A 34-year-old laboratory technician is brought to the emergency department after a container of concentrated sodium hydroxide splashed into his right eye 20 minutes ago. He immediately rinsed his eye for a few minutes at a nearby sink before being transported. On arrival, he reports severe pain and blurred vision. Past medical history is negative. Physical examination shows significant eyelid edema and a diffusely hazy cornea. The conjunctiva appears pale and porcelain-white in several areas.
Which of the following is the most appropriate next step in the management of this patient?
The correct answer is:
D) Instillation of topical proparacaine followed by copious irrigation
This patient has sustained a chemical eye injury, specifically an alkali burn from sodium hydroxide. Chemical burns to the eye are true ophthalmologic emergencies that require immediate intervention before a detailed history or full physical examination, including visual acuity, is performed. The single most important step in management is immediate and copious irrigation with a neutral solution, such as normal saline or Ringer’s lactate, to remove the offending agent and normalize the ocular pH. In the emergency department, this is typically facilitated by using a topical anesthetic, such as proparacaine, and a Morgan lens. Irrigation should continue for at least 30–60 minutes and until the pH of the conjunctival sac is neutralized (pH 7.0–7.4), as measured by litmus paper. Alkali burns are generally more severe than acid burns because alkalis cause liquefactive necrosis, which allows the chemical to penetrate deeply into the ocular tissues. The porcelain-white appearance of the conjunctiva is an ominous sign indicating ischemia due to vascular destruction.
Answer choice A: Application of a topical neutralizing acidic solution, is incorrect. Attempting to neutralize a base with an acid (or vice versa) is strictly contraindicated, as the resulting exothermic reaction can cause additional thermal damage to the ocular tissues.
Answer choice B: Immediate measurement of visual acuity, is incorrect. While visual acuity is often the "fifth vital sign" of the eye, it should be deferred in the setting of a chemical burn until irrigation has been initiated. "Irrigate first and ask questions later" is the rule for chemical splashes.
Answer choice C: Immediate slit-lamp examination, is incorrect. Similar to visual acuity, a detailed slit-lamp examination should only be performed after the eye has been thoroughly irrigated and the pH has been stabilized.
Answer choice E: Patching the eye and urgent ophthalmology consultation, is incorrect. While an ophthalmologist should be consulted urgently, the primary provider must not delay irrigation. Patching is not indicated in the hyperacute phase and may trap the chemical against the eye.
Key Learning Point
In the management of chemical eye injuries, especially alkali burns, immediate and copious irrigation with saline or water is the most critical step. Irrigation should be initiated immediately and continued until the ocular pH is neutralized.
