The author provides a review of the current literature regarding the principles of classification, management protocols of acute ocular and periocular burns and the role of the burn and oculoplastic surgeon involved in their care.
More than two-thirds of facial burns involve the eye or periocular area and 7.5-27% of all patients treated for burns have ocular involvement. Eighty-four percent of these are due to chemicals and 16% due to thermal injury. Reflex blinking of eyelids, Bell’s phenomenon, in response to heat and smoke, and protective movements of the arms and head, usually protect the cornea and eyelid margins.
Frequent ocular injuries seen as a result of facial burns include lid burns, corneal burns, foreign bodies, abrasions, perforations and contracture leading to ectropion. Because of the life-threatening nature of severe burn injuries to the face and the associated massive swelling of eyelids, ocular injuries may not be noticed early and treatment may be delayed. Appropriate early intervention can have a significant effect on the final outcome for the burn patient. Permanent visual impairment is rare if prompt management is done. Superficial lid burns usually heal spontaneously and can be managed conservatively with ophthalmic antibiotic ointments, artificial tears. However, in deeper burns, early surgical intervention in the form of eschar debridement or release of contracted lids and resurfacing defects with split skin grafts can prevent secondary corneal damage. This paper is a review of the current literature regarding the principles of classification, management protocols of acute ocular and periocular burns and the role of the burn and oculoplastic surgeon involved in their care.
Eyelids are important structures and play a role in protecting the globe from trauma, brightness, in maintaining the integrity of tear films and moving the tears towards the lacrimal drainage system and contribute to the aesthetic appearance of the face. Periocular burns involving eyelids and adjacent structures have been found to have increased recently. A comprehensive classification of periocular burns would help in stratifying these injuries, as well as study outcomes.
Figure 1: Common causes of alkali and acid injuries.
Burns to the eyelids may be caused by thermal, electrical, chemical or ionising radiation sources. The most serious injuries are due to chemical burns by strong acid or bases. Chemicals can be classified as either acidic or alkaline agents (Figure 1); a new classification of ocular surface burns. Many of these are used in homes, industries and agriculture, causing burns when they come into contact with the eye, resulting in a significant threat to vision, especially those that are alkaline. The extent and severity of the injury is influenced by various factors, such as the nature, quantity and concentration of the solution, the contact duration, solution penetrability and pH. While most burns occur from direct contact with the outer eye surfaces, chemicals can also reach the ocular tissue through systemic absorption via the skin, lungs or digestive tract. The intact cornea can resist a wide range of pH without injury, but a pH <4 or >10 results in an increase in permeability, which can cause severe ocular complications. The purpose of managing these burns is to eliminate or limit the causative agent from penetrating the ocular structures by irrigation; and, promoting ocular surface healing through medical and surgical intervention.
Eyelid burns are classified depending on how deep and severe they penetrate the skin’s surface (Table 1).
Two major classification schemes for corneal burns are the Roper-Hall (modified Hughes) classification and the Dua classification (Figure 2).
Figure 2: The two major classification schemes for corneal burns:
the Roper-Hall (modified Hughes) classification and the Dua classification.
The Roper-Hall classification is based on the degree of corneal involvement and limbal ischaemia. The Dua classification is based on an estimate of limbal involvement (in clock hours) and the percentage of conjunctival involvement. In a randomised controlled trial of acute burns, the Dua classification was found to be superior to the Roper-Hall in predicting outcome in severe burns. However, both classification schemes are commonly employed in daily practice. A reliable system to address eyelid injuries, the system for periocular trauma classification for periocular injuries (SPOT) (Figure 3), has taken into account the periocular soft tissue injuries, i.e. upper eyelid, lower eyelid, medial and lateral canthus injuries, based on observed clinico-anatomical patterns of eyelid injuries.
Figure 3: SPOT classification.
This classification scheme provides guidance for ophthalmic and facial reconstructive surgeons to provide optimal outcomes in eyelid injuries. Based on the classification scheme and review of existing literature, an algorithm is presented to facilitate repair and reconstruction (Figure 4).
Figure 4: Zone topography according to the SPOT classification.
While there is variability in treatment strategies of chemical burns, most authors recommended a graded approach depending on the severity of injury. Mild burns (Roper-Hall grade I) respond well to medical treatments and lubrication, while more severe burns necessitate more intensive medical therapies and surgery. Table 2 shows a paradigm for the initial treatment of chemical injury based on the Roper-Hall grade of injury.
Figure 5: Stages of ocular recovery following chemical injury.
The goal in the management of periorbital burns is preservation of vision, prevention of future complications and restoration of an acceptable aesthetic outcome. Total visual loss is thankfully rare, but early ophthalmology intervention is vital given the evidence of corneal damage as a brief therapeutic window exists.
The final outcome of an eye burn depends on the cause of the burn, the depth of the injury, which structure(s) of the eye were involved, whether other parts of the body were burned, and the development of complications. With eye burns of any type, close follow-up care is important during the first several weeks to prevent scarring, exposure keratitis and other complications of ocular and periocular burns. Primary prevention and patient counselling on proper eye protection, first aid measures, and initial management is essential because most of the ophthalmic complications can be avoided with these measures.
The medical team working in the burn casualty must prioritise first aid measures in all facial burn patients, like irrigation of the eyes, trimming of the charred eyelashes, use of artificial tears, padding of the eyes and topical antibiotics. A thorough ophthalmological examination in the first 24 hours of burn injury must be made mandatory. Consequent eye examinations must be made to look for any adverse consequences and any intervention made as early as possible to prevent adverse outcomes in these patients.
Classification systems are necessary in order to provide a framework in which to scientifically study the aetiology, pathogenesis and treatment of diseases in an orderly fashion. Based on classification schemes, the ophthalmic, oculoplastic and facial reconstructive surgeons will be guided to provide optimal outcomes in eyelid injuries in order to facilitate repair and reconstruction.
Declaration of competing interests: None declared.
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