Finally, antibiotic cover, use of non-adrenergic mydriatics (cause vasoconstriction and aggravate ischaemia) and antiglaucoma medication if necessary are important in prevention and management of complications. Surgical intervention in the form of tenoplasty and autologous conjunctival grafts from the other eye are important in cases of limbal ischemia. Autologous serum drops help in epithelial healing.

Oral ascorbate (topical is extremely irritant) up to 2 g/day is important to replenish the depleted aqueous ascorbate levels. Control of inflammation involves the judicious use of steroids, antiproteases like tetracycline, sodium citrate (10%) and application of amniotic membrane. It is imperative to assess the intraocular pressure using finger palpation if other means are unreliable or not practical. The latter has been shown to be more reliable in determining prognosis of the injury. Two prognostic classifications are in vogue, the Roper-Hall and the Dua’s classification. Complete and thorough assessment includes systematic examination of every structure of the eye, use of fluorescein stain and classification of the burn. Irrigation is the first and important step in preventing further damage and eliminating the injurious agent. The overall acute stage management of chemical burns involves (a) Prevention of further damage by elimination as much of the injurious agent as possible, (b) complete and thorough assessment, (c) control for the acute inflammatory reaction, (d) facilitation of the healing process and (e) prevention and management of complications. Any visible particulate matter in the conjunctival sac and fornices, examined by double eversion where possible, whether lying on the surface or impregnated in the tissue should be removed or excised. Of all the irrigating agents mentioned, Diphoterin®, which is a hypertonic, amphoteric chelating agent that helps wash the chemicals with additional neutralisation and chelation action and prevents further tissue penetration of the chemicals has proven to be more effective with smaller quantities required to achieve neutralization of the chemical agent. If pH is neutral, it is important to re-check after a pause of a few minutes as chemicals from the tissue can leech out indicating that more irrigation is needed.

After initial irrigation, which can be done with balanced salt solution, or any other available solutions such as water, saline, phosphate buffered saline, ringer lactate or Diphoterin®, irrigation is stopped, pH is checked and irrigation re-instituted if the pH is not neutral. Use of topical anaesthesia to relieve pain and to release blepharospasm is often essential (copious irrigation over eyelids squeezed shut is known to occur). Copious irrigation of the open eye(s), preferably with a sterile neutral solution, is the essential immediate measure, regardless of the nature of the chemical. Assessment of pH with the litmus paper is a crude but practical means of ascertaining whether the agent was an acid or alkali, but more so to know whether it is normal or not, and to serve as a baseline from which a change can be measured.

Alkaline tattooed eyeballs