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Ростовский Государственный Медицинский Университет

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CHAPTER21 Radiation burns

Further treatment

Owing to vascular damage and reduced basal cell density (>20 Gy) radiation wounds are often non- healing and susceptible to infection and sepsis.

• Anti- emetics eective in radiotherapy such as ondansetron may be

useful in radiation nausea

• Radiation burns should be kept clean with washing and well hydrated to

prevent further desquamation. Exposure to chemical or physical irritants

or sunlight should be avoided

• Steroid (beclomethasone spray) or hydrophilic (alovera) creams

signicantly reduce moist desquamation, with equal eectiveness

• Moist desquamation should be treated as a burn wound, swabbed and

covered

• Radiation burn wounds may be dicult to close surgically with grafting

due to poor microvasculature and low capillary density. Conservative

treatment should be used initially, treating other sequelae of radiation

exposure. Other denitive management options including free aps may

be necessary

• Marrow failure will likely require bone marrow transplantation

Further reading

American College of Surgeons. Advanced trauma life suppor t (ATLS) course manual. Chicago:ACS. Waghmare CW. Radiation burn– from mechanism to management. Burns 2013;39.212– 19. Waselenko, MacVittie TJ, Blakely WF. Medical management of the acute radiation syndrome: re-

commendations of the Strategic National Stockpile Radiation Working Group. Annals of Inter nal

Medicine 2004;140:1037– 51.

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Chapter22

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Ocular burns

Clinical ndings in ocular burns 184 Key steps in rst aid 185 First aid 186 Clinical presentations of ocular burns 188 Prognosis of grading 188 Principles of medical treatment of ocular burns 189 Principles of surgical treatment of ocular burns 189 Further reading 190 References 190

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CHAPTER22 Ocular burns

Clinical ﬁndings inocular burns

Burns to the orbit are an inevitable consequence of the exposure of the eyelid, conjunctiva, cornea, and internal orbit to external physical and chemical irritants. Accidental exposure to dangerous chemicals can take place at the workplace or at home, with commonly used products such as detergents and cleaning agents containing acids or alkalis. Children and adults are both at risk of accidental and non- accidental orbital burns.

Although it is important to ascertain the circumstances under which an orbital burn was sustained, a focused history and examination can be commenced while simultaneously administering rst aid. The prognosis of an orbital burn is dictated by the time and concentration of chemical contact with the orbit and the initial early decontamination regime performed.

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KEY STEPS INFIRST AID

Key steps inﬁrst aid

• Provide immediate early orbital lavage with water, ampohteric or

neutralizing solutions

• Take protective measures such as gloves

• Open the eye with the help of an assistant or the patient if they are

motivated

• Initiate lavage using a ushing technique before commencing drop- by-

drop applications every second for at least 15 minutes

• Examine the deep fornices while rinsing the lids and conjunctiva

Encourage the patient to carry out eye movements to all extreme positions

• Remove any visualized foreign bodies using a soft cotton swab.

• Carry out orbital lavage for 15 minutes ensuring precise time keeping

• Apply antibiotic gentamycin and steroidal dexamethasone eye drops

following lavage

• Refer to Ophthalmology

Disadvantages ofdelayed rst aid

• Continued damage secondary to burn

• Signicantly poorer visual prognosis

• Increased incidence of corneal opacity, non- healing ulcers, and glaucoma

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CHAPTER22 Ocular burns

First aid

Rinsing solutions

Features

• Important for decontamination of corrosives

• Apolyvalent solution is needed for eective decontamination as

contents of the spill may be unknown

• Many dierent solutions are available on the market

Amphoteres

Features

• Chemically reactive towards acids and alkali

• Act within the frame of known biochemical activity like amino acids.

• Special solutions are available on the market distributed by Prevor Int.

