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Purpose: To assess the clinical outcomes of symblepharon release in patients with ocular surface chemical injury using Gore-Tex as a novel treatment option., Methods: This was a retrospective analysis of 23 eyes of 22 chemical injury patients done during a period of January 2014 to December 2021 at a tertiary eye care centre in South India. All patients underwent symblepharon lysis along with Gore-Tex application over the sclera with minimum 1 year follow up. The patients were assessed for demographic details, visual acuity, intraocular pressure, anterior and posterior segment details, photographic documentation, preoperative diagnosis, previous surgical details in recurrent cases, surgical procedures, final visual acuity, surgical outcomes, and complications. The clinical outcomes were assessed and outcomes were defined as success, partial success, or failure., Results: The median age was 17 years (IQR, 12-39 years). Among them 10 eyes with symblepharon had grade 3 length, 12 eyes grade 3 width and 12 eyes had grade 3 loss of palisades of Vogt. The success was achieved in 52.2% of the patients; partial success in 34.8% and 13.3% had failure. The mean duration of recurrence was 6.75 ± 3.6 months. Failure was noted in young patients with mean age 9.75years and with grade 3c symblepharon. There was no sight threatening complications noted., Conclusion: The study showed very good results with Gore-Tex as a novel treatment option for chemical injury patient with symblepharon formation. It can be easily employed to prevent the symblepharon recurrence of various ocular surface disorders., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: To evaluate limbal graft transplantation success in pediatric patients with chemical injury-induced limbal stem cell deficiency (LSCD) using the 'LSCD Working Group' staging system., Methods: Medical records of 11 eyes of 11 children who underwent limbal graft transplantation (limbal autograft/limbal allograft) were included. Surgical success was defined as improvement in the post-operative 1st year LSCD stage., Results: The mean age was 12 ± 5 (4-17) years. Causative agent was alkaline in 4(36.4%) and acid in 3(27.2%) patients. Limbal autograft was performed in 9 (81.8%) eyes with unilateral LSCD, and allograft transplantation was performed in 2 (18.2%) eyes with bilateral LSCD. The mean follow-up time was 33.89 ± 30.73 (12-102.33) months. The overall limbal graft transplantation success rate was 72.7%. Among 9 patients who receive limbal autograft, 8 had improvement in post-operative LSCD stage, 1 had stable LSCD stage. Of the 2 patients who receive limbal allograft, post-operative LSCD stage remained the same in 1 and worsened in 1 patient. The mean time between injury and the surgery was 30.47 ± 30.08 (7-108.47) months. Penetrating keratoplasty was performed in 3 (27.2%) of 11 patients following limbal graft transplantation., Conclusion: Management of LSCD in children is challenging and appears to be somewhat different from that of adults. Limited data in the literature indicate that cultivated or simple limbal epithelial transplantations (CLET/SLET) are primarily preferred in children. Although the tendency to take small tissue from the healthy eye is noteworthy, conventional limbal allograft and autograft transplantations also show promising results without any further complications in at least 1 year follow-up period., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

The Boston Keratoprosthesis type I (KPro-I) has been shown to be successful in restoring vision after severe ocular burns; however, its long-term outcomes in phthisical eyes have rarely been reported. A monocular woman with a history of severe alkali chemical injury necessitating facial transplantation presented with a light perception left eye after a complicated course, including failed KPro-I, therapeutic penetrating keratoplasty, endophthalmitis, hypotony, total retinal detachment, and structural changes, including a shrunken 18 mm axial length and eye wall thickening. The patient underwent a combined vitrectomy with silicone oil and KPro-I implantation, resulting in her regaining ambulatory visual acuity (20/250) at 3 years' follow-up ., (Copyright ©2024. All rights reserved. Reproduction in whole or in part in any form or medium without expressed written permission of the Digital Journal of Ophthalmology is prohibited.)

Competing Interests: The authors have no conflicts of interest to disclose.

A 40-year-old woman underwent periocular plasma skin regeneration, a cosmetic treatment for periorbital rejuvenation. She subsequently developed bilateral thermal keratitis, manifesting as blurred vision, irritation, and redness, with a vision decrease to 20/60 and 20/50 in her OD and OS, respectively. Examination demonstrated bilateral large, irregular corneal epithelial defects and edema, necessitating treatment with amniotic membrane grafts, bandage contact lenses, and hypertonic saline. One year posttreatment, her visual acuity improved to 20/20 and 20/25, albeit with ongoing symptomatic dryness and bilateral anterior stromal haze. This case, as only the second reported instance of ocular damage from periocular plasma skin regeneration, underscores the need for heightened awareness of potential ocular complications following plasma skin regeneration and reinforces the importance of protective measures during periocular procedures., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2024 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose: Scar contracture of the eyelid following facial burns often has adverse consequences. Total cicatricial contracture often makes adjustment flap translation challenging to implement. Previously used upper and lower eyelid adhesion methods are ineffective for patients with severe cicatricial contracture, and ectropion can easily recur. This study aimed to retrospectively examine upper and lower eyelid adhesions using an orbicularis oculi muscle flap and verify its stability., Methods: In patients with ectropion caused by severe scar contracture following head and face burns, we employed a tunnel orbicularis oculi muscle flap technique, which involved creating a tunnel between the skin and the tarsal plate of the eyelid, mobilizing the orbicularis oculi muscle, and rotating it into this tunnel to provide stable adhesion of the upper and lower eyelids. Full-thickness skin grafting was then performed. The eyelids were examined postoperatively to determine whether reoperation was necessary and to monitor for any potential complications., Results: This study included 26 patients and 46 eyes. No accidental disconnection occurred after eyelid adhesion, which lasted for an average of 21.87 ± 10.08 months before the eyelid adhesion was cut open. No complications or adverse reactions occurred, and the adhesions did not break unexpectedly., Conclusions: Repairing eyelid ectropion with the tunnel orbicularis oculi muscle flap is a simple procedure that immediately creates tension against upper and lower eyelid contractures, providing long-term stable adhesion. This method avoids structural disorders, such as eyelid margin scarring, minimally influences surrounding tissues, and has few postoperative complications. It holds great value for repairing eyelid tissue defects and warrants further study., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Facial burns involving the periorbital region may lead to cicatricial ectropion and lagophthalmos, causing severe exposure keratopathy and eventually blindness if uncorrected. In these patients, it is critical to provide aesthetic and functional surgical correction to protect the ocular surface from chronic desiccation in addition to visual rehabilitation. Conventional methods may not be sufficient to provide visual rehabilitation in complex cases. Scleral lenses can be a multipurpose alternative for these patients. Herein, we present the challenging case of a patient who developed cicatricial lagophthalmos and exposure keratopathy after facial transplantation due to gasoline burns and received a scleral contact lens for visual rehabilitation., Competing Interests: Conflict of Interest: No conflict of interest was declared by the authors., (©Copyright 2024 by the Turkish Ophthalmological Association / Turkish Journal of Ophthalmology published by Galenos Publishing House.)

