References

1.2.6  Specific Treatment Options

First the recognition of severe ischemia as a result of the eye burn was addressed by emerging vasodilatators like Priscol that was proposed and used by Nagy F. [22] (Ophthalmologica Basel 121, 1951, 345). A systematic eye burn research started with some people related to the Boston Cornea Foundation around persons like Roswell Pfister, Chris Dohlmann, Martin Reim, and Christopher Paterson. They all first focused on different parts of clinical evaluation of eye burns. Roswell Pfister looked for intermediate phase treatment concepts with mediator, metabolic, and histological definitions of the problem. Martin Reim focused on metabolic disorders, new surgical options, and corneal transplantation after eye burns, whereas his friend J. Friend focused on elementary biochemical issues. Mostly coming from biochemistry, Chris Dohlmann found the devastating eye burns worth to develop a keratoprosthesis, which has been implanted from then on up to today. Last but not the least out of this working group was Christopher Paterson who focused on first aid, intraocular pressure, and treatment with vitamin C and citrate together with RR Pfister. Nevertheless, all of those researchers found the chronic inflammation and the treatment options in theoretical and practical approach to be an interesting scientific and clinical topic.

Systematic research in treating started with modification of the synthesis of collagens by high doses of vitamin C introduced by Reim, Pfister, and Paterson and citrate treatment introduced by Pfister. Surgical improvements with Passow’s incisions, and Thiel’s peridectomy and improved plastic lid surgery increased the healing chances. The enthusiasm to control ongoing inflammation in eye burns being introduced by topical and systemic corticosteroids in the 1970s lead to improvements but clinicians were disappointed that severe scars, disabling corneal opacities and severe glaucoma were out of control in severe cases. Improvements of other disciplines in ophthalmology like glaucoma valves, keratoprosthesis, transplantations under immunosuppression, and stem cell transplants were used in parallel to the rise of those new techniques. Today an equilibrated concept of modern first aid with amphoteres, steroids, vitamin c, antibiotic, and defined surgical techniques is the common repertoire of specialists in the field of ocular reconstruction after eye burns. Thus in the last 10 years,

we have not lost one eye from eye burns, which in comparison to the old times is a great success. Surgical techniques now aim to restore sight which we do not achieve in all cases today. Major improvements like the longtime forgotten amnion technique from de Rüther and others in 1990 result in enormous improvement of the therapeutic reservoir of modern ophthalmology.

1.2.7  Future and Present

of Reconstitutive Concepts

Mostly Prof. Sh Tseng with his stem cell concept in transplantation should be mentioned as a protagonist of the “new world” of concepts with adult stem cells opening the door for future concepts reaching in the horizon of today performed stem cell proliferation and seeding provided by Pellegrini et al. The future of stem cell concepts with reformation of individual stem cells by gene therapy or other techniques might solve the severe problems in eye burns in future. Nevertheless, the first gleam of hope for artificial corneas rose with research of reconstituted endothelium from K. Engelmann and M. Böhnke as well as from the group around May Griffith who tried to reconstitute human three-dimensional models.

References

 1. History of the treatment of burns. Burns (Suppl 1), S1–S46 (1988)

 2. Thierry, B.: les papyrus médicaux de l’Égypte pharaonique. Fayard, Paris (1995)

 3. Heister, Institutions de chirurgie, traduit du latin par M Paul, Paris, 1771, livre II, chap. XVI

 4. Dupuytren, G.: Leçons cliniques sur les brûlures. Clinique Par 2, 83–85, 89–90, 138–140 (1830); Coubret, J.-B.: Dissertation sur les brûlures. Paris (1813); Marsal, J.B.A.: Dissertation sur les effects et le traitement de la brulure. Paris (1812); Moulinié, J.: Brûlures. Paris (1812)

 5. Boyer, J., Guinard, L.: Des brûlures causes des troubles fonctionnels et accidents généraux qu’elles déterminent. Etude et recherches expérimentales, Paris (1895)

