Abstract
Purpose:To develop clinical practice guidelines (CPGs) for prevention, diagnosis, treatment and follow-up of ocular injuries caused by exposure to mustard gas.Methods:The clinical questions were designed by the guideline team. Websites and databases including National Guidelines Clearinghouse, National Institute for Clinical Excellence, Cochrane, and PubMed were searched to find related CPGs and explore possible answers to the clinical questions. Since there were no relevant CPGs in the literature, related articles in Persian and English languages were extracted. Each article along with its level of evidence was summarized. Additionally, hand search was performed by looking the reference list of each article. Consequently, recommendations were developed considering the clinical benefits and side effects of each therapeutic modality. The recommendations were re-evaluated in terms of customization criteria. All recommendations along with the related evidence were scored from 1 to 9 by experts from all medical universities of Iran. The level of agreement among the experts was evaluated by analyzing the given scores.Results:The agreement was achieved for all recommendations. The experts suggested a number of minor modifications which were applied to the recommendations. Finally, CPGs were developed with 98 recommendations under three major domains including prevention of injury, diagnosis and management of the acute and delayed-onset mustard gas ocular injuries.Conclusion:Considering the lack of CPGs for the prevention, diagnosis, and management of mustard gas-induced keratitis, these recommendations would be useful to prevent the serious ocular complications of mustard gas and standardize eye care services to the affected individuals.
Highlights
Mustard gas (MG) is a cytotoxic chemical agent with the ability to form large blisters
A‐1‐ When there is the possibility of using MG, it is recommended to prevent ocular injuries by considering the following points: A‐1‐1‐ It is recommended that all personnel carry necessary standard protective equipment including
Evidence levels (EL): II ‐ Consensus C‐3‐2‐5‐ Temporary* or permanent punctual occlusion[22,27,29,30,31] EL: II ‐ Consensus C‐3‐2‐6‐ Tarsorrhaphy in case of severe dry eye[22,27] EL: II C‐3‐2‐7‐ Prescribing the corticosteroids eye drops with control of possible complications or topical cyclosporine A (0.05%) (Twice a day)[22,27,29,30,38,75] EL: II C‐3‐2‐8‐ In cases with significant peripheral corneal thinning who present with noticeable symptoms such as redness, tearing, decreased visual acuity and risk of corneal perforation, kratolimbal allograft surgery is recommended.[31]
Summary
Mustard gas (MG) is a cytotoxic chemical agent with the ability to form large blisters. It is available in sulfur mustard and nitrogen mustard forms;[1] both of them are used as a chemotherapy agent in the treatment of some dermatological diseases.[2] While nitrogen mustard is more toxic, sulfur mustard (SM) is more common as a chemical weapon since it can remain active for a longer period of time.[3,4,5,6,7]. SM was used as a chemical weapon for the first time in 1917, on a battlefield in Ypres, Belgium, during World War I.[8,9,10,11] The majority of MG victims were inflicted during wars. The highest rate of MG use as a chemical warfare was in the Iraq‐Iran war (1980–1988).[12,13]
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