|Year : 2021 | Volume
| Issue : 4 | Page : 634-636
Lesson to be learned: A case of ocular trichloroacetic acid burn in an infant
Saroj Gupta, Deepak Soni
Department of Ophthalmology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
|Date of Submission||11-Dec-2020|
|Date of Acceptance||23-Mar-2021|
|Date of Web Publication||09-Oct-2021|
Dr. Saroj Gupta
Department of Ophthalmology, All India Institute of Medical Sciences, Bhopal - 462 020, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Pediatric ocular chemical injuries constitute a true ocular emergency and require urgent evaluation and treatment. We report a case of ocular chemical burn in an 11-month-old infant following contamination of ophthalmic eye drop vial with trichloroacetic acid. The child developed superficial corneal burn which was managed successfully with a favorable outcome.
Keywords: Alkali burn, ocular chemical injury, pediatric ocular burn, trichloroacetic acid
|How to cite this article:|
Gupta S, Soni D. Lesson to be learned: A case of ocular trichloroacetic acid burn in an infant. Indian J Ophthalmol Case Rep 2021;1:634-6
Ocular chemical injuries secondary to accidental exposure constitute a major group of ophthalmic emergencies that can result in severe trauma to the eye and significant ocular morbidity. The most common chemical injury reported in pediatric patients is Lime burn from bursting of Chuna packets (65.6%), followed by toilet cleaner (14.9%).
Managing ocular chemical injuries in the pediatric age group is a challenge, mainly because of delayed presentation with unaddressed immediate irrigation, difficulty in timely diagnosis, and adequate management of complications. We report a case of accidental trichloroacetic acid (TCA) ocular burn in an infant, which was managed conservatively with complete recovery.
| Case Report|| |
An 11-month-old male child accompanied by his parents presented to the emergency outpatient department with complaints of watering, photophobia, and difficulty in opening the left eye (LE). Parents gave a history of consultation to a general practitioner half an hour back for the complaints of watering in LE, which they noticed from the last few weeks. There was no history of trauma or any foreign body contact. However, on a detailed history, it was established that an eye drop was instilled in the child's LE, for examination under topical anesthesia half an hour back, which resulted in sudden whitening of the cornea, therefore the child was referred to our tertiary care institute for management.
Based on history, a diagnosis of possible inadvertent chemical injury was made. The pH of the conjunctival sac was checked with pH test strips, which revealed values in the acidic range (2.2) in the LE, suggestive of chemical injury by an acid. Proparacaine hydrochloride 0.5% eye drops were instilled and the eye was immediately irrigated with a copious amount of normal saline using Morgan lens, till pH was normalized. A thorough ocular examination was then performed under topical anesthesia to look for any traces of particulate matter in the conjunctival fornices in the LE. There was periorbital edema with superficial corneal burn involving lower one-third of the cornea with 4 to 9 'clock hours of limbal involvement. The inferior bulbar and palpebral conjunctiva of the lower fornix showed congestion and chemosis. Fluorescein staining revealed an area of 5 'clock hours of the inferior corneal epithelial defect, [Figure 1]a with staining of the adjacent inferior bulbar and palpebral conjunctiva. The superior fornix, upper bulbar conjunctiva were unaffected. The upper part of the cornea was slightly hazy due to edema. Iris details were visible from the upper part of the cornea and the pupil was central, circular, briskly reacting to light. Clinical findings were suggestive of grade III ocular burn as per Dua's classification of ocular surface burn. Ocular examination in the right eye was normal.
|Figure 1: (a) Left eye clinical picture at presentation with inferior 11 × 5 mm corneal epithelial defect (fluoresceine stained) with five clock hours of limbal involvement and 50% conjunctival involvement as seen inferiorly. (b) after 72 h of topical treatment- decreased size of epithelial defect and resolving congestion. (c and d) Picture at 1 week and 2 weeks after treatment showing resolving epithelial defect. (e) At 3 weeks follow-up, clear cornea with no evidence of corneal scar and neovascularization|
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The child was treated conservatively with topical therapy; fluorometholone 0.1% every 2 h, tobramycin 0.3% four times a day, along with cycloplegic and lubricating eye drops. The child was kept under frequent follow-up examinations. After 72 h of topical therapy, conjunctival congestion and corneal edema improved significantly with a decrease in corneal epithelial defect [Figure 1]b. At one week and two weeks follow-up, the corneal epithelial defect further decreased and anterior chamber details were visible [Figure 1]c and [Figure 1]d. Topical steroid drop was tapered. At three weeks follow-up, there was complete healing of epithelial defect with no evidence of any corneal scarring, neovascularization, and limbal stem cell deficiency [Figure 1]e.
In subsequent follow-up visits, a detailed ocular examination was performed to look for any complications or sequelae of acid burn. Sodium fluorescein staining was done to evaluate the ocular surface and a rough estimate of lacrimal meniscus height was done during examination. The child remained under regular follow-up and no complications were noted till the last follow-up at 8 months.
