Adapted from Hamill et al.3
Al-Moujahed A, Chodosh J. Outcomes of an Algorithmic Approach to Treating Mild Ocular Alkali Burns. JAMA Ophthalmol. 2015;133(10):1214-1216. doi:10.1001/jamaophthalmol.2015.2302
Ocular alkali burns can cause corneal blindness. They typically occur in young males in accidents or assaults, and the most common agents include lye, ammonia, magnesium hydroxide, potassium hydroxide, and lime.1 Treatment indicated at the time of injury is irrigation to return the pH to normal,2 but the optimal care following pH normalization is less well defined and, to our knowledge, has not been studied in clinical trials. In 2013, we proposed a clinical algorithm for treatment of acute ocular alkali burns to standardize their treatment, specifically defining the use of topical corticosteroids, oral vitamin C, oral doxycycline, bandage contact lenses, and amniotic membrane (Figure).3 We now describe our initial results with this algorithm at the Massachusetts Eye and Ear Infirmary Emergency Department and show that the algorithm sped the time to restoration of best-corrected visual acuity following mild ocular alkali injuries.
On approval of the Human Studies Committee of the Massachusetts Eye and Ear Infirmary, we reviewed the electronic medical records of patients who presented to the Massachusetts Eye and Ear Infirmary Emergency Department within 2 years prior to and 1 year after institution of the algorithm (June 1, 2013). Informed consent was not required owing to the retrospective nature of the study. We included patients burned with a known alkali agent or, if the agent was unknown, those with an ocular surface pH greater than or equal to 7.4 at presentation or documented in the medical record from an outside emergency department. Cases were categorized a priori in 2 ways: (1) best-corrected visual acuity at final visit worse than 20/30, vs equal to or better than 20/30; and (2) time to best-corrected visual acuity of more than 2 weeks, vs equal to or less than 2 weeks. To avoid mixing paired data (2 eyes from the same patient) with unpaired data, the initially worse eye in bilaterally injured patients was chosen for analysis by the 2-tailed Fisher exact test.
Our sample included 28 patients (35 eyes) and 15 patients (17 eyes) who matched the inclusion criteria during the 2 years prior to and 1 year after institution of the guideline, respectively. Patient demographic characteristics are summarized in the Table. All patients reported normal vision prior to injury. Not all burns prior to institution of the management protocol were graded by the examining physician, but all patients included after the protocol was instituted had grade 1 burns by Roper-Hall criteria.4 All patients before and after institution of the guideline had their eyes irrigated immediately and were seen at our facility within several hours of injury. Treating alkali-burned eyes with the guideline showed an increased proportion of patients whose visual acuity recovered to 20/30 or better (relative risk = 0.54; 95% CI, 0.17-1.67; P = .29). Management with the new guideline was associated with a greater proportion of patients whose visual acuity recovered to 20/30 or better within 2 weeks or less (relative risk = 0.42; 95% CI, 0.20-0.87; P = .005). Assuming patients lost to follow-up did not have visual acuity recovery to 20/30 or better within 2 weeks of injury gave a relative risk of 0.45 (95% CI, 0.24-0.84; P = .001).
Optimal treatment of ocular alkali burns in the emergency setting is critical to reduce visual morbidity. Various interventions have been shown in animal models and in limited human case series to play a potential role in treatment.3 However, given the lack of level 1 evidence for any intervention, evidence-based guidelines for treatment of ocular alkali burns are lacking. Despite the weaknesses and limitations of our small retrospective study, the results suggest that application of an evidence-based clinical algorithm in the acute phase of injury can improve outcomes in mild alkali burns, potentially reducing injury-related costs and recovery time. A prospective randomized clinical trial is needed to properly evaluate the benefits of any treatment protocol.
Corresponding Author: James Chodosh, MD, MPH, Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, 243 Charles St, Boston, MA 02114 (firstname.lastname@example.org).
Published Online: July 30, 2015. doi:10.1001/jamaophthalmol.2015.2302.
Author Contributions: Dr Chodosh had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Al-Moujahed, Chodosh.
Acquisition, analysis, or interpretation of data: Al-Moujahed, Chodosh.
Drafting of the manuscript: Al-Moujahed, Chodosh.
Critical revision of the manuscript for important intellectual content: Al-Moujahed, Chodosh.
Statistical analysis: Al-Moujahed, Chodosh.
Administrative, technical, or material support: Chodosh.
Study supervision: Chodosh.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Funding/Support: This study was supported by an unrestricted grant to the Department of Ophthalmology, Harvard Medical School from Research to Prevent Blindness.
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.