Severe Ocular Burns
the treatment of corneal limbal destruction and its complications.27 It addresses unilateral limbal insufficiencies when there is a contralateral healthy eye donor. The complete conjunctival pannus that covers the cornea is removed beyond the limbus by about 3 mm. The graft is removed through a cornea incision located 1 mm forward of the limbus. The dissection realises a tunnelling of about 2 mm behind the limbus. To avoid creating a limbal insufficiency in the eye donor, the graft cannot exceed a 180°.28
Limbal autotransplant allows
a corneal re-epithelialisation of good quality in 75–100 % of cases and constitutes a barrier to a neovascular cicatricial phenomenon of conjunctival origin.29
The optimum period between the burn date
and intervention is disputed. Most authors believe it is better to wait several months to allow diminution of inflammatory reaction. Nevertheless, some recommend to intervention early on, that is before the appearance of complications linked to the LSC deficit.8
The aim
of limbal allotransplant is identical to that of an autotransplant. Limbal allotransplant is recommended for widespread limbal lesions that are bilateral or unilateral on only one eye.
The amniotic membrane is a tissue located at the interface between the placenta and the amniotic liquid was first used for ocular burn by Sorsby and Simmonds in 1947.30
It is composed of an unstratified
epithelium, a basement membrane and an avascular mesenchyme. The amniotic membrane facilitates re-epithelialisation by decreasing the inflammatory and cicatricial reaction.31
A piece of amniotic membrane,
epithelial face up, is sutured to the cornea by separated points of nylon 10/0. The amniotic membrane is covered by the corneal epithelium, integrated with the stroma and then resorbed. The current practice is to realise the amniotic membrane transplant rapidly, during the early phase of the burn. Good results are also observed when it is performed later on.
Usually around 10 %, the rejection risk of transfixiant keratoplasty (TK) is higher in cases of chemical burn, especially because of the frequency and the importance of stromal neovascularisation of the receptor cornea.32
TK does not introduce LSCs and it is not
1. Zagelbaum B, Tostanowski J, Kerner D, Hersh PS, Urban eye trauma, Ophthalmology, 1993;100:851–6.
2. Jones NP, Hayward JM, Khaw PT, et al., Function of an ophthalmic accident and emergency department: results of a six months survey, Br Med J, 1986;292:188–90.
3. Morgan SJ, Chemical burns of the eye: causes and management, Br J Ophthalmol, 1987;71:854–7.
4. Schultz GS, Strelow S, Stern GA, et al., Treatment of alkali-injured rabbit corneas with a synthetic inhibitor of matrix metalloproteinases, Invest Ophthalmol Vis Sci, 1992;33:3325–31.
5. Tseng SC, Concept and application of limbal stem cells, Eye, 1989;3:141–57.
6. Roper-Hall MJ, Thermal and chemical burns of the eye, Trans Ophthalmol Soc UK, 1965;85:631–46.
7. Dua HS, King AJ, Joseph A, A new classification of ocular surface burns, Br J Ophthalmol, 2001;85:1379–83.
8. Wagoner MD, Chemical injuries of the eye: current concepts in pathophysiology and therapy, Surv Ophthalmol, 1997;41:275–313.
9. Gérard M, Merle H, Chiambaretta F, et al., An amphoteric rinse used in the emergency treatment of a serious ocular burn, Burns, 2002;7:670–3.
10. Kuckelkorn R, Kottek A, Reim M, Intraocular complications after severe chemical burns: incidence and surgical treatment, Klin Monatsbl Augenheilkd. 1994;205:86–92.
11. Burns FR, Paterson CA, Prompt irrigation of chemical eye injuries may avert severe damage, Occup Health Saf, 1989;58:33–6.
12. Schrage NF, Kompa S, Haller W, Langefeld S, Use of an amphoteric lavage solution for emergency treatment of eye burns. First animal type experimental clinical considerations, Burns, 2002;28:782–6.
13. Kuckelkorn R, Keller G, Redbrake C, Emergency treatment of
Keratoprosthesis remains the ultimate surgical resource for bilateral corneal blindness, when TK and LSC treatments are no longer realisable. Although harder to perform, the results of keratoprosthesis are sometimes very encouraging.33
Initially developed by Thoft, conjunctival transplants do not allow corneal epithelium healing.34
In this area it has been replaced LSC
transplants. Nevertheless, it remains indicated for conjunctival fornix reconstruction corrected by cicatricial fibrosis.
Conclusion
Chemical burns can be responsible for severe, bilateral and irreversible alteration to the visual function. The initial clinical examination is sometimes hard to perform because of the severe symptomatology. Nevertheless, it allows classification of the lesions, establishes a prognosis and most importantly, guides the therapeutic care. Prognosis for the worst ocular burns has improved during the past decade thanks to a better knowledge of the corneal epithelium physiology. Surgical techniques to restore LSCs that were destroyed have changed the prognostics of severe corneal burns.