Purpose: To study and compare the demographic and clinical profile of acute ocular burns (AOB) in children and adults., Methods: This retrospective case series included 271 children (338 eyes) and 1300 adults (1809 eyes) who presented to two tertiary eye care centers within one month of sustaining AOB. Data regarding demographics, causative agents, severity of injury, visual acuity (VA), and treatment were collected and analyzed., Results: Males were more commonly affected particularly among adults (81% versus 64%, P < 0.00001). Among children, 79% sustained domestic injuries, whereas 59% of adults had work-place injuries (P < 0.0001). Most cases were due to alkali (38%) and acids (22%). Edible lime (chuna, 32%), superglue (14%), and firecrackers (12%) in children, and chuna (7%), insecticides, lye, superglue (6% each), toilet cleaner (4%) and battery acid (3%) in adults, were the main causative agents. The percentage of cases with Dua grade IV-VI was greater in children (16% versus 9%; P = 0.0001). Amniotic membrane grafting and/or tarsorrhaphy were needed in 36% and 14% of affected eyes in children and adults, respectively (P < 0.00001). The median presenting VA was logMAR 0.5 in children and logMAR 0.3 in adults (P = 0.0001), which improved significantly with treatment in both groups (P < 0.0001), but the final VA in eyes with Dua grade IV-VI burns was poorer in children (logMAR 1.3 versus logMAR 0.8, P = 0.04)., Conclusion: The findings clearly delineate the at-risk groups, causative agents, clinical severity, and treatment outcomes of AOB. Increased awareness and data-driven targeted preventive strategies are needed to reduce the avoidable ocular morbidity in AOB., Competing Interests: None

Purpose: The purpose of this study was to report a case series of sight-threatening ocular injuries caused by calcium carbide guns used as fire crackers., Methods: Medical records of 15 eyes of 14 patients with ocular injuries caused while using carbide guns, visiting the Institute, from January 2021 to January 2022, were retrospectively reviewed. The collected data included patients' demography (age, sex), presenting ophthalmic features, management, and outcome. Grade I and II ocular injuries were managed medically. All grade III-V injuries were managed using Amniotic Membrane Transplantation., Results: All patients were male. The mean age of the patients was 23.57 ± 11.76 years. According to the Dua classification, 5 eyes (33.3%) had Grade I-II ocular surface burns, 3 eyes (20%) had grade III burns, and 7 eyes (46.6%) had grade IV-VI burns. Presenting visual acuity ranged between hand movements to 20/50, and in 6 eyes (40%), the visual acuity was ≤20/200. Five eyes were managed medically alone, and 10 (66.6%) eyes needed surgical intervention (Amniotic Membrane Transplantation). After a mean follow-up of 14.23 ± 11.92 weeks, complete epithelization was seen in 10 eyes (66.6%). Partial limbal stem cell deficiency and its sequelae such as conjunctivalization of the cornea were noted in 7 eyes (46.6%)., Conclusions: Calcium carbide-related ocular injuries can result in corneal blindness secondary to limbal stem cell deficiency in young individuals. Loss of vision in this age group can lead to loss of economic productivity and cosmetic disfigurement. More advocacy efforts are thus needed to prevent these injuries., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

An enhanced online and manual grading system, based on the I's and E's, for acute ocular chemical injuries is being proposed. E-PIX is designed to be an online/manual grading system that includes all the parameters that adversely affect the outcome of acute chemical injuries. The importance of addressing the I's and E's in chemical burns cannot be underestimated. These include the need for the documentation and management of epithelial defect (E), intraocular pressure (P) (IOP), ischemia (scleral) (I), and exposure (X) (acronym - E-PIX). Epithelial defect includes that involving the limbus (L), along with conjunctival (C), corneal (K), and tarsal (T). These additional parameters are graded and represented as an annotation along with the limbal grade providing a comprehensive grading for the injury. A manual entry sheet and a freely accessible online grade generator are a part of the system. The proposed enhanced grading offers a final annotation that provides a clear understanding of all factors that can lead to vision-threatening complications ensuring their assessment and hence subsequently their addressal to improve outcomes, if abnormal. The prognostication continues to be based on the grade of limbal involvement. The additional annotations impact prognosis and outcome if not addressed. Including the laterality of injury provides, in addition, a futuristic understanding of available options. The grade generator retains the flexibility to be dynamic with changes reflecting upon the healing process in the acute stage. The proposed system aims to provide primary and tertiary caregivers alike with a uniform grading system., Competing Interests: None