• Diphoterine® has a proven high decontamination capacity of alkali, acids,

alkylants, solvents, tear gas, capscain, oxidants, and reductors

Water

Features

• Freely available

• Polyvalent but not buering

• Dilution of spills due to hypo- osmolar nature of water creating a

concentration gradient

• Dilution is eective when used early in exposure to reduce

concentration levels within the tissue

Buers

Features

• Many buers available on market

• Borate buer more eective in akalis

• Phosphate buer more eective in acids

• Special highly concentrated phosphate buers are available as ‘pH

neutral’ to deal with acids and alkalis alike

• Complication of phosphate buer use in orbital burns includes

secondary corneal calcication and is therefore not recommended

Anti- hydrouoric acid therapies

Features

• Hydrouoric acid acts on calcium and magnesium levels causing severe

tissue necrosis and arrhythmias

• Decontaminating agents have to neutralize the free uoric ions

• Calcium gluconate is used to rinse skin that has come into contact with

hydrouoric acid

• Using calcium gluconate at a 2% concentration results in the white

corneal precipitates of insoluble CaF2 or MgF2 solids

• Anti- HF solution® is an eective amphoteric binder of the uoride ion,

keeping the cornea clear and decontaminated

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After rst aid rinsing

• Note clinical ndings

• Eective rst aid therapy can prevent long- term damage to eyes, even

from highly corrosive agents

• Dua etal.1 classication grades prognosis for the cornea, but the Reim

classication (1997) grades the overall prognosis for the whole eye following injury

FIRST AID

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CHAPTER22 Ocular burns

Clinical presentations ofocular burns

• Corneal erosion due to initial damage of the epithelium and later due to

the lack of healing capacity of the epithelial layer dependent on limbal

stem cell survival and activity

• Corneal opacity indicating reversible and in later stages irreversible

damage of the corneal collagen glycoprotein matrix

• Ischaemia of the limbal vessel arcade, with healing deciency expected

in damage exceeding 60%

• Turbidity of lens and damage of iris are indicators of deep corrosive

action and inammatory response of the eye

• Conjunctival chemosis, indicating severe damage. Rinsing with

hyperosmolar amphoteric solutions has resulted in a reduction in this

symptom

• Conjunctival ischaemia is a more objective measure to evaluate the

depth of damage of the conjunctiva and sclera

Prognosis ofgrading

Table 22.1 shows the prognosis for healing.

Table22.1 Simple prognosis healing underthe Dua classication ofocular burns

Grade I Very good healing under therapy

Grade II- III Good healing under therapy

Grade IV Good to possible healing with surgical intervention

Grade V Possible to poor healing with surgical intervention

Grade VI Unlikely healing under therapy and surgical intervention

For the full grading system, see Dua HS, King AJ, Joseph A. A new classication of ocular surface burns. British Journal of Ophthalmolog y 2001;85(11):1379– 83

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PRINCIPLES OFSURGICAL TREATMENT OFOCULAR BURNS

Principles ofmedical treatment ofocular burns

• Improve corneal epithelial healing by lubrication with hyaluronic acid

derivates

• Antibiotic protection, omitting macrolides (eg. gentamycin) and

uoroquinolones (ciprooxacin) due to interference with epithelial healing

• Use steroids to inhibit the devastating autoimmune response and

damage to stem cells

• Preservatives should be avoided as the high frequency of eye drops

used cause damage to the surface of the eye

• Stop phosphate application on the eye as corneal calcication can occur

Proposed best practice

• Unpreserved hyaluronic acid lubricants

• Ointments of antibiotic and steroids, eg. Dexa- Polyspectrane®,

Isopto Max

Principles ofsurgical treatment ofocular burns

• Debridement of necrotic tissue under general anaesthetic

• Earliest surgical intervention is between 2 and 3days after appropriate

conservative treatment

• Residual conjunctival defects following necrosectomy can be successfully

closed by tenonplasty, described by Teping etal.

• Persistent corneal erosion following treatment with high dose steroids,

lubricants, and antibiotic protection may warrant placement of an amniotic membrane graft combined with placement of a protective soft bandage lens

• Corneal grafts, autologous or homologous limbal stem cell grafts with

systemic and local immune suppression as well as keratoprosthetic surgery should be considered for advanced stage burns of the orbit

These surgical approaches have a high risk of failure; however, when carried out meticulously in the hands of a specialist, these procedures can restore sight.

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CHAPTER22 Ocular burns