Chemical Eye Injury
Known or suspected chemical splash to the eye. Irrigate first: do not wait for history, visual acuity or pH testing.
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OphthalmologyEmergency
Chemical Eye Injury Management
Chemical Eye Injury Management: Chemical Eye Injury → Irrigate Now: Copious Irrigation → While Irrigating: Check for Other Injury → Check pH in Both Eye...
Pathway Overview
18 steps
Algorithm Steps
18 total
01Start 02Action Irrigate Now: Copious Irrigation
Start before any other assessment; time to irrigation drives outcome. Suspected open globe: do not irrigate or press on the eye; shield it, keep nil by mouth and call ophthalmology now.
- Topical anaesthetic if at hand (do not delay irrigation): tetracaine 0.5% or 1%, or oxybuprocaine 0.4%; repeat as needed
- Sodium chloride 0.9% or Hartmann's via a giving set; tap water if nothing else
- Evert lids (double-evert upper lid); sweep fornices; remove particles with a wet cotton bud
- Give at least 1-3 L (about 30 min), then check pH
- Never try to neutralise with an acid or alkali
- Remove contact lenses; irrigate away from the other eye
- Child who cannot cooperate: sedation or GA may be needed; call early
03Warning While Irrigating: Check for Other Injury
Do not stop irrigation for these checks.
- Face or airway burn, or inhaled fumes: assess airway now
- Hydrofluoric acid: risk of systemic toxicity (low calcium, arrhythmia); call Poisons 13 11 26
- Both eyes exposed: irrigate both and check pH in both
04Action Check pH in Both Eyes
Stop irrigation for 5 minutes, then touch pH indicator paper to the lower fornix.
- Target: normal pH, 7.0-7.2 (RCH accepts 6-8 on indicator paper)
- Abnormal: irrigate again
- Recheck later: retained particles can make pH drift again
05Decision pH Normal and Stable in Both Eyes?
Continue irrigation until pH is normal.
- If Yes
06Warning pH Normal: Discuss With Ophthalmology Today
Discuss every chemical eye burn with ophthalmology. The ophthalmologist grades the injury at the slit lamp.
- Call now: alkali, reduced vision, corneal haze or limbal blanching
- No topical steroid until an ophthalmologist advises it
- No topical anaesthetic drops to take home (delays healing)
07Action Assess and Grade (Roper-Hall)
After irrigation: visual acuity, fluorescein staining and IOP. Slit-lamp grading of limbal ischaemia by the ophthalmologist; Dua grading is also used.
- Grade I: corneal epithelial damage, no limbal ischaemia - good prognosis
- Grade II: corneal haze, iris details visible, <1/3 limbal ischaemia - good prognosis
- Grade III: total epithelial loss, stromal haze hides iris details, 1/3-1/2 limbal ischaemia - guarded
- Grade IV: opaque cornea, iris and pupil hidden, >1/2 limbal ischaemia - poor
08Decision Roper-Hall Grade?
Grade I: topical treatment. Grade II-IV: intensive ophthalmologist-led treatment.
- Grade II-IV
09Warning Grade II-IV: Check Before Oral Doxycycline or Vitamin C
Do not delay topical treatment for these checks.
- Doxycycline: not in pregnancy, breastfeeding or children under 12 years; not with oral retinoids
- High-dose vitamin C: avoid in renal impairment or kidney stones
- Child, severe burn or doubtful adherence: consider admission
10Action Grade II-IV: Intensive Treatment (Ophthalmologist-Led)
Start in the first week. Doxycycline and oral vitamin C only if no contraindication (see previous step).
- Fluoroquinolone drops QID (e.g. ciprofloxacin 0.3%)
- Prednisolone acetate 1% hourly while awake for 7-10 days
- Sodium ascorbate 10% drops hourly while awake (compounded)
- Atropine 1% drops for cycloplegia and pain, frequency as the ophthalmologist advises (young child: systemic toxicity; not in angle closure)
- Doxycycline 100 mg orally BID (adults)
- Oral vitamin C (adults): dose as the ophthalmologist advises
- Preservative-free lubricants; check IOP; debride necrotic epithelium
11Warning Steroids: Review by Day 10-14
Epithelium not healed by day 10-14: taper the steroid (risk of corneal melt and perforation). The ophthalmologist may switch to medroxyprogesterone 1% drops QID (compounded).
12Action Grade III-IV: Early Surgery (Ophthalmologist)
Consider surgery in the first week for grade III-IV burns.