Background: In acute chemical injury, damage can range from ocular surface epithelial defects to limbal and scleral ischemia. This may subsequently progress to corneal or scleral melting and perforation and finally result in phthisis bulbi. Thus, acute chemical injury is a potentially blinding condition and warrants attention. The accurate technique to assess the damage incurred should be practiced to avoid undertreatment and subsequent complications. Surgical intervention wherever needed should be appropriately timed and should be performed. The primary aim of medical or surgical intervention in acute chemical injury is to attain a stable and epithelized ocular surface. Even a conjunctival phenotype over the cornea is a desirable outcome., Purpose: This video discusses the nuances involved in the assessment and planning of Tenon advancement with amniotic membrane grafting for treating limbal ischemia in acute chemical injury., Synopsis: The video demonstrates the technique of restoration of limbal vascularization by performing Tenon advancement with amniotic membrane grafting and its outcome., Highlights: Ocular surface painting with fluorescein dye is essential to assess the areas of surface involvement. Merely instilling the fluorescein dye in the cul-de-sac will underestimate the extent of the damage. Tenon advancement should ideally be planned between 7 and 10 days following an injury when actual limbal blanching is obvious. A stable and epithelized ocular surface is the desirable outcome irrespective of the epithelial phenotype., Video Link: https://youtu.be/06XhwLKnsIA., Competing Interests: None

This case report aims to describe a modified continuous suturing technique for firm fixation of a human amniotic membrane graft in a patient with persistent epithelial defect (PED) after a chemical eye injury. As a result of this technique, the amniotic membrane (AM) was firmly fixed to the corneal surface with eight continuous and locked episcleral sutures that resembled an octagon graft. This technique was performed in a 14-year-old patient with PED after a chemical corneal burn. Three weeks after the surgery, the PED was completely healed. This simple continuous suturing technique can allow firm and stable fixation of AM grafts on the ocular surface in cases of PED after chemical burn. It may prevent early loss of the graft and facilitate corneal epithelial wound healing., Competing Interests: Conflict of Interest: No conflict of interest was declared by the authors., (©Copyright 2022 by Turkish Ophthalmological Association | Turkish Journal of Ophthalmology, published by Galenos Publishing House.)

Objectives: To report demographic characteristics, types and grades of injury, regional distribution of injury severity, clinical findings, and long-term results of acute ocular chemical burns., Methods: Medical records of patients with chemical burns between 2010 and 2020 who were admitted to Ege University less than 72 hr after the injury were reviewed. Age, gender, cause of the burn, injury severity, initial and final best-corrected visual acuity, surgical intervention, and complications were recorded. The injury severity was graded according to Dua classification., Results: A total of 104 patients (137 eyes) were included. The mean age was 42.69±17.39 (7-90) years with a male-to-female ratio of 86:18. The most common causes were home (32.6%) and industrial accidents (45.1%). The causative agent percentages for alkaline, acid, and neutral were 49.0%, 35.5%, and 5.7%, respectively. The percentages of eyes in each grade (1-6) were 16.0%, 16.0%, 15.3%, 16.7%, 17.5%, and 18.2%, respectively. Complications mostly occurred in eyes with grade 2 or higher injuries (83.7%). The relationship between injury grade and limbal stem-cell deficiency was statistically significant (P<0.001). Surgery was mostly needed in grade 4 or higher injuries (44 eyes)., Conclusion: The severity of the burn is one of the most important prognostic factors in chemical burns. It is important to determine the spreading of the regional injury severity beside the global one to predict complication risk of the injuries. In the present study, the injury distribution was homogeneous in all grades. Limbal stem-cell deficiency development took place mostly in grade 5 and 6 burns as expected., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2022 Contact Lens Association of Ophthalmologists.)

Objectives: To report 10 years of pediatric ocular chemical burn experience in a tertiary eye care center in Turkey., Methods: Thirty-three patients aged 18 years and younger who presented with ocular chemical burn between 2011 and 2021 were enrolled. Demographic data and clinical characteristics of patients were reviewed. Limbal stem cell deficiency (LSCD) stage was assessed according to LSCD working group's staging system. The initial and final best-corrected visual acuities were recorded., Results: The mean age was 10.4±5.5 (0.25-18) years with an F/M ratio of 12/21. Eleven (33.3%) of the patients were injured with acid and 5 (15.1%) with alkaline. The most common causative agent was nail polish remover (n=7, 21.2%), followed by cologne (n=5, 15.1%) and hand sanitizer (n=4, 12.1%). The severity of burn was ≥grade 4 in 20 patients (60.6%). Chemical injury resulted in LSCD in 18 patients (54.5%). Surgery was performed (LSCD ≥Stage 2 B) in 13 patients (39.3%); limbal stem cell transplantation (LSCT) (n=11), staged amniotic membrane transplantation, and symblepharon release (n=2). Penetrating keratoplasty after LSCT was performed in three of 11 patients. The mean follow-up time was 31.9±28.6 months (6-102.33) after the surgery., Conclusions: In pediatric population, accurate diagnosis and management of ocular chemical burns are challenging. Although the severity of burn and consequently LSCD rate seems to be high in children, comparative studies in a larger population are still needed., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2021 Contact Lens Association of Ophthalmologists.)