Above all, prevention is essential to decrease the incidence of burns, especially in the industrial world, since a large number of dramatic cases could have been avoided with a minimum of information, training and regulation. n
chemical and thermal eye burns, Acta Ophthalmol Scand, 2002;80:4–10.
14. Gérard M, Josset P, Louis V, et al., Existe-il un délai pour le lavage oculaire externe dans le traitement d’une brûlure oculaire par l’ammoniaque? Comparaison de deux solutions de lavage: sérum physiologique et Diphotérine®, J Fr Ophtalmol, 2000;5:449–58.
15. Merle H, Donnio A, Ayéboua L, et al., Alkali ocular burns in Martinique (French West Indies). Evaluation of the use of an amphoteric solution as the rinsing product, Burns, 2005;2:205–11.
16. Morgan SJ, A new drug delivery system for the eye, Industrial Med, 1971;40:11–3.
17. Brodovsky SC, McCarty CA, Snibson G, et al., Management of alkali burns. An 11-year retrospective review, Ophthalmology, 2000;107:1829–35.
18. Brent BD, Karcioglu ZA, Effect of topical corticosteroids on goblet-cell density in an alkali-burn model, Ann Ophthalmol, 1991;23:221–3.
19. Chung JH, Kang YG, Kim HJ, Effects of 0.1 % dexamethasone on epithelial healing in experimental corneal alkali wounds: morphological changes during the repair process, Graefes Arch Clin Exp Ophthalmol, 1998;236:537–45.
20. Davis AR, Ali QH, Aclimandos WA, Hunter PA, Topical steroid use in treatment of ocular alkali burns, Br J Ophthalmol, 1997;81:732–4.
21. Perry HD, Hodes LW, Seedor JA, et al., Effect of doxycycline hyclate on corneal epithelial wound healing in the rabbit alkali-burn model. Preliminary observations, Cornea, 1993;12:379–82.
22. Seedor JA, Perry HD, McNamara TF, Golub LM, Systemic tetracycline treatment of alkali induced corneal ulceration, Arch Ophthalmol, 1987;105:268–72.
23. Pfister RR, Paterson CA, Ascorbic acid in the treatment of alkali burns of the eye, Ophthalmology, 1980;87:1050–7.
24. Reim M, Overkamping B, Kuckelkorn R, 2 years’ experience with Tenon-plasty, Ophthalmologe, 1992;89:534–40.
25. Kuckelkorn R, Schrage N, Reim M, Treatment of severe eyes burns by tenoplasty, Lancet, 1995;345:657–8.
26. Schermer A, Galvin S, Sun TT, Differentiation-related expression of a major 64K corneal keratin in vivo and in culture suggests limbal location of corneal epithelial stem cells, J Cell Biol, 1986;103:49–62.
27. Shimazaki J, Shimmura S, Tsubota K, Donor source affects the outcome of ocular surface reconstruction in chemical or thermal burns of the cornea, Ophthalmology, 2004;111:38–44.
28. Holland JH, Schwartz GS, The evolution of epithelial transplantation for severe ocular surface disease and a proposed classification system, Cornea, 1996;15:549–56.
29. Frucht-Pery J, Siganos CS, Solomon A, et al., Limbal cell autograft transplantation for severe ocular surface disorders, Graefes Arch Clin Exp Ophthalmol, 1998;236:582–7.
30. Sorsby A, Simmonds H, Amniotic membrane graft in caustic burns of the eye (burns of second degree), Br J Ophthalmol, 1947;31:409–18.
31. Hao Y, Ma DH, Hwang DG, et al., Identification of antiangiogenic and anti-inflammatory proteins in human amniotic membrane, Cornea, 2000;19:348–52.
32. Brown SI, Bloomfield SE, Pearce DB, Follow-up report on transplantation of the alkali burned cornea, Am J Ophthalmol, 1974;77:538–42.
33. Stoiber J, Forstner R, Csaky DC, et al., Evaluation of bone reduction in osteo-odontokeratoprosthesis by three- dimensional computed tomography, Cornea, 2003;22:126–30.
34. Thoft RA, Conjunctival transplantation, Arch Ophthalmol, 1977;95:1425–7.
sufficient to treat widespread limbal ischaemia. It must be performed with a limbal transplantation. TK can be realised at the same time as a limbal allotransplant. Nevertheless, epithelial scarring and the corneal transparency are better when the TK is realised later on (between one and 13 months).27
Profound lamellar keratoplasty consists of stroma and graft epithelium transplants while respecting Descemet’s membrane and the receiving endothelium. It is used for corneal burns that do not affect Descemet’s membrane and the endothelium.
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