Severe Eye Burns Research Articles

Tarsoconjunctival Advancement: A Modified Surgical Technique to Correct Cicatricial Entropion and Metaplasia of the Marginal Tarsus

Severe eye burns and mucocutaneous cicatricial disorders frequently cause upper and lower lid entropion with metaplasia of the tarsal conjunctiva, dislocation of the meibomian gland orifices, trichiasis, and tarsal scars near the lid margin. Between 1985 and 1993, 26 patients (29 eyes, 36 lids) were treated by excision of pathologic tissue and advancement of the tarsoconjunctival layer. The presented procedure is used mainly in cicatricial entropion with keratinization of the marginal tarsus.

Autologous transplantation of nasal mucosa after severe chemical and thermal eye burns.

Between February 1992 and March 1994, reconstruction of the fornices in 17 patients with extensive symblephara or lid fusion after most severe eye burns was performed with nasal mucosa from the inferior conchae as graft material. The time between accident and transplantation ranged from 2-64 months. All patients were followed for 6 to 31 months. Reconstruction of the fornices was achieved in 13 patients. Postoperative Schirmer-tests revealed markedly improved results. Impression cytology showed a persistence of goblet-cells and an excess of mucus. We have subsequently performed keratoplasties in 5 of these patients and are planning penetrating keratoplasties in a further 8 cases. In 4 patients, partial symblepharon formation recurred within 2-3 months after transplantation of nasal mucosa. The main advantage of nasal mucosa over buccal or labial mucosa may be the transplantation of intraepithelial goblet cells, leading to an improvement and stabilisation of the tear film.

Fluorescence angiography of the anterior eye segment in severe eye chemical burns

Severe eye burns usually result in extensive necrosis of the conjunctiva and subconjunctival tissue. To reduce the reactive inflammatory response excision of the necrotic tissue is necessary. Between August 1990 and December 1994 fluorescein angiograms of the anterior eye segment were performed in 13 (17 eyes) patients with most severe eye burns. The angiographies were carried out 1-4 days after the accident. Conventional photo angiography was performed using a fundus camera (NF 505-AF Nikon). The angiograms revealed characteristic patterns that provided exact information on the perfusion of burned conjunctival and underlying tissue. It was particularly useful in the detection of clinically not recognisable subconjunctival ischemia. In addition, perfusion of the episcleral vessels and the extent of scleral ischemia could be quantified. According to the angiographic findings subtile excision of the necrotic tissue was performed and vascularized tissue was preserved. Anterior segment angiography is a valuable method in assessing the extent of necrosis of the conjunctiva and underlying tissue and in determining scleral ischemia. It provides a basis for deciding the extent of surgical debridement of necrotic tissue in the acute phase of the burn. The quantification of limbal and scleral ischemia may give useful information for early plastic-reconstructive procedures.

Expert assessment of initial surgical management after experimental chemical eye burn

Initial surgical treatment of severe eye burns is important for the long lasting healing period. To look closer at the efficacy of the early surgical treatment and the possible consequences for woundhealing, the surgical interventions were examined in an animal experiment. The right eye of 20 rabbits each was burned with 1 n NaOH for 30 seconds followed by a surgical treatment 48 hours later. In the first study necrosectomy, tenonplasty, application of an artificial epithelium and blepharoplasty was withdrawn and the fornices were prevented from cicatrization by mechanical treatment treatment with blunt spatula. Antiinflammatory depotinjection of Volon A 40 was applicated additionally. After an interval of 4-18 weeks the eyes were examined histologically. A higher risk for infections could be observed in eyes which underwent blepharorhaphy. Furthermore proliferative processes and corneal ulcerations were predominant. In contrast to these findings the latter complications could be prevented due to the clinical inspection of the artificial epithelium and described mechanical irritation of the fornices in the second study. It could be shown that proliferative processes are major complications after severe burns of the eye. Nevertheless the intensity could be minimized by the consequent therapy. Furthermore it could be demonstrated that the artificial epithelium is an effective tool providing good prognosis for subsequently planned keratoplasty. To enable necessary postoperative inspection blepharoplasty should be avoided.