Purpose: To describe the management and outcome of an ocular surface alkali burn in the setting of previous laser in situ keratomileusis (LASIK)., Methods: This is a case report and review of relevant literature., Results: A 25-year-old man with a history of LASIK presented 4 weeks after a sodium hydroxide splash to his left eye with visual acuity of 20/60 and a nonhealing epithelial defect adjacent to sectoral inferior limbal ischemia in the setting of trichiasis from upper eyelid cicatricial entropion. After topical corticosteroids were discontinued following the repair of the entropion, the patient returned 3 days later with worsening vision and severe diffuse lamellar keratitis with the melting of the LASIK flap. After promptly lifting the flap and debriding the interface, inflammation was managed with oral, instead of topical, corticosteroids. Over several weeks, the epithelium healed, and inflammation and interface edema resolved. At 10 years of follow-up, the patient had developed a localized pseudopterygium with mild corneal neovascularization but maintained 20/20 uncorrected visual acuity., Conclusions: A chemical burn over a LASIK flap poses a challenge for managing corticosteroids, which are required to prevent diffuse lamellar keratitis but can also contribute to keratolysis beyond the first week after an alkali injury. Oral corticosteroid therapy may be beneficial in this situation, with a low threshold to lift the LASIK flap and debride the interface if inflammation occurs., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Corneal transparency relies on the precise arrangement and orientation of collagen fibrils, made of mostly Type I and V collagen fibrils and proteoglycans (PGs). PGs are essential for correct collagen fibrillogenesis and maintaining corneal homeostasis. We investigated the spatial and temporal distribution of glycosaminoglycans (GAGs) and PGs after a chemical injury. The chemical composition of chondroitin sulfate (CS)/dermatan sulfate (DS) and heparan sulfate (HS) were characterized in mouse corneas 5 and 14 days after alkali burn (AB), and compared to uninjured corneas. The expression profile and corneal distribution of CS/DSPGs and keratan sulfate (KS) PGs were also analyzed. We found a significant overall increase in CS after AB, with an increase in sulfated forms of CS and a decrease in lesser sulfated forms of CS. Expression of the CSPGs biglycan and versican was increased after AB, while decorin expression was decreased. We also found an increase in KS expression 14 days after AB, with an increase in lumican and mimecan expression, and a decrease in keratocan expression. No significant changes in HS composition were noted after AB. Taken together, our study reveals significant changes in the composition of the extracellular matrix following a corneal chemical injury.

Eye burns, which are usually caused by chemicals such as acidic, alkaline and heat-related substances, are true medical emergencies. These substances can lead to potential permanent damage to the eyelids, cornea, ocular surface and intraocular tissues. In severe cases, eye burns may result in blindness. Currently, there is a lack of uniform and standardized guidelines for the diagnosis and treatment of eye burns. As a result, a considerable number of patients have a poor prognosis. Therefore, the Cornea Group of Chinese Ophthalmological Society has developed this consensus statement after thorough discussions, hoping to provide guiding opinions on the clinical diagnosis and treatment of eye burns. (Chin J Ophthalmol, 2021, 57:254-260) .

Purpose: To report photokeratitis caused by the improper use of germicidal lamps purchased during the COVID-19 pandemic., Methods: Case series., Results: Seven patients presented with acute ocular surface pain after exposure to UV-emitting germicidal lamps. Visual acuity was 20/30 or better in 13 of 14 eyes (93%). Anterior segment examination revealed varying degrees of conjunctival injection and diffusely distributed punctate epithelial erosions (PEEs) in every patient. No intraocular inflammation was identified across the cohort and all fundus examinations were normal. Treatment varied by provider and included artificial tears alone or in combination with antibiotic ointments and/or topical steroids. Five patients were followed via telehealth, one patient returned for an in-office visit, and one patient was lost to follow-up. Five of six patients endorsed complete resolution of symptoms within 2-3 days., Conclusions: Patients should follow manufacturer recommendations when using UV-emitting germicidal lamps and avoid direct exposure to the ocular surface.

Competing Interests: None

Purpose: To evaluate the outcomes of early amniotic membrane transplant (AMT) in acute ocular surface burns using Dua's classification., Methods: In this retrospective analysis conducted at a tertiary eye care center in Western India. We included 27 eyes of 24 patients from May 2014 to May 2019 who underwent AMT within 2 weeks post insult along with medical treatment for acute ocular surface burns using Dua's classification for grading on presentation. Post-operative assessment for ocular surface epithelization, corneal vascularization, symblepharon formation, and visual outcome at the time of complete epithelization was done., Results: Eight, seven, three, and nine eyes with grade III, IV, V, and VI, respectively, were included in the study. The mean duration of the presentation was 5.5 ± 3.6 days, with the mean follow-up of 4.83 ± 2.2 months. Alkali burn (62.96%, 17/27 eyes) was the commonest. The mean epithelization time was 5.80 ± 2.92 weeks. Corneal vascularization for >6 clock hours was seen in 52.38% (11/21 eyes with vascularization). Symblepharon was seen in 55.55% (15/27 eyes). Vision improvement and corneal vascularization to a lesser extent (<6 clock hours) was observed in Group A (grades III and IV) as compared to group B (grades V and VI) and found to be significant (P-value = 0.031, P value = 0.007, respectively)., Conclusion: Amniotic membrane grafting is a useful aid in moderate grades of acute ocular surface burns with an important adjunct role in severe cases., Competing Interests: None

