A new classification of ocular surface burns Table 1 Classification of severity of ocular surface burns by Roper-Hall2 Grade Prognosis Cornea

I II III IV Conjunctiva/limbus No Good Corneal epithelial damage limbalischaemia <1/3 Good Corneal haze, iris details visible limbalischaemia Total epithelial loss, stromal 1/3 Guarded haze, iris details obscured limbalischaemia Cornea opaque, iris and pupil > Poor obscured limbalischaemia

A new classification of ocular surface burns

Table 2 New classification of ocular surface burns Grade Prognosis Clinical findings I II III IV V VI Very good 0 clock hours of limbal involvement 3 clock hours of Good limbal involvement >36 clock hours of Good limbal involvement Good to >69 clock hours of guarded limbal involvement Conjunctival involvement 0% 30% >3050% >5075% Analogue scale 0/0% 0.13/1 29.9% 3.16/31 50% 6.19/51 75% 9.1 11.9/75.1 99.9%

Guarded >9<12 clock hours of >75<100% to poor limbal involvement Very poor

Total limbus (12 clock Total conjunctiva 12/100% hours) involved (100%) involved

The analogue scale records accurately the limbal involvement in clock hours of affected limbus/percentage of conjunctival involvement. While calculating percentage of conjunctival involvement, only involvement of bulbar conjunctiva, up to and including the conjunctivalfornices is considered.

Table 2: Burn depth and outcome Second degree Superficial Mid-dermal Cause< Hot liquid, short exposure Hot liquid, longer Appearance Wet, pink, blisters Less wet, Pain severe moderate Healing 10-14 days 2-4 Scar minimal moderate

moderate moderate exposure, flash flame red blisters weeks Red with Indeterminate 2-6 moderate or As above patchy, moderate (mid or deep) weeks severe white arms Chemicals, direct 3-8 severe Deep-dermal Dry, white minimal contact flames weeks (needs graft) Indeterminate Chemicals, flames Dry, white none (2nd or 3rd) mild to Third degree Chemicals, flames, severe, Dry, white, need (full explosion, with very none depending or char graft thickness) high temperature on timing and type of graft

Mid-dermal

References www.medskills.eu

The first 7 days after chemical eye injury constitute the acute phase of recovery. During this time, the tissues rid themselves of contaminants while reestablishing the superficial protective layer of the corneal epithelium. Reepithelialization is the most crucial factor in ultimate visual recovery; therefore, the firstimportant therapeutic consideration is prompt, unhindered reepithelialisation

The healing period from 8 to 20 days after the injuryconstitutes the early reparative phase. This is thetransition period of ocular healing, in which the immediateregeneration of ocular surface epithelium andacute inflammatory events give way to chronic inflammation, stromal repair, and scarring. The most importanttreatment goal remains the establishment of anintact epithelium. If the corneal epithelium did notfully heal during the acute phase, then the physicianmust aggressively treat the patient to minimize therisk of corneal thinning and perforation.

Three weeks after a chemical injury occurs, the healing process begins the late reparative phase. Application of ocular lubricants and tear substitutes must be continued to ensure a healthy epithelium. Chemical agents can cause loss of corneal sensation, decreasing the blink reflex and reducing the production of tears. Destruction of the associated mucin and lipid-producing cells also leads to an inadequate corneal tear film. Severe injury can lead to pannus formation during this time. Persistent corneal epithelial defects or recurring epithelial breakdown can be surgically managed by tarsorrhaphy.

HUGHESS CLASSIFICATION OF OCULAR CHEMICAL INJURY

Category of Injury Mild Erosion of corneal epithelium

Clinical Finding Faint haziness of cornea Corneal opacity blurs iris detail No ischemic necrosis of conjunctiva or sclera Mild ischemic necrosis of conjunctiva or sclera Blurring of pupillary outline Significant ischemic necrosis of conjunctiva or sclera

Moderately severe

Very severe

Source: Ralph RA. Chemical burns of the eye. In: Duane TD, Jaeger EA, eds. Clinical Ophthalmology.Vol 4. Philadelphia, Pa: Harper & Row; 1987: 4.

THOFTS CLASSIFICATION OF OCULAR CHEMICAL INJURY

Category of Injury Grade I

Clinical Findings Corneal epithelial damage

Prognosis Good No ischemia Good

Grade II

Cornea hazy, but iris detail seen

Ischemia less than 13 of limbus Guarded

Grade III

Total loss of corneal epithelium

Stromal haze blurs iris detail Ischemia of 13 to 12 of limbus Poor Ischemia more than 12 of limbus

Grade IV

Cornea opaque, obscuring view of iris or pupil

Sources: (1) Roper-Hall MJ. Thermal and chemical burns.Trans OphthalmolSoc UK. 1965;85:631. (2) Thoft RA. Chemical and thermal injury. IntOphthalmolClin. 1979;19(2):243256. (3) Parrish CM, Chandler JW. Corneal trauma. In: Kaufman HE, Barron BA, McDonald MB, eds. The Cornea. 2nd ed. Boston, Mass: Butterworth-Heinemann; 1998: 642.