Therapy of persistent erosion after severe chemical eye burn with the excimer laser

The course after severe eye burns is characterized by many complications which require a longlasting and intensive therapy. The success of treatment is menaced especially by superficial problems like persistent erosiones which occur also after keratoplasty. As a cause of persistent erosions, pathological changes of Bowmans' membrane are discussed. Therefore, it was removed by PTK (phototherapeutic keratectomy) in our patient, in order to allow better adhesion of the epithelium to the deeper, less changed layers. The patient suffered from a severe burn accident of his right eye with liquid cement. After proliferations were excised twice, we had to glue on a hard contact lens as an artificial epithelium due to a persistent erosion. Later, the development of a bacterial keratitis required keratoplasty. The epithelium remained intact for eleven months, but then an erosion arose and persisted for nine months. Therefore we performed a PTK and the epithelium closed subsequently within four days. The treatment of persistent erosions has been very difficult so far, and often procedures like artificial epithelium or even keratoplasty have been necessary. The astonishing course of our patient indicates, that PTK is a promising and less invasive therapy in these cases.

Keratoplastik mit Skleraring nach schwersten Verätzungen des vorderen Augenabschnittes

Corneo-scleral ulcerations and perforations are severe complications after most severe eye burns. One possibility to handle this situation is a keratoplasty with a scleral rim. This retrospective study was carried out to show the outcome after total replacement of the cornea after most severe eye burns. Between 1986 and 1991 we carried out 12 keratoplasties with a scleral rim in 9 most severely burnt eyes of 7 patients. In 9 cases this intervention was the first transplantation. In 3 eyes a re-keratoplasty had to be carried out. All eyes could be saved after this surgical intervention, although all but two transplants failed. In eight cases the transplant decompensated and/or was replaced by scar tissue. Two transplants remained clear. Visual acuity was light perception in five cases, intact light projection in two cases, 1/35 in one case because of cataract formation and 0.8 in another case at the end of the observation period. The reasons for graft failure were multifactorial. Epithelial problems were the reason for graft failure in eight cases. Two of these also showed shrinkage of the eye lids with incomplete lid closure. In six cases severe vascularisation with scar formation was observed. It is remarkable that immunoreactions occurred only in four cases. This may be due to the fact that all patients were treated systemically with cyclosporin A. In one case the transplant failed after extensive surgery of the anterior segment. Our results show that the keratoplasty with a scleral rim can save the eye in the difficult situation of corneo-scleral ulceration or perforation. Nevertheless a visual rehabilitation could not be achieved in seven of nine cases. But all eyes were in a satisfying condition for further smaller transplants to achieve better visual acuity.

2213 Early treatment of severe eye burns with an excimer laser

2213 Early treatment of severe eye burns with an excimer laser

Early treatment of severe eye burns with an excimer laser

Early treatment of severe eye burns with an excimer laser

Therapeutic hydrophilic bandage lenses after perforating keratoplasty in severe eye chemical burns

The prognosis of penetrating keratoplasty after severe eye burns is uncertain. Beside of immune reactions the outcome is determined by surface problems. Between July 1991 and October 1993 in 15 patients (16 eyes) with grade IV eye burns penetrating keratoplasties with large diameters (11-16 mm) were carried out. Cultured corneas were used with an intact epithelium. In 9 eyes hydrophilic bandage lenses (Geaflex 70, Fa. Wöhlk, Kiel) were applied initially, in the remainder 7 eyes within 7 days postoperatively. The lens radius best suited was found out by trial, because corneal topography was not possible for many weeks. In 12 (75%) eyes the lens had to be fitted steep, with a radius from < or = 8.7. A change in lens radius during the healing course was rare. The frequent use of artificial tear drops was important, because many eyes showed clinical manifestations of dry eye syndrome. Complications during soft contact lens wearing were rare. In 5 eyes microbiological examination was positive, but successfully treated. Under the protection of soft contact lenses 9 eyes maintained an intact epithelium. In the remainder eyes severe vascularisation with large persistent epithelial defects occurred mostly as a consequence of immune reactions. These keratoplasties developed on growth of inflammatory pannus or progressive ulceration. The average of the follow-up time was 22 months. The use of large diameter keratoplasties in combination with hydrophilic bandage lenses proved to be successful to maintain the integrity of the epithelium in these high-risk keratoplasties. The prognosis of these transplants is, however, determined by immune reactions.

Poor prognosis of severe chemical and thermal eye burns: the need for adequate emergency care and primary prevention.