A 6-year-old female child presented with severe acute ocular chemical burn in the right eye 2 days after injury with cement. She underwent removal of all foreign bodies from the ocular surface and amniotic membrane transplantation. Three months later, she developed unilateral total limbal stem cell deficiency (LSCD) with symblepharon in two quadrants. Three months after the acute injury, the patient underwent autologous simple limbal epithelial transplant in the right eye with one-clock hour of limbus harvested from the left eye. At the same sitting, she underwent symblepharon release in two quadrants of the right eye with conjunctival autograft harvested from the left eye followed by conjunctival graft suturing to the areas of bare sclera in the right eye. One year after surgery, the patient's visual acuity improved from counting fingers close to face preoperatively to 20/50 (uncorrected) with no recurrence of LSCD or symblepharon., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To compare outcomes of management in the early stage of severe chemical injury (grade 4 and worse; Dua classification) with amniotic membrane grafting (AMG) alone vs allogenic simple limbal epithelial transplantation (alloSLET)., Design: Retrospective comparative interventional case series., Methods: Retrospective comparative interventional series. Records of patients with severe ocular chemical injury who underwent AMG alone (between 2009 and 2013) vs alloSLET (between 2013 and 2017) were analyzed for grade of injury, time of and interventions for epithelial healing, ocular surface status post healing (grade of symblepharon, and limbal stem cell deficiency [LSCD]), and type of and need for interventions in the chronic stage., Results: Among patients presenting in early stage of severe chemical injury, 38 eyes (median age 11 years) managed with AMG alone were compared with 39 eyes (median age 8 years) managed with alloSLET. The mean time of presentation post injury was 33.85 ± 27.5 and 40.6 ± 23.5 days in the AMG and alloSLET group, respectively. The rate of epithelial healing was faster in the alloSLET group and the difference was noted to be statistically significant (odds ratio [OR] 0.966, P = .001). Similarly, the lower occurrence of LSCD (OR 0.137, P = .004) and need for keratoplasty (OR 0.093, P = .003) favored alloSLET over AMG. Final best-corrected visual acuity of >20/200 was achieved in 39.4% and 53.8% in the AMG and alloSLET groups, respectively., Conclusion: AlloSLET helps in faster epithelialization of the surface, thus reducing the need for subsequent surgeries in the chronic stage and aiding faster visual rehabilitation. The outcomes of alloSLET appear superior to amniotic membrane grafting alone and should be considered in eyes with grade 4 and above (Dua classification) chemical injuries in the early stage., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: To investigate whether subconjunctival bevacizumab help prevent corneal graft neovascularization and prolong the graft survival of patients with chemical burns., Methods: We performed a prospective nonrandomized comparative case series study. Twenty-six eyes received subconjunctival bevacizumab (10 mg/0.4 mL) once and topical immunosuppressive agents after sclerocorneal lamellar keratoplasty as the treatment, and 13 eyes received a topical immunosuppressant alone and served as the control group. The main outcomes were a cumulative probability of graft survival, development of corneal neovascularization, and complications., Results: The postoperative follow-up time was 14.3 months (range, 2-62 mo). The cumulative graft survival time was significantly longer in the treatment group than that in the control group (42.9 ± 5.9 vs. 4.8 ± 0.7 mo; log rank < 0.001). In the treatment group, 19 of the 26 grafts (73.1%) survived as transparent with a mean follow-up of 18.7 ± 3.0 months. At the end of the follow-up, 4 grafts remained free of neovascularization, 2 developed edema without neovascularization, and 15 remained transparent with a stable ocular surface and some neovascular vessels in the peripheral transplant interface. The other 5 grafts became opaque and neovascularized. In the control group, all grafts became opaque and neovascularized within the follow-up period (5.5 ± 0.7 mo). During the follow-up, a corneal epithelial defect developed in 9 eyes in the treatment group and 7 in the control group., Conclusions: Early application of subconjunctival bevacizumab after sclerocorneal lamellar keratoplasty can significantly prevent corneal neovascularization and promote graft survival for severe late-stage ocular chemical burns.

Ocular burns are ophthalmological emergencies, owing to their potentially serious visual complications. Prompt recognition, irrigation and comprehensive examination including fluorescein staining is recommended to optimise outcomes. Burns standards recommend ophthalmological services be available in a 'timely' manner. This paper is a retrospective review of facial burn admissions between November 2017 and November 2018 at the Queen Elizabeth Hospital Birmingham (QEHB), a regional burns centre in the United Kingdom. This study aims to assess referral rates to ophthalmology, timeliness of review and the proportion of patients reviewed within a 24h window. From the data available we also aim to determine the frequency of fluorescein examination. Of 88 patients admitted with facial burns, data was available for 80 patients. The majority (n=77, 87.6%) suffered thermal burns. Twenty-two (27.5%) patients were referred to ophthalmology, and 18 (22.5%) had a documented review. Mean time from admission to review was 45.0h, with 10 (52.6%) patients being seen within 24h. Of 80 patients, 50 (62.5%) patients had no documented fluorescein examination. Further prospective studies are necessary to inform clinical guidelines and optimise management of facial burns., (Copyright © 2019 Elsevier Ltd and ISBI. All rights reserved.)

Purpose: To present a case of a patient who suffered a macular burn after an attempted YAG laser capsulotomy because of the inadvertent use of the selective laser trabeculoplasty mode of a dual-mode laser., Method: Case report., Results: A 62-year-old man with slight opacification of the posterior capsule noted sudden central vision loss immediately after an attempted YAG laser capsulotomy. The selective laser trabeculoplasty mode of a dual-mode laser had inadvertently been used. Color photographs, fluorescein angiography, and spectral domain optical coherence tomography revealed a laser burn in the macula. The patient's central vision was impaired., Conclusion: Inadvertent selection of the selective laser trabeculoplasty mode when attempting to perform a YAG laser capsulotomy with a dual-mode laser may cause a macular burn with impairment of central vision. We encourage all users of dual-mode lasers to actively choose and verify the appropriate settings to minimize the risk of inadvertent retinal damage.

Purpose: To summarize the clinical characteristics of patients with ocular chemical injuries and evaluate their potential relationship with the visual outcome by analyzing the medical records of these patients from January 1, 2012, to December 31, 2017., Methods: This is a retrospective case series study. Patient data included age, gender, occupational classification, location of ocular chemical injury, initial and final best-corrected distance visual acuity (BCDVA), intraocular pressure (IOP), nature and chemical phase, distribution and severity of chemical injury, management methods, and complications. All variables were evaluated for their potential relationship with visual outcome., Results: A total of 160 patients were hospitalized with ocular chemical injuries. Majority of the patients were factory workers and arrived at the consultation room less than 24 h after injury. The most common ocular injury setting, classification of severity, causative chemical, chemical phase, and complications were workplace, grade II, unknown and mixed substance, liquid, and elevated IOP, respectively. The risk factors for poor final BCDVA were identified as older age, poor initial BCDVA, and irrigation 24 h after injury (P < 0.001, P < 0.001, and P = 0.011, respectively)., Conclusions: We elaborate the clinical characteristics and outcomes of patients with ocular chemical injuries in Jinshan District, Shanghai. A comprehensive education program should be established and the use of protective eyewear should be promoted to prevent occupation-related ocular chemical injuries.