On tracing the sequence of events retrospectively, it was found that the ocular examination was done by the primary care physician in a general hospital. TCA solution was available in the examination room as it was used by the dermatologists, otolaryngologists, and other specialists for some procedures. The paramedic staff had done the mistake of filling the empty vial of lidocaine 4% eye drop with TCA 30% solution and did not label it properly in bold letters. Later at the time of ocular examination, the TCA solution was instilled inadvertently in the patient's eye in place of lidocaine 4% eye drop resulting in ocular burn.
| Discussion|| |
Alkaline injury with lime (Chuna), is the most common type of ocular injury reported among children less than 3 years of age., Acid ocular injuries are less common and they cause less severe injury in comparison to alkaline agents. Like other acids, TCA dissociates into hydrogen ions and anions, once it comes in contact with the ocular surface. Hydrogen ions lower the pH, while anions precipitate proteins and prevent further deeper penetration of the acid.
TCA is commonly used by otolaryngologists for chemical cauterization of tympanic membrane perforations, and by dermatologists for facial skin peeling.,, Cases of ocular injury with accidental seepage of TCA into the eye while performing skin peeling in adults have been reported., Another incident was reported by Iyer et al., where sulfuric acid and hydrochloric acid were isolated from eye drop bottles of two patients, resulting in tarsal conjunctival defects with severe scleral ischemia.
Anisometropia from induced astigmatism, deprivation amblyopia from corneal opacification, are the prime consequences that children with acid ocular injury may suffer. The ocular surface is prone to tear film disturbances due to inflammation, loss of goblet cells, and conjunctival scarring. The assessment and quantification of dry eye is a major issue in pediatric patients. The Tear Film and Ocular Surface Society (TFOS) has defined standard values for evaluating tear film and ocular surface in adults. There are no established standard values or diagnostic cut-offs, and tests specifically developed for children. Ocular surface staining with sodium fluorescein requires very limited cooperation and can provide useful information on tear film and epithelial damage in children.
Immediate management plays a vital role in deciding the prognosis. In this case, timely diagnosis and emergency management helped in successful outcome. The lesson to be learned from the index case is that the content of a drug vial should never be replaced with another drug or a chemical. In case, the contents are replaced, the vial should be labeled properly in bold letters.
| Conclusion|| |
Though it is very rare and unusual, it is important to be aware of the possibility of accidental contamination/replacement of the contents of a vial with other agents. A high index of suspicion will help in making early diagnosis and management in such cases. The appropriate training of the paramedic staff is mandatory to prevent such events from happening, which can lead to permanent visual impairment.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
The authors have not received grant support or research funding and do not have any proprietary interests in the materials described in the article.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Abbott J, Shah P. The epidemiology and etiology of pediatric ocular trauma. Surv Ophthalmol 2013;58:476-85.
Vajpayee RB, Shekhar H, Sharma N, Jhanji V. Demographic and clinical profile of ocular chemical injuries in the pediatric age group. Ophthalmology 2014;121:377-80.
Dua HS, King AJ, Joseph A. A new classification of ocular surface burns. Br J Ophthalmol 2001;85:1379-83.
Agarwal T, Vajpayee R. A warning about the dangers of chuna packets. Lancet 2003;361:2247.
D'Souza AL, Nelson NG, McKenzie LB. Pediatric burn injuries treated in US emergency departments between 1990 and 2006. Paediatrics 2009;124:1424-30.
Wagoner MD. Chemical injuries of the eye: Current concepts in pathophysiology and therapy. Surv Ophthalmol 1997;41:275-313.
Singh M, Kaur M, Singh B, Singh K, Singh A, Kaur A. Role of trichloroacetic acid and gel foam in closure of tympanic membrane perforations. Niger J Clin Pract 2017;20:1233-6.
] [Full text]
Fung JF, Sengelmann RD, Kenneally CZ. Chemical injury to the eye from trichloroacetic Acid. Dermatol Surg 2002;28:609-10; discussion 610.
Ozturk MB, Ozkaya O, Karahangil M, Cekic O, Oreroğlu AR, Akan IM. Ocular complication after trichloroacetic acid peeling: A case report. Aesthetic Plast Surg 2013;37:56-9.
Iyer G, Agarwal S, Srinivasan B, Narayanasamy A. Isolation of acid from eye drop bottles being used by patients presenting with presumed scleritis. Indian J Ophthalmol 2018;66:1084-7.
] [Full text]
Singh P, Tyagi M, Kumar Y, Gupta KK, Sharma PD. Ocular chemical injuries and their management. Oman J Ophthalmol 2013;6:83-6.
] [Full text]
Rojas-Carabali W, Uribe-Reina P, Muñoz-Ortiz J, Terreros-Dorado JP, Ruiz-Botero ME, Torres-Arias N, et al
. High prevalence of abnormal ocular surface tests in a healthy pediatric population. Clin Ophthalmol 2020;14:3427-38.