intensive topical steroids, ascorbate, citrate, and antibiotics, were compared with eyes treated by conservative management with antibiotics, and a short course of steroids. MAIN OUTCOME MEASURES: Time to corneal reepithelialization, final best-corrected visual acuity, and time to visual recovery, length of hospital stay, and complications were analyzed. RESULTS: The standard protocol tended to delay corneal reepithelialization by one day (P: = not significant) in eyes with grade 1 burns (n = 76) and by 2 days (P: = 0.04) in grade 2 burns (n = 52), with no difference in final visual outcome. There were 37 eyes with grade 3 burns. Those treated with the standard protocol showed a trend toward more rapid corneal reepithelialization. Twenty-seven of 29 (93%) eyes with grade 3 injuries achieved a final best-corrected visual acuity of 20/40 or better compared with 3 of 6 (50%) eyes not treated according to the standard protocol (P: = 0.02). Eyes with grade 4 burns (n = 12), whether treated with the standard protocol or not, required 10 to 12 weeks for corneal reepithelialization. There was no statistically significant difference in final visual acuity. CONCLUSIONS: On the basis of our findings, a number of recommendations can be made for the management of alkali injuries. Patients with a grade 1 or 2 injury do not require routine admission and do not benefit from the use of intensive treatment with ascorbate and citrate. A trend toward more rapid healing and a better final visual outcome were apparent in grade 3 burns, but our standard protocol made no difference in grade 4 burns.

Amniotic membrane transplantation for acute chemical or thermal burns.

PURPOSE: To determine whether preserved human amniotic membrane (AM) can be used to treat ocular burns in the acute stage. DESIGN: Prospective, noncomparative, interventional case series. PARTICIPANTS: Thirteen eyes from 11 patients with acute burns, 10 eyes with chemical burns and 3 with thermal burns of grades II-III (7 eyes) and grade IV (6 eyes), treated at 7 different facilities. METHODS: Patients received amniotic membrane transplantation (AMT) within 2 weeks after the injury. MAIN OUTCOME MEASURES: Integrity of ocular surface epithelium and visual acuity during 9 months of follow-up. RESULTS: Ten patients were male and one patient was female; most were young (38.2 +/- 10.6 years). For a follow-up of 8.8 + 4.7 months, 11 of 13 eyes (84.63%) showed epithelialization within 2 to 5 weeks (23.7 +/- 9.8 days), and final visual acuity improved > or = 6 lines (6 eyes), 4 to 5 lines (2 eyes), and 1 to 3 lines (2 eyes); only one eye experienced a symblepharon. Eyes with burns of grade II to III showed more visual improvement (7.3 +/- 3 lines) than those with burns of grade IV (2.3 +/- 3.0 lines; P < 0.05, unpaired t test). In the group with grade II or III burns, none had limbal stem cell deficiency. All eyes in the group with grade IV burns did experience limbal stem cell deficiency. CONCLUSIONS: Amniotic membrane transplantation is effective in promoting re-epithelialization and reducing inflammation, thus preventing scarring sequelae in the late stage. In mild to moderate burns, AMT alone rapidly restores both corneal and conjunctival surfaces. In severe burns, however, it restores the conjunctival ocular surface without debilitating symblepharon and reduces limbal stromal inflammation, but does not prevent limbal stem cell deficiency, which requires further limbal stem cell transplantation. These results underscore the importance of immediate intervention in the acute stage of eyes with severely damaged ocular surface. Further prospective randomized studies including a control group are required to determine the effectiveness of AMT in acute chemical and thermal burns of the eye.