 6. Lelong, F.: Dissertation sur les brûlures. Paris (1819)

 7. Mainot, P.V.: Essai sur la brûlure. Paris (1830)

 8. Nélaton, A.: Eléments de pathologie chirurgicale, vol I, pp. 285–303. Paris (1844)

 9. Obenaus, C.F.E.: De combustione cutanea eiusque effectu lethifero. Leipzig (1847)

10.Buhl, Mittheilungen aus des Pfeuferschen Klinik, Epidemische Cholera, Ztschr. f. rat. Med. n.F. 6,77

11.Passavant, G.: Bemerkungen über Verbrennungen des menschlichen Körpers und deren Behandlung mit dem permanenten warmen Bade. Deutsche Klinik Berl 10, 365–366, 373–375 (1858)

12.Wilks, S.: On some diseases of children. Guy’s Hosp Rep Lond 3 S 6, 101–148 (1860)

13.Berthelot, M.: les Alchimistes grecs. Paris (1888)

14.http://www.icrc.org/Web/fre/sitefre0.nsf/html/5FZGZT

15.Passow, A.: Early operation performable in ambulant practice in therapy and prevention of corneal lesions and necrosis in burns of the eye. Klin Monatsblatter Augenheilkd Augenarztl Fortbild 127(2), 129–142 (1955). German (No abstract available)

16.Passow, A.: Early operation in chemical and thermal injuries to get rid of the toxic products; experience with eye and skin. Med Klin (Munich) 51(8), 293–297 (1956). German

17.Thiel, H.L.: Treatment of caustic eye burns. Med Monatsschr 12(8), 542–544 (1958). German

18.Thiel, H.L.: Proceedings: The treatment of eye injuries (author’s transl). Langenbecks Arch Chir 334, 429–434 (1973)

19.Laux, U.: The water pic instrument for immediate intensive irrigation of the eye at the place of accident. Zentralbl Arbeitsmed Arbeitsschutz Prophyl 26(10), 215–220 (1976). German

20.Laux, U., Roth, H.W.: Intensive irrigation of the eye in lime burns by means of pulsating water stream (author’s transl). Klin Monatsbl Augenheilkd 165(4), 664–669 (1974). German

21.Laux, U., Roth, H.W., Krey, H., Steinhardt, B.: Aqueous humor pH in experimental lye burns and influence of different treatment measures (author’s transl). Albrecht Von Graefes Arch Klin Exp Ophthalmol 195(1), 33–40 (1975). German

22.Nagy, F.: Priscol therapy of corrosions and burns of the eye. Ophthalmologica 121(6), 345–352 (1951)

2.1  Introduction

Ocular chemical burns are a significant problem [1] because they may destroy the entire corneal epithelium and extend into the fornices [2]. More than 25,000 chemical products – oxidizers, reducing agents, corrosives, etc. – have the potential to cause chemical burns [3]. Because serious eye burns can result in loss of sight or require corneal transplants, such chemical burns must be taken seriously.

2.2  Data Limitations and Scope

of the Problem

No international or national databases were found that specifically collect data on ocular chemical injuries. There are individual publications detailing burns in general or chemical burns (including eye and/or skin burns) in a region or country and case series from burn centers, hospitals, or groups of hospitals. Occupational burn data are usually regional in nature or are case series. National Poison Center databases such as the US American Association of Poison Centers’ National Poison Data System (NPDS) collect data on the annual number of eye exposures, but do not contain specific information

A.H. Hall

TCMTS, Inc., Laramie, WYOMING, USA, and Colorado School of Public Health, Denver, Colorado, USA

e-mail: ahalltoxic@msn.com

regarding the specific chemical substance(s) involved, the type of initial decontamination, the time from exposure to initial decontamination, and clinical outcomes. National occupational exposure databases such as the US Department of Labor Statistics (BLS) also contain only nonspecific data and also do not collect specific information regarding the specific chemical substance(s) involved, the type of initial decontamination, the time from exposure to initial decontamination, and clinical outcomes. Information such as the number of lost work days, number of eye injuries, industry segment, and rates of injury per 10,000 full-time workers from the US BLS data do provide some insights into the scope of the problem.