The epidemiology and wound healing following medical and surgical treatment of 101 patients with 131 severely burnt eyes due to chemical or thermal agents have been analyzed. Most of the accidents occurred at work (72.3%); the majority of the burns were chemical (84.2%), of which 79.8% were caused by alkalis. The long average duration of treatment on ward (5.2 +/- 4.1 months) and the high number of surgical interventions (8.0 +/- 8.0) indicate the difficulties in treatment and the delayed recovery of the affected eyes. Despite improved possibilities of immuno-suppression after keratoplasty (cyclosporin A) and new methods of surgery (Tenon plasty), the possibilities of an optical rehabilitation are still limited. A visual acuity of 6/60 or better was achieved in 39 eyes (32.2%). Immediate irrigation was reported in 56.1% of accidents at the place of work and in 42.8% of accidents sustained at home. There was a significant difference with respect to the extent of damage, the treatment on ward and the number of surgical interventions. The visual prognosis for eyes which received immediate irrigation was significantly improved. Eye protection was not used in any of the 101 cases. Spread of information is necessary for adequate emergency care for eye burns as well as for permanent employment of protective glasses in high-risk occupations.

Conjunctival tissue examination in severe eye burns: a study with scanning electron microscopy and energy-dispersive X-ray analysis.

Long-lasting inflammation is a major problem in treatment after severe eye burns and may find expression in an altered elemental composition of the conjunctiva. Particulate contamination of biological tissue induces such inflammatory processes. In the anterior eye segment, trauma or subsequent therapy may give rise to such contamination. Scanning electron microscopy and energy-dispersive X-ray analysis are able to detect traumatic residues of submicron size and changes of the elemental composition. Conjunctival specimens from first-time peridectomy of three healthy and nine severely burnt-eyes were examined with scanning electron microscopy and energy-dispersive X-ray analysis. The samples were prepared as cryo- or paraffin sections, mounted on carbon blocks and coated with evaporated elemental carbon. The samples of healthy conjunctiva showed higher concentrations of Na, P and CI. These elements showed lower concentrations in conjunctival stroma of burnt eyes excised before the 20th day after trauma than in material obtained subsequently. In two burnt conjunctival specimens there was severe traumatic contamination with Ca in Ca(OH)2 and CaO burns, and in one case the traumatic substance was Si, in a peroxide plus silicone spray burn. In the remaining six cases, particulate contamination with Fe, Al, Ni, Zn, Cu, Ti and other substances was present in the burnt conjunctivas, while no contamination was detected in the specimens of healthy conjunctivas. The origin of the contaminant particles is assumed to be the trauma itself and the subsequent therapy. These investigations stress the importance, for clinical purposes, or early peridectomy and contamination-free therapy.

Intraokulare Komplikationen nach schweren Verätzungen - Häufigkeit und chirurgische Behandlung

The prognosis of severe eye burns is determined by the area of the injured conjunctiva and the damage of the cornea. Furthermore the extension of damage to intraocular structures influences the clinical course and the surgical management. The clinical course of 66 patients with 90 severely burnt eyes in the time from January 1985 to December 1993 were examined with special regard to primary and secondary intraocular complications. In 62 (68.9%) eyes, the whole anterior eye segment was burnt, while in 28 (31.1%) eyes the damage was limited to the cornea and limbus. A cataract occurred in 23 (25.6%) eyes short time after the burn and an early secondary glaucoma in 14 (15.6%) eyes. In the further clinical course, 41 (45.6%) eyes developed a secondary cataract and 20 (22.2%) eyes a late secondary glaucoma. Within 3 months after the burn, 18 eyes were treated with a Tenon plasty, a penetrating keratoplasty and a cataract extraction. In 12 eyes a cataract extraction was combined with a penetrating keratoplasty more than one year after the injury. In the other cases cataract extraction and keratoplasty were performed in separate operations. In 8 eyes intraocular lenses were implanted. In 15 (16.6%) eyes secondary glaucoma had to be treated by trabeculectomy or by the implantation of a von Denffer implant. Penetrating keratoplasty was performed in 55 eyes, 35 of them were unsuccessful as a consequence of graft rejection or increasing vascularisation. One third of the patients achieved a long-term visual acuity of 0.1 and more. After severe burn a high rate of intraocular complications has to be expected. The surgical management of such eyes differs from standard procedures. Principally, all devitalized tissue of the anterior chamber like fibrinous and retrocorneal membranes should be excised in an early stage after the burn. Penetrating keratoplasties and extraction of the cataractous lens should be performed in a combined procedure. The implantation of an intraocular lens is limited to a few special cases.