Purpose: To explore a new classification scheme for acute ocular burns., Methods: Medical records of 345 patients (450 eyes) with acute ocular burns treated at Shandong Eye Institute between January 2013 and January 2018 with a 12-month minimum follow-up were retrospectively reviewed. A total of 8 parameters in the acute phase were evaluated and graded on a scale from 0 to 3 according to their severity., Results: The key factors affecting the prognosis of acute ocular burns were conjunctival involvement (386 eyes, 85.8%), corneal epithelial defect (349 eyes, 77.6%), and limbal ischemia (244 eyes, 54.2%). Visual acuity in 181/450 eyes (40.2%) was worse than 6/60. The injury severity of the cornea, limbus, bulbar conjunctiva, eyelid, and fornix and intraocular signs in the acute phase was significantly correlated with the logarithm of the minimum angle of resolution (logMAR) visual acuity (correlation coefficient [R] 0.481-0.933, P < 0.0001) and corneal opacification, neovascularization, and symblepharon scores in the stable phase (R 0.513-0.855, P < 0.0001). The mean total score for the 8 parameters in the acute phase was 5.34 ± 4.04 (range 0-14); higher scores indicated worse visual acuity (R = 0.899, P < 0.0001). The total score for acute-phase parameters was significantly correlated with that for the stable-phase parameters (R = 0.872, P < 0.0001)., Conclusions: The severity of acute-phase parameters is significantly correlated with the final visual outcome and prognosis. The new grading scheme can help clinicians more accurately analyze the degree of ocular burns, determine a reasonable treatment protocol, and rationally evaluate the prognosis.

Purpose: To describe a modified non-traumatic amniotic membrane transplantation (AMT) technique and evaluating its efficiency for the ocular surface injury after chemical burn were aimed., Methods: Twenty eyes of 20 patients (F: 6, M: 14) with acute chemical burn for whom modified non-traumatic AMT was utilized were evaluated retrospectively. In this technique, amniotic membrane (AM) was fixated onto a symblepharon ring with continuous suturing. The healing time of the corneal epithelial defect due to ocular surface chemical injury and melting duration of AM were evaluated. Development of infection or symblepharon, recurrence or persistence of epithelial defect, corneal perforation and the ring falling out with AM were evaluated as complications., Results: Mean age of the patients was 24.7 ± 11.7 years old (14 months-40 years). Mean duration of applying the non-traumatic AMT after contact with the chemical agent was 8.4 ± 6.2 days (2-21 days). The mean duration of the epithelial defect healing was 27.8 ± 8.8 days (11-40 days) in the grade II, III, and IV (n = 12) cases, while in the grade V and VI (n = 8) cases, a persistent epithelial defect developed, and the mean duration of the epithelial defect healing was 83 ± 23.1 days (42-120 days) (p = 0.0002). The mean melting duration of the AM was 22.7 ± 10 days (10-42 days)., Conclusion: By using this modified AMT technique, AM can be utilized efficiently, easily, and non-traumatically in every center for the treatment of the ocular surface injury due to chemical burn.

Purpose: The purpose of this study was to investigate the thermal injuries caused by ultrasonic pars plana phacoemulsification and aspiration (PPPEA) using pig eyes., Method: Using a 20-gauge (G) vitrectomy system (Accurus ® , Fragmatome; Alcon Laboratories) in both the 'open-tip' and 'closed-tip' techniques, PPPEA was performed in pig eyes and the subsequent thermal injuries generated around the scleral wound were measured by infrared thermal imaging (thermography). Post surgery, the state of the scleral wound was observed under a microscope, and a tissue slice containing the scleral wound was then prepared and observed under an optical microscope., Results: Thermography measurements revealed a slight temperature rise around the scleral wound in the open-tip case, yet a marked temperature rise in the closed-tip case. The scleral wound incision produced by the open tip was linear, while that produced by the closed tip was expanded. Histological examination revealed mild degeneration of the sclera around the wound in the open-tip case, yet marked tissue degeneration by thermal injuries in the closed-tip case., Conclusion: Our findings showed that in PPPEA, the temperature of the tip of a 20G vitrectomy system rapidly increases due to the closed-tip technique, thus producing obvious thermal damage to the scleral wound. In order to prevent thermal injuries to the scleral wound during PPPEA, it is important to shorten the time of ultrasonic oscillation during surgery as much as possible while the tip is occluded with nuclear fragments.

Purpose: There is currently uncertainty about the most efficacious decontamination solution for corrosive chemical eye burns. This 30-year longitudinal study evaluated the relative efficacy of two different decontamination methods. Passive decontamination consists of rinsing with tap water, 0.9% normal saline, isotonic buffered phosphate solution, or Ringer's lactate. Active decontamination adds an amphoteric, polyvalent, and chelating component with Previn® (Diphoterine®) solution (Laboratoire Prevor, Valmondois, France)., Methods: A prospective evaluation of patients treated in two specialized eye clinics for eye burns was begun in 1988. Recorded data included exposure circumstances, type of corrosive, different types of first therapy, and clinical treatment and outcome. Patients were treated from clinic admission and up to 24 h after the corrosive chemical burn with rinsing for 15 min using two different protocols. From 1988 to 2005, sterile 0.9% normal saline or Ringer's lactate was used. Since 2006, sterile, hypertonic, amphoteric Previn® solution was used. Comparative statistical analysis was done with the Fisher contingency tables and Wilcoxon tests., Results: There were a total of 1495 patients with 2194 chemically burned eyes. In 1988-2005, the annual incidence was 66.1/year; in 2006-2017, it was 65.5/year. Similar incidences were noted when initial rinsing was with tap water or isotonic buffered phosphate solutions. There was a significantly more severe outcome of corrosive chemical eye burns with any first aid rinsing solutions other than Previn® solution or tap water was used (p < 0.001). Previn® solution or tap water rinsing in the pre-hospital setting and secondary rinsing with Previn® solution in the hospital decreased lesion severity in comparison with all other rinsing solutions (p < 0.001)., Conclusion: The frequency of corrosive chemical eye burns was comparatively high despite tightening of occupational health and safety regulations over the past 30 years. The severity of corrosive chemical eye burns has been dramatically decreased since the introduction of Previn® solution for initial and secondary rinsing. A new protocol for immediate Previn® solution use by the Cologne Fire Brigade and secondary Previn® solution rinsing in hospital has reduced the frequency of severe corrosive chemical eye burns to less than 60% as compared to the period of 1988-2005 when other rinsing solutions were utilized.