2.2.1  Individual Publications/Case Series

Josset et al. [4] found that there were approximately 7,000 serious chemical splash injuries in France per year, with about half of these cases involving the eyes [4]. Chemical eye splashes made up about 9.9% of ocular trauma in the USA and 7.2% in a UK casualty department; however, most were with rather innocuous substances such as hairsprays and shampoos [5]. Acid and base eye burns were 1.6% and 0.6%, respectively, of total eye injuries [5].

Ocular burns comprise about 7–18% of ocular trauma presenting to emergency departments in the USA and eye injuries account for about 3–4% of total occupational injuries [6]. Most of these (approximately 84%) are chemical burns. About 15–20% of patients with facial burns also have ocular burns. The ratio of acid/alkali chemical ocular burns is 1:1–1:4 [6].

In a 5-year retrospective study of 383 patients with eye injuries (397 eyes involved) in Croatia, 13.6% sustained chemical injuries [7]. Of the total patients with burned eyes, 54 required hospital admission [7]. A 7-year retrospective study of 60 hospitalized cases of pediatric eye injuries in Hong Kong found that 10% were ocular chemical burns [8].

In a US study of compensable work-related ocular injuries, the incidence of eye burns was 23.4 per 10,000 employees [9]. The majority of these were associated with chemical exposures.

In a retrospective study of 148 cases of occupational eye injuries in Germany, ocular burns (not specified as chemical or other etiology) comprised 15.5% of the total [10]. In another German study of 101 patients with 131 severely burned eyes, 72.3% of the injuries were work-related, 84.2% were chemical injuries, and 79.8% of these were due to alkalis [11]. Of the 42 cases of alkali ocular burns admitted to a German eye clinic between 1985 and 1992, 73.8% involved industrial accidents [11]. In Finland in 1973, 11.9% of all industrial accidents were ocular injuries and burns comprised 3.6% of these (chemical or other injury mechanism not specified) [12].

A 7-year retrospective Australian study of 182 industrial burns found that 5.5% were ocular burns due to chemicals, gas explosions, and electric flashes (percentages not specified) [13]. In another Australian study of 159 cases of hospital-admitted alkali ocular burn patients from 1972–1981, the majority of burns were Grade 1 or 2 and none of these resulted in vision loss [14].

In contrast, in a US Poison Center study of a random sampling of 500 cases of chemical eye exposure over a 6-month period in 1986, the majority (84.4%) occurred in the home and involved household products [15]. These most commonly involved accidental exposures in children [15].

2,403,539 human poison exposure cases, including 136,534 eye exposures (5.4%), with 2 deaths [16].

2.2.3  US Bureau of Labor Statistics Data

The US Bureau of Labor Statistics collects data annually regarding workplace injuries. The latest data at the time of this writing are from 2006. While these data are quite nonspecific and difficult to relate directly to the epidemiology of ocular chemical injuries, they do provide some insight into the scope of the problem. All of the following data refer to private industry and cases of nonfatal injuries or illnesses resulting in lost work days.

The incidence rate in 2006 for chemical burns (not specified as to eye and/or skin) was 1 per 10,000 fulltime workers and the median number of lost work days was 3 [17]. There were 7,490 chemical burns (also not specified as to eye and/or skin). Eye injuries and illness totaled 35,970 with the largest number, 17,760 (49%), occurring in the Total Goods industry segment [17]. The industry segment, Chemicals and Chemical Products, accounted for 19,480 occupational injuries or illnesses, with the largest number, 19,480 (65%), occurring in the Total Service Providing industry segment.

Overall, chemical burns comprised 0.6% of total occupational injuries and illnesses resulting in lost work time and chemicals and chemical products accounted for 1.6 % of such injuries or illnesses [17]. The incidence of chemical burns (not specified as to eye and/or skin) was 0.8 per 10,000 full-time workers. The incidence rate for the Chemicals and Chemical Products industry segment was 2.1 per 10,000 fulltime workers.

The percent distribution of lost work days in the Chemicals or Chemical Products industry segment was as follows [17]:

2.2.2  American Association of Poison

Centers National Poison Data

System (NDPS)

Data on poison exposures reported to US Poison Centers are collected on a daily basis and published yearly in the American Association of Poison Centers National Poison Data System (NPDS) Annual Report [16]. In the latest published report for the year 2006, there were