Autologous transplantation of nasal mucosa after severe chemical and thermal eye burns

Extensive conjunctival scarring is common after severe chemical and thermal eye burns. There is often not enough healthy conjunctiva from the other eye available to correct the symblepharons, therefore other autologous tissues have to be transplanted. From February 1992 until March 1993 13 patients were treated with free nasal mucosal grafts from the inferior turbinates for reconstruction of the fornices. The newly created deep fornices were secured by a silicone band. In 3 patients an Illig plastic shell was used additionally. The surgical treatment was supplemented with an intensive treatment with topical corticosteroids to decrease the inflammatory reaction. The patients were followed for an average of 7-18 months. The interval between the accident and the transplantation ranged from 2-26 months. In 10 patients a reconstruction of the fornices was achieved. In all patients, however, some slight scars could be observed. Postoperative Schirmertest was markedly improved. These results encourage us to plan a penetrating keratoplasty in 7 cases. 3 patients showed a recurrence of the symblepharon 2 months after the transplantation. The nasal mucosa graft material is best suited for repair of extensive symblepharon. The advantages of this tissue are the availability of large pieces of mucosa and the transplantation of intraepithelial goblet-cells. Long-term effects are the improvement and stabilisation of the tear film.

Survival of corneal grafts after severe burns of the eye

The authors investigated 32 human corneal buttons of patients suffering from severe eye burns. The keratoplasties were performed in different periods after the burn and collected within five years. Grafts were followed-up until they failed because of ulceration or until rehabilitating keratoplasties were performed. Early (up to six months after the burn) and late (more than 12 months after the burn) obtained corneas showed different cellular reactions in the corneal stroma. Inflammatory cells such as granulocytes and lymphocytes decreased with increasing periods after the burn. More than 12 months after the burn, minor inflammatory cellular reactions but increasing scar formation could be found. Four out of 19 early-, two out of eight intermediate- (between six and 12 months after the burn) and one of the late performed keratoplasties failed and had to be replaced by new corneal grafts. Due to the conditions in the graft beds the explanted corneal grafts showed a cellular reaction in the stroma comparable to the previously explanted burnt corneae. Further complications occurred because of problems concerning the ocular surface. After preliminary therapeutical keratoplasties rehabilitating keratoplasties could be successfully performed in four cases between 19 and 39 months.

Klinische Erfahrungen mit aufgeklebten harten Kontaktlinsen

Persistent epithelial defects of the cornea are difficult to treat and can lead to severe complications such as melting processes. Therefore the application of a glued-on hard contact lens as an artificial epithelium has been recommended for many years, to protect the denuded corneal stroma. This paper presents a 7-year retrospective study on the application of a hard contact lens as an artificial epithelium. 46 patients with 50 eyes were treated with this method from january 1985 to march 1992. The majority of the patients suffered from most severe burns of the whole anterior eye segment (group I: n = 29 eyes) or of the cornea alone (group II: n = 13 eyes). A smaller number of patients (group III: n = 8 eyes) presented corneal melting processes associated with other diseases. The patients of group II and III showed the best outcome concerning spontaneous epithelialization and prognosis for a penetrating keratoplasty. The treatment with a glued-on hard contact lens was limited by the high rate of complications (92%) in group I and II. In one third of the cases of group I these complications led to further surgical interventions (e.g. conjunctivoplasty of the globe). The results also show, that the application of a glued-on hard contact lens in patients with most severe eye burns is a long-term treatment (> one year). The poor prognosis of corneas with severe healing problems of the epithelium can be improved by the application of a glued-on hard contact lens as an artificial epithelium. In severe burns of the whole anterior eye segment however, the treatment with an early keratoplasty should be considered.

No N-ras mutations in human uveal melanoma: the role of ultraviolet light revisited

cases (Van't Veer et al., 1989). The primary tumours of these 7 patients were exclusively located on continuously sunexposed body sites. These mutations were all near dipyrimidine sites, suggesting an active role for ultraviolet (UV) radiation in the induction of the mutations. Shukla et al. (1989) found in one out of 22 tested primary cutaneous melanomas N-ras mutation in codon 61, but no details of sun exposure were available. Melanoma of the uvea (iris, ciliary body and choroid) is the most common primary intraocular malignancy in adults (Cutler & Young, 1975). The incidence of uveal melanoma in whites is eight times the incidence in blacks and threefold greater than in certain Asian groups (Hakulinen et al., 1987). In the Caucasian population individuals with light irides have three times the risk of developing uveal melanoma compared to persons with brown eyes (Gallagher et al., 1985). Early life exposures to sunlight have been found to be especially important in the development of intra-ocular melanoma. (Tucker et al., 1985). Recent epidemiological studies have reported an elevated risk for Northern European ancestry, light skin colour, the presence of 10 or more cutaneous naevi, use of sunlamps a-nd intense sun exposure (Seddon et al., 1990). Holly et al. (1990) found an increased risk of developing uveal melanoma for the apparent effects of UV exposure (severe eye burn, snow blindness), and for host factors, like light eye colour and a propensity to burn rather than tan. These findings implicate sunlight as an environmental risk factor for this disease. The colour of the iris is determined by the degree of pigmentation; limited pigmentation leads to a blue or grey iris and high concentrations of melanin are present in brown irides. Melanin can absorb UV as well as visible light. To investigate possible UV mediated activation of N-ras

