Eyelid eversion and irrigation are frequently done together to ensure that both particulate material and chemical irritants are removed from the entire ocular surface.
Indications for Eye Irrigation and Eyelid Eversion
Chemical injury to the eye Chemical burns Ocular burns can occur after thermal or chemical injuries and can result in serious complications, including permanent blindness. (See also Overview of Eye Trauma.) The blink reflex usually... read more (caustic chemical burns are a medical emergency; irrigation should begin as soon as possible, with on-site flushing with whatever water is available, even before medical help arrives)
Treatment of foreign body sensation when no particulates are visible (sometimes successful)
Contraindications to Eye Irrigation and Eyelid Eversion
If eye perforation is suspected, irrigation should be deferred until formal eye examination can be done. If the cornea may have a deep injury or foreign body, irrigation using a scleral lens may cause further injury and should not be done. Irrigate the eye manually, gently, and very carefully.
Complications of Eye Irrigation and Eyelid Eversion
The cornea or conjunctiva may be mechanically abraded by the tip of the IV tubing, by the scleral lens, or by an irrigating stream pointed directly at the cornea.
Equipment for Eye Irrigation and Eyelid Eversion
Irrigating solution, eg, normal (0.9%) saline, Ringer’s lactate, warmed when possible; several liters may be needed for prolonged irrigation
IV tubing and IV pole
Drainage basin and towels to collect irrigation fluid runoff
Face/eye protection, gloves, and gown for operator(s)
Local anesthetic (eg, 0.5% proparacaine eyedrops); sometimes for prolonged irrigation, 10 mL of 1% lidocaine is to be added to each liter of irrigation solution
Expanded pH paper or pH test strips
Gauze pads, eyelid retractors
Cotton-tipped applicators (swabs)
Scleral (irrigating) lens
Patients exposed to chemicals may have other serious chemical burn injuries in addition to ocular burns Ocular Burns Ocular burns can occur after thermal or chemical injuries and can result in serious complications, including permanent blindness. (See also Overview of Eye Trauma.) The blink reflex usually... read more . Ocular burns should be treated simultaneously with treatment of these other serious injuries.
Request emergency ophthalmologic consultation for serious ocular burns, especially those involving deep corneal injury, but do not delay irrigation while awaiting the ophthalmologist.
If you are unsure about the severity of a chemical ocular injury, proceed with irrigation of the eye.
Positioning for Eye Irrigation and Eyelid Eversion
Place the patient supine on the bed or stretcher.
Hang bags of saline irrigation fluid several feet above the patient’s head (proper fluid flow depends on this height).
Place a plastic drainage basin under the patient’s eye to collect the irrigation fluid and towels on the stretcher.
An assistant may be used to retract the eyelids during irrigation and should stand on the opposite side of the stretcher.
Step-by-Step Description of Procedures and Key Teaching Points
Immediate initiation of irrigation is the prime objective when treating chemical ocular burns. Defer other parts of evaluation and treatment, even normally preliminary tasks, including external examination of the eye and rudimentary assessment of visual acuity, until after irrigation.
Whenever possible, check the pH of the eye before irrigation, by touching the lower fornix with a piece of pH paper or the pH strip from a urine dipstick. If pH paper is not immediately available, check pH as soon as possible after beginning irrigation. Normal pH of the eye as measured with pH paper is about 7.0.
Ask the patient to look upward, and then place a drop of topical ocular anesthetic into the lower fornix of the affected eye. Tell the patient to keep the eye closed until the irrigation begins, in order to retain the drug. Drops may need to be re-instilled every 5 to 10 min during irrigation.
If particulate material may be in the eye and significant chemical exposure is unlikely, sweep potential particulate matter out with a moistened cotton-tipped applicator before irrigation. Sweep both the inferior and superior fornices.
In one hand, hold the end of the IV tubing about 3 to 5 cm from the eye. Fully open the tubing to achieve optimal irrigation flow.
Direct the irrigation stream over the entire surface of the eye, including both the inferior and superior fornices and the cornea. The stream should flow over the surface and should never be pointed directly at the cornea.