Objectives: While immediate diagnosis and irrigation is standard chemical eye burn practice, it is unknown to what extent specific pH measurements influence management, given the frequent clinical availability of narrow-spectrum nitrazine pH strips. We hypothesize that exclusive broad-spectrum pH strip implementation leads to more accurate measurement and expedited ophthalmologic consultation., Methods: At a Level I trauma center over 25 months, all emergent adult ophthalmology consultations for chemical burns were included in a pre-intervention (n = 22) and post-intervention (n = 20) study design. During this time, narrow-spectrum nitrazine pH strips available to non-obstetric emergency department (ED) staff were exclusively replaced by broad-spectrum strips. Causative chemical, time from triage to ophthalmology consultation, examination findings, ocular pH by ED and ophthalmology staff, and irrigation quantity were analyzed., Results: Most burns were alkaline. Time from triage (p = 0.043) and irrigation quantity following consultation (p = 0.047) each decreased following exclusive ED implementation of broad-spectrum pH strips. There was greater pH congruence between consulting and primary physicians after intervention (p = 0.03)., Conclusions: Exclusive non-obstetric implementation of broad-spectrum pH strips may allow greater accuracy and faster management of ocular chemical burns. Availability of narrow-spectrum pH strips may be dangerous clinically by falsely reassuring the examiner with inherent inaccuracy., (© 2018 by the Society for Academic Emergency Medicine.)

Purpose: To compare anatomical and functional results between three types of keratoprosthesis (KPro) in chemical injury and autoimmune disease., Methods: 70 clinically comparable cases were included as follows: Boston KPro Type 1 25 eyes, osteo-odonto-keratoprosthesis (OOKP) 23 eyes, Tibial bone KPro 22 eyes. Survival times for anatomical and functional success were evaluated with Kaplan-Meier estimations and Log-rank tests. KPro exchange was considered a complication, not as failure., Results: Prosthesis retention in chemical injury group at 5 years was 86% for OOKP, 100% for Tibial bone KPro, and 65% for Boston KPro (p = 0.09), while in the autoimmune disease group it was 66% for Tibial bone KPro and 50% for Boston KPro (p = 0.19; OOKP only one case). Functional success in the chemical injury group at 5 years was 86% for OOKP, 84% for Tibial bone KPro and 71% for Boston KPro (p = 0.38), while in the autoimmune group, it was 44% for Tibial bone KPro and 15% for Boston KPro (p = 0.15; OOKP only one case). The post-operative complications in all groups were: retinal detachment, vitreous hemorrhage, endophthalmitis, retro-prosthetic membrane, uncontrolled glaucoma, the last two being more common in Boston KPro., Conclusions: For both diagnoses, chemical injury and autoimmune diseases, there was a tendency for better long-term anatomical and functional results with Tibial bone KPro followed by OOKP and Boston KPro Type 1. However, these results were not statistically significant., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To observe spectral-domain optical coherence tomography (SD-OCT) features and to determine whether baseline OCT features can be used as predictors of visual acuity outcome in eyes with acute welding arc maculopathy., Methods: This retrospective study enrolled twenty-two eyes of eleven subjects with acute welding arc maculopathy. All subjects were evaluated by SD-OCT at baseline and final visit. The involved parameters included best-corrected visual acuity (BCVA), central macular thickness (CMT), the length of ellipsoid zone (EZ) defects, the greatest linear dimension (GLD) of outer retinal lesions, EZ reflectivity and relative EZ reflectivity (defined as the ratio of EZ reflectivity to retinal pigment epithelium reflectivity on OCT)., Results: Acute welding arc maculopathy was presented as abnormal hyperreflectivity, hyporeflectivity and defects of outer retinal layer in fovea on OCT. Compared with baseline, BCVA improved significantly accompanied by decreased GLD of outer retinal lesions and the length of EZ defects at final visit (P = 0.0004, P < 0.0001 and P < 0.0001, respectively). No significant changes were shown on CMT (P = 0.248). In multivariate regression analysis, final BCVA was associated with baseline BCVA and the length of EZ defects (P = 0.012 and P = 0.045, respectively). However, EZ reflectivity and relative EZ reflectivity were not associated with final BCVA (P > 0.05)., Conclusion: In conclusion, SD-OCT images clearly reveal morphological changes in outer retinal layer in acute welding arc maculopathy. The baseline BCVA and length of EZ defects are the strongest predictors of final BCVA.

Purpose: Limbal ischemia is an important prognostic factor in the management of ocular burns. In this study, we evaluated the reliability of clinically assessing limbal ischemia among ophthalmic professionals., Methods: This study included 111 ophthalmic professionals who were shown 12 diffuse illumination color slit-lamp photographs of eyes with recent chemical injuries. Respondents were asked whether the photos were assessable and if yes, then to indicate the presence, location, and grade of limbal ischemia in each case. The responses were collected using a standard data collection sheet and the inter-observer agreement was calculated., Results: All participants responded to every question. Of the 1,332 responses, images were deemed assessable in 1,222 (91.7%) instances. The overall agreement (Fleiss' kappa) for the presence of limbal ischemia and severity of limbal ischemia was 0.106 and 0.139, respectively (P < 0.012). Among the four groups of observers, practicing cornea specialists displayed significantly (P < 0.003) higher kappa values (0.201-0.203) when compared to residents (0.131-0.185), fellows (0.086-0.127), and optometrists (0.077-0.102). All indicated a poor level of inter-rater consistency., Conclusion: The results indicate that clinical assessment of limbal ischemia is highly subjective and there is lack of reliability even among cornea specialists who regularly manage patients with ocular burns. A non-invasive, standardized, objective, accurate, and reliable modality for ocular surface angiography is desperately needed for proper assessment and prognostication of ocular burns., Competing Interests: None

