Article

TREATMENT PLAN

FEEL THE BURN

As I write this column, the 4th of July is just around the corner. As the holiday approaches, I have been seeing the multiple warnings regarding the fire hazard of fireworks, especially given the drought that my area is currently under. By the time this is published, the 4th of July will be a faint memory. However, while the use of fireworks peaks during the summer holiday, they are used during other periods throughout the year as well.

While entertaining, fireworks also represent a great hazard to ocular health, especially among our children and young adults when unsupervised. This represents a preventable cause of ocular trauma. According to the Consumer Product Safety Commission (CPSC), there were 12,900 firework-related injuries in 2017, nearly two-thirds of which necessitated an emergency room visit. (CPSC, 2018). The eye and ocular adnexa accounted for the third most common area injured at 14%. And, in a recent report from a Level I trauma center in the United States, the most common ocular injuries were corneal abrasions (67%), hyphemas (42%), eyelid injuries (39%), and ruptured globes (17%) (Chang et al, 2016).

Corneal abrasions can also be accompanied by thermal injuries to the cornea. One popular firework device is sparklers, which burn at temperatures between 1,800º and 3,000º Fahrenheit.

Radiant energy burns can be the result of either thermal or ultraviolet exposure, both of which have a greater prognosis compared to chemical injury burns. But even though they have a better prognosis, these injuries still represent emergencies that should be treated and managed in an expedited fashion.

Evaluation

Evaluation of the periocular structures is important to assess damage to the eyelids and periocular skin. Any loss of lashes or eyebrow could indicate either a partial- or a full-thickness burn (Malhotra et al, 2009). Eyelid burns may create deformities that could cause lagophthalmos and entropion and could eventually lead to exposure keratopathy.

A classification system commonly used for the skin divides the severity of the burns into five categories depending on the depth of the tissue involved. Severe burns of the periocular area and, likely, the ocular surface will necessitate emergency intervention. Ocular surface burns can also be assessed using the Roper-Hall classification system (Roper-Hall, 1965) or the more recent system developed by Dua et al (2001). Both grading systems assess the level of involvement of the cornea and conjunctiva, especially the limbal region.

Treatment

Prompt treatment and management are important to aid the healing of the ocular surface and periocular structures. First aid management of the eyelid would include cleansing, removal of debris with irrigation and a sterile swab, and surface protection of the skin and ocular surface to include lubrication within the first 24 hours.

If patients are unable to close their eyelid, they may require a suture tarsorrhaphy to protect the ocular surface. Additionally, singed lashes should be removed or cut to prevent spillage onto the ocular surface. Depending on the extent of the eyelid and periocular injury, an oculoplastic or plastic surgeon consult may be warranted.

Corneal burns from ultraviolet exposure will typically appear as a punctate keratopathy and can be managed with topical lubrication and possibly a topical antibiotic, depending on the depth of the insult. Pain management can include ibuprofen and/or acetaminophen. The same treatment would be necessary for thermal burns from other sources.

It may also be necessary to remove necrotic corneal tissue to ensure clean healthy borders to allow for epithelial healing. Amniotic membrane placement may also be warranted, depending on the size of the corneal burn and the involvement of the limbus. Bandage soft contact lenses or scleral lenses can be a useful adjunct to aid in the healing of the corneal surface. CLS

For references, please visit www.clspectrum.com/references and click on document #274.