Retract the eyelids to adequately irrigate the fornices. Use the hand that is not holding the IV tubing; or, or an assistant with gauze pad in each hand can retract the lids. An eyelid retractor may also be used, particularly if blepharospasm is present. An eyelid retractor can cause pain that requires treatment (usually treatable with topical proparacaine).
When treating a chemical burn, also rapidly flush the skin surfaces of the eyelids and periorbital area to remove lingering chemicals.
The duration of irrigation depends on the clinical scenario and must continue until the pH is normalized. In many cases, 15 to 20 min of irrigation are required and several liters of irrigant are often used. In acid and, particularly, in alkali burns, some experts suggest 1 to 2 h of irrigation. With alkali burns, irrigation may need to continue for many hours.
For prolonged irrigation (eg, > 15 min), consider using a scleral lens The Scleral Lens Eye irrigation is used to flush particles and harmful chemicals from the conjunctiva and cornea. Eyelid eversion is used to expose the superior palpebral conjunctiva and fornix, so that foreign... read more . Consider adding 10 mL of 1% lidocaine to each liter of irrigation fluid to provide anesthesia and switching to a commercially available irrigation fluid instead of saline or Ringer’s lactate.
Check the pH of the eye(s) when irrigation is finished. If the pH is not normal, continue irrigation. If the pH is normal, re-check it after another 20 min to see whether irrigation should be started again because chemicals can continue to leach out of the tissue and alter what appeared to be a normalized pH.
After irrigation is complete, evert the upper eyelid, to ensure that there are no residual deposits in the superior conjunctiva.
First, press gently on the superior part of the upper lid with a cotton-tipped applicator. Then, manually lift the upper lid margin, folding it backward over the applicator (ie, upward and backward toward the patient’s forehead).
Hold the everted eyelid in place by placing the applicator over the everted conjunctiva.
Particularly if a foreign body or bodies are suspected, expose the superior fornix by using double eyelid eversion (ie, first everting the eyelid and then inserting a swab under the everted eyelid and lifting it up until the fornix is visible)
Sweep both the inferior and superior fornices to remove any visible particles as well as residual particles that cannot be seen.
The Scleral Lens
Use a scleral lens if prolonged irrigation is necessary, such as in patients with significant alkali burns. Because scleral lenses do not irrigate vigorously and may not thoroughly irrigate the fornices, use them only after manual irrigation with at least one liter of saline. If the eye may be perforated, or if the cornea may have a deep injury or foreign body, irrigation using a scleral lens may cause further injury and should not be done.
Apply a topical anesthetic before inserting the lens.
Attach the lens to the saline tubing, and open the intravenous tubing so fluid flows slowly through the device.
Ask the patient to look downwards, and insert the lens under the upper lid. Next, ask the patient to look upward, and insert the other half of the lens under the lower lid.
Once the lens is in place, increase the flow of saline through the tubing.
Scleral lenses can be used to irrigate both eyes simultaneously.
Aftercare for Eye Irrigation and Eyelid Eversion
Do an ophthalmologic examination, including assessment of visual acuity Visual acuity The eye can be examined with routine equipment, including a standard ophthalmoscope; thorough examination requires special equipment and evaluation by an ophthalmologist. History includes location... read more , measurement of intraocular pressure Tonometry The eye can be examined with routine equipment, including a standard ophthalmoscope; thorough examination requires special equipment and evaluation by an ophthalmologist. History includes location... read more , and slit-lamp examination Slit-lamp examination The eye can be examined with routine equipment, including a standard ophthalmoscope; thorough examination requires special equipment and evaluation by an ophthalmologist. History includes location... read more of the cornea and conjunctiva with fluorescein staining, to assess for corneal abrasion.
When necessary (eg, severe chemical burns), obtain ophthalmologic consultation for continuing care or 24-h follow-up care.
Prescribe lubrication (preservative-free artificial tears and ointment) and topical antibiotics (eg, moxifloxacin 0.5% drops tid for about 3 days) for patients with mild corneal damage resulting from minor chemical exposures.
Consider using an eye patch or systemic analgesics to help alleviate pain, as well as a cycloplegic (homatropine 5% or cyclopentolate 1% twice daily; avoid phenylephrine because it can cause vasoconstriction and increase ischemia).
Instruct the patient to return to the emergency department within 24 hr if symptoms fail to improve or worsen.
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