Purpose: This study aimed to characterize the injuries involving periorbital region in our severely burned patients., Method: A 2 years retrospective study was conducted with a total of 210 severe burns admissions. Periorbital burn injuries (all produced in association with facial injuries) were encountered in 126 patients, representing the study group that was further analyzed for multiple parameters: demographics, mechanism of injury, TBSA (total body surface area), burn depth, inhalation injury, need for intubation and mechanical ventilation. The presence and severity of ocular injuries were also evaluated., Results: Analyzing our study group (n=126), we observed the presence of multiple negative prognosis factors: elderly patients, extensive burns, deep burns affecting functional areas, unfavorable mechanism (electric, chemical or explosions), inhalation injuries, need for intubation and mechanical ventilation, leading to severe morbidity and high mortality level. Ocular injuries were encountered in 37 patients (30 primary and 7 secondary lesions). The predominance of primary ocular lesions is explained trough high severity burns encountered in our patients with high mortality and lack of long-term clinical observations., Conclusion: The clinical outcome for periorbital burn injuries depends on patient characteristics, etiology, burn extension and depth, associated lesions, infectious risk and the quality of the treatment applied. Presence of ocular injuries in various severity degrees impose an adequate evaluation and specialized treatment, being associated with important morbidity. In severely burned patients, it is mandatory to apply preventive measures to avoid ocular complications. If exposure keratopathy is detected, prompt ophthalmologic treatment is essential to avoid functional impairment including loss of vision. Abbreviations: TBSA = total body surface area, MSOF = multisystem organ failure, OCS = orbital compartment syndrome, AION = anterior ischemic optic neuropathy.

We wish to report an ocular chemical injury caused by inadvertent dispensing and administration of an erectile dysfunction cream (Vitaros) instead of an ocular lubricant (VitA-POS) to highlight this potential source of error. Prescribing errors are common, and medications with similar names/packaging increase risk. However, it is unusual in this case that no individual (including the patient, general practitioner or dispensing pharmacist) questioned erectile dysfunction cream being prescribed to a female patient, with ocular application instructions. The patient was treated for a mild ocular chemical injury with topical antibiotics, steroids and lubricants, with good response. However, we believe this to be an important issue to report to enhance awareness and promote safe prescribing skills., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2018. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To evaluate and describe the microstructural changes at the ocular surface in response to habitual ocular sun exposure, correlate them with the UV protection habits and follow their dynamics using in vivo confocal microscopy(ICM)., Methods: For a period of minimum 4 months 200 subjects (400 eyes), aged 28 ± 7.3 years, were recruited with the agreement that they will spend their summer exclusively in the region of the Black Sea coast at 43 °N latitude and will be examined before and after the summer. All subjects filled in a questionnaire about habitual UV protection and were examined clinically and by ICM., Results: Questionnaire results demonstrated that 83.5% (167 participants) of the subjects considered the sun dangerous for their eyes, but 78% (156 subjects) believed that there is danger exclusively during the summer period. Although no clinical changes were detected, microstructural analysis of the cornea demonstrated statistically significant (p = 0.021) decrease of the basal epithelial density - from 6167 ± 151 cells/mm 2 before to 5829 ± 168 cells/mm 2 after the summer period. Microstructural assessment of the conjunctiva demonstrated characteristic cystic lesions with dark centres and bright borders encountered in only 25 eyes(6%) before, and affecting 118 eyes(29.5%) after the summer. The total area of the cysts after the summer increased fivefold. Spearman analysis proved negative correlation between sun protection habits and number of cysts., Conclusion: Summer sun exposure for one season leads to clinically undetectable, microstructural changes affecting the cornea, bulbar and palpebral conjunctiva with transient, but possibly cumulative nature., (Copyright © 2018 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.)

Purpose: To present data on chemical ocular burns in children seen at a single tertiary care facility resulting from accidental eye exposure to the contents of laundry detergent pods., Methods: All emergent pediatric ophthalmology consultations specific for chemical ocular burns at a level I trauma center were included as part of a prospective quality improvement investigation over a 13-month period. Age, causative agent, and examination findings at presentation and final follow-up were recorded and analyzed., Results: A total of 12 children with chemical ocular burns were seen during the study period. All patients were ≤5 years of age. Most chemical ocular burn consultations (n = 8) were specific to ocular exposure of laundry detergent pod contents; the remainder were associated with conventional cleaning agents or pesticides (n = 4). There was a significant association between laundry detergent pod as causative agent and a patient age of 2-5 years, compared to <2 years and any other agent (P = 0.018 [Fisher exact test])., Conclusions: In our study, laundry detergent pods were the most frequent cause of chemical ocular burns in children. Additionally, preschoolers may be at a higher risk of sustaining these injuries. Increased public awareness, product safety improvements, and/or regulation may be advisable to decrease the ocular hazards associated with laundry detergent pods., (Copyright © 2018 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Chemical burn injury of the eye is a medical emergency that requires immediate intervention and structured ophthalmic assessment without unnecessary delay. Chemicals, alkali in particular but also acids, cause profound damage to the anatomy of the ocular surface or even deeper eye structures. The injury is potentially sight-threatening and can, in the worst cases, lead to loss of the eye. Reconstructive surgery is complex and often involves multiple surgeries but can give very good results in carefully selected cases. This article summarizes present evidence-based guidelines relevant for Swedish conditions and in use at St. Erik Eye Hospital in Stockholm.