Additional Steps to be Taken

• Perform slit lamp examination, take the visual acuity and the IOP (oral acetazolamide treatment must be initiated if the IOP is elevated), measure the pH of the ocular surface, and grade the injury.

• If the injury is Grade I or II, topical therapy should be used: corticosteroids [17]; ascorbic acid [5, 16]; and antibiotics. Admission is not mandatory,12 but daily evaluations are recommended until the corneal epithelium is healed.

• If the injury is Grade III or IV,i3 the irrigation must be continued, using phosphate-free solutions such as Isopto Max" or Corti-bicironi5 [17], and the patient should be admitted.

• All efforts are aimed at rescuing the limbal stem cells [19] by reducing the inflammation and scar formation (and by subsequent surgery, see below). Hourlyi® drops of corticosteroids, ascorbic acid, and antibiotics, continued for up to 2 weeks, are employed.

• Superficial debridement should be done twice daily by rinsing the eye with ringer lactate solution.

• A round-tipped glass rod should be rolled across the upper and lower fornices to prevent adhesion development.

• If insufficient limbal regeneration is seen within the first 4 days, an amniotic graft should be placed to secure the corneal surface and improve healing.

• At least 2 days after the injury, the demarcation of necrotic areas is well appreciated. The necrotic tissue should be surgically removed; if the necrosis involves large areas of the limbus and conjunctiva, an initial tenonplasty is required [12]. Tenon's capsule is bluntly dissected; its soft sheets are advanced up to the limbus (Fig. 3.1.3) and fixed to the

12 This also depends on factors such health insurance system, the patient's socioeconomic and hygienic situation, and financial circumstances.

13 The prognosis is poor, mostly because of the damage to the limbal stem cells.

14 Alcon Pharma GmbH, Freiburg, Germany

15 S&K Pharma, Perl, Germany

16 Ointment is used for nighttime.

sclera by full-thickness sutures (similar to that in scleral patching; see Chap. 2.3).

• In Grade IV burns, the primary goal of treatment is to prevent secondary damage such as glaucoma or ulceration with perforation.

Fig. 3.1.3 Prochaska-Marburg tenonplasty. The epibulbar tissues are liberated and advanced up to, and sutured to, the limbus. a Schematic drawing. b Intraoperative photograph

Once the acute phase is passed and the surface of the eye is stable, the patient can be discharged on topical corticosteroids, antiglaucoma medications, and antibiotics; these are used until the redness diminishes.

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