- Amniotic membrane transplant, ideally in the first week
- Tenonplasty for limbal or scleral ischaemia or necrosis
- Raised IOP not controlled with medicines: glaucoma surgery
- Later: limbal stem cell transplant or keratoprosthesis once inflammation is controlled
13Action Close Ophthalmology Follow-up
Severe burns: review daily at first.
- Watch for persistent epithelial defect, corneal thinning or melt
- New stromal infiltrate: culture and treat infection at once
- Check IOP at each visit; treat raised IOP
- Symblepharon: the ophthalmologist may sweep or release adhesions
14Decision Epithelium Healed and Eye Stable?
Healed epithelium, controlled inflammation and normal IOP.
- If Yes
15Outcome Healed: Taper Treatment, Long-Term Review
Most grade I-II burns heal well. Keep long-term checks for dry eye and glaucoma, even if the eye looks healthy.
If No16Outcome Not Healed: Cornea Specialist Care
Persistent defect, melt or limbal stem cell deficiency: cornea and ocular surface specialist. Grade III-IV burns often need long-term care.
- Grade I
17Action Grade I: Topical Treatment
Plan agreed with ophthalmology.
- Chloramphenicol 1% eye ointment or 0.5% drops QID until the epithelium heals
- Prednisolone acetate 1% QID only if the ophthalmologist advises
- Preservative-free lubricant drops often
- Pain: oral analgesia; cyclopentolate TDS if the ophthalmologist advises
- Ophthalmology review next day, or as the ophthalmologist directs
- Path rejoins step 13Shared downstream outcome
If No18Action pH Abnormal: Irrigate Again
Irrigate further, re-evert lids and sweep fornices for particles, then recheck pH after 5 minutes. Alkali, particles or pH still abnormal: call ophthalmology now and keep irrigating. Alkali burns may need many litres.
- Path rejoins step 04Shared downstream outcome
Guideline Source
AAO EyeWiki: Chemical (Alkali and Acid) Injury of the Conjunctiva and Cornea (Roper-Hall graded treatment); RCH Acute eye injury CPG (2022); Soleimani and Naderan, Clin Ophthalmol 2020 review
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Grading and all treatment after first aid are ophthalmologist-led; drug regimens are expert practice based mainly on animal and retrospective studies.
- Hydrofluoric acid and other systemically toxic chemicals need toxicology advice (Poisons Information Centre 13 11 26).
- Does not cover thermal, radiation or open-globe injuries.
- Long-term outcome depends on limbal stem cell survival; severe burns may need limbal stem cell transplant or keratoprosthesis.
Contraindicated Populations
Suspected open globe (penetrating eye injury): do not irrigate; shield and refer as a penetrating eye injury
Applicable Regions
AUUSEUGlobal
AU: Erythromycin eye ointment is not on the ARTG; use chloramphenicol 1% eye ointment or 0.5% drops. Prednisolone acetate eye drops are supplied as Prednefrin Forte (with phenylephrine). Sodium ascorbate 10% and medroxyprogesterone 1% eye drops are compounded. Poisons Information Centre 13 11 26.
EU: Amphoteric solutions (for example Diphoterine) may be available for first aid; do not delay irrigation to find them.
US: Irrigate with normal saline or lactated Ringer's; erythromycin ointment is a common grade I antibiotic.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Chemical Eye Injury Management?
The Chemical Eye Injury Management is a emergency clinical algorithm for Ophthalmology. It provides a structured decision tree to guide clinical decision-making, based on AAO EyeWiki: Chemical (Alkali and Acid) Injury of the Conjunctiva and Cornea (Roper-Hall graded treatment); RCH Acute eye injury CPG (2022); Soleimani and Naderan, Clin Ophthalmol 2020 review.
What guideline is the Chemical Eye Injury Management based on?
This algorithm is based on AAO EyeWiki: Chemical (Alkali and Acid) Injury of the Conjunctiva and Cornea (Roper-Hall graded treatment); RCH Acute eye injury CPG (2022); Soleimani and Naderan, Clin Ophthalmol 2020 review (DOI: 10.2147/OPTH.S235873).
What are the limitations of the Chemical Eye Injury Management?
Known limitations include: Grading and all treatment after first aid are ophthalmologist-led; drug regimens are expert practice based mainly on animal and retrospective studies.; Hydrofluoric acid and other systemically toxic chemicals need toxicology advice (Poisons Information Centre 13 11 26).; Does not cover thermal, radiation or open-globe injuries.; Long-term outcome depends on limbal stem cell survival; severe burns may need limbal stem cell transplant or keratoprosthesis.. Individual patient factors may require deviation from these recommendations.
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