Cement in the Eye — Management

Step 1 — Immediate Irrigation (Do NOT delay)

• Instill a topical anaesthetic (e.g., proparacaine) before irrigating — this dramatically improves comfort and cooperation.
• Use sterile balanced buffered solution (normal saline or Ringer's lactate) as first choice; tap water is acceptable if nothing else is immediately available — do NOT delay irrigation waiting for the ideal solution.
• Irrigate continuously for 15–30 minutes (or until pH is neutral/7.4).
• Use IV tubing connected to a 1–2 L bag of saline/lactated Ringer's for continuous flow, or a Morgan lens (if using a Morgan lens, replace between each liter to avoid trapping chemical).
• Check pH with litmus paper before and after irrigation; continue irrigating until pH reaches 7.4.
• Turn the head so the affected eye is lower to avoid contamination of the unaffected eye.

⚠️ Alkali burns tend to re-elevate pH even after initial normalisation due to continued chemical release from tissue — recheck pH after 30 minutes and re-irrigate if needed.

Step 2 — Remove Retained Particulate Matter

• Perform double eversion of the upper eyelid and sweep the conjunctival fornices with a cotton-tipped applicator to identify and remove any retained cement particles.
• Cement is particulate and can be trapped under the lid, continuing to release alkali — this step is critical.
• Debridement of necrotic corneal epithelium at the slit lamp to promote re-epithelialization and remove residual chemical.

Step 3 — Assessment and Grading (Roper-Hall Classification)

• Assess visual acuity, corneal clarity, limbal ischaemia, IOP, iris and lens status.
• Slit-lamp exam with fluorescein staining.

Step 4 — Medical Treatment

• Topical antibiotic ointment (e.g., chloramphenicol 4×/day) for ~1 week
• Topical steroids (4–8×/day, tapered after 7–10 days) to reduce inflammation
• Cycloplegia for comfort (e.g., atropine 1% twice daily)

• All of the above, plus:
• Ascorbic acid: topical sodium ascorbate 10% every 2 hours + systemic vitamin C 1–2 g four times daily (promotes collagen synthesis; avoid in renal disease)
• Citric acid: topical sodium citrate 10% every 2 hours (inhibits neutrophil activity and collagenase)
• Acetylcysteine 10–20% 4×/day to inhibit collagenase and prevent ulceration
• Hospital admission for Grade 3–4 to ensure adequate drop instillation

Step 5 — Surgical Options

• Tenon capsule advancement to re-establish limbal vascularity
• Amniotic membrane grafting — promotes epithelialization and suppresses fibrosis
• Limbal stem cell transplantation (autograft from fellow eye or allograft) — to restore normal corneal epithelium
• Tissue adhesive glue or keratoplasty for actual/impending perforation

• Division of symblepharon / conjunctival bands
• Conjunctival or mucous membrane grafting
• Correction of cicatricial entropion
• Keratoplasty for corneal scarring — delay ≥ 6 months
• Keratoprosthesis in severely damaged eyes

Key Points Specific to Cement/Lime

• Lime (calcium hydroxide) is one of the most common industrial alkali burns.
• Cement is particulate — retained particles under the lid continue releasing alkali and cause ongoing damage. Particle removal is non-negotiable.
• Cement burns may initially appear milder than they are, as particulate lime may not immediately dissolve — pH can re-rise after initial irrigation.