Ein neues Behandlungskonzept für schwere Verätzungen und Verbrennungen der Augen

Combined surgical and drug therapy has proved efficacious in the treatment of severe eye burns. Initially, necrotic epibulbar tissue is excised. The sclera, denuded over a large area and in many cases ischemic, is covered with tenon flaps, prepared and advanced from the undamaged parabulbar connective tissue. For several months, artificial epithelium is used to protect the denuded and to a large extent acellular corneal stroma. Subsequently drug therapy, including corticosteroids, Healon, and prostaglandin synthesis inhibitors, is instituted to reduce the inflammatory reaction of the burned anterior segment. Regeneration of the conjunctival and later also the corneal epithelia may be improved by epidermal growth factor, autologous fibronectin, and proteinase inhibitors (Trasylol). This therapy avoids some complications which could not previously be influenced, and creates more favorable conditions for later corneal grafts.

Surgical procedures in the treatment of most severe eye burns

Report of some clinical observations in 16 patients with severe and most severe burns of 19 eyes. Major problems were delayed regeneration of the epithelium, extensive ulceration of the sclera near the limbus, and subsequent corneal ulceration. The therapy with anti-inflammatory drugs, macromolecular hyaluronic acid, fibronectin, epidermal growth factor, free transplants of oral mucosa and conjunctiva was sometimes helpful, but could not induce stable epithelial regeneration. The major problem remained the inability of the epithelium to regenerate on the cornea. Therefore, an artificial epithelium was applied in many cases. When healthy conjunctiva touched closely the artificial epithelium at the limbus, it remained tightly attached to the corneal stroma, preserved it's structure and even prevented corneal vascularisation for many months. However, when corneo-scleral ulceration was present, the artificial epithelium failed to protect the corneal stroma from secondary ulceration and sloughed off. Therefore, new surgical procedures, a conjunctiva-Tenon flap and a Tenon plasty were introduced to cover and to cure corneoscleral ulceration. These operations formed a new limbus, attached tightly to the rim of the artificial epithelium and prevented secondary ulceration underneath. Then under the protection of the artificial epithelium and the Tenon plasty the eye could be treated topically with corticosteroids for a long time. When the inflammatory response to the burn was healed, the natural epithelium recovered and the eye became ready for successful keratoplasty.

Die Tenonplastik als neues Operationsprinzip in der Frühbehandlung schwerster Verätzungen*

A special danger in cases of severe chemical and thermal eye burns is the development of corneoscleral ulceration. To treat these most severe burns tenonplasty was developed as a new surgical treatment. The principle of tenonplasty is based on a plastic operation in which vital connective tissue of the orbit is used. First, all necrotic tissue is removed from the conjunctiva and sclera. The Tenon tissue is then bluntly separated from the equatorial region of the globe and from extraocular muscles. It is important to keep its blood vessels intact and to prepare the Tenon sheet with a smooth surface, because regenerating conjunctival epithelium has to slide on this layer. After preparation, the elastic Tenon flap can be moved to the limbus and sutured tightly to the sclera, thus providing a revascularization of the denuded sclera and the limbus region. In all patients the scleral ulceration healed and the eyes were saved from anterior segment necrosis. Although rapid regeneration of conjunctival epithelium on the Tenon layer always occurred rapidly, the cornea was completely covered by new epithelium in only a few cases: an artificial epithelium was therefore applied early in most patients. After tenonplasty and application of an artificial epithelium high local doses of corticosteroids can be given to suppress reactive inflammation and prevent neovascularization of the cornea.

Tierexperimentelle und klinische Untersuchungen zum Einsatz von Antiphlogistika bei Verätzungen des Auges

In animal experiments and a clinical study of chemically burned eyes the anti-inflammatory effect of topically applied steroids and indomethacin (an inhibitor of cyclooxygenase) was investigated. Both the animal model and the clinical tests indicate the desirability of immediate local application of dexamethasone eyedrops 0.1% under careful biomicroscopic control of the burned eye and with local antibiotics. The use of topical steroids is a part of the authors' treatment for moderately severe and severe chemical eye burns (second degree, beginning third degree). However, this anti-inflammatory therapy cannot be recommended with indomethacin alone, because of the leukotriene-induced, increased infiltration of polymorphonuclear neutrophils and corneal ulceration.