Cement in eye . What's its management
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cement lime alkali ocular chemical injury management
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"ocular chemical burn" AND treatment
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Cement in the Eye - Management
Cement contains calcium hydroxide (Ca(OH)₂) - a strong alkali (pH ~12-13). This makes it one of the most dangerous ocular chemical injuries. Alkali penetrates more deeply than acids via liquefactive necrosis, causing ongoing damage long after initial contact.
STEP 1 - Immediate Irrigation (Emergency - Do This First)
This is the single most important intervention. The speed and efficacy of irrigation is the most important prognostic factor.
- Start immediately - do not delay for any assessment
- In pre-hospital setting: tap water is ideal - have the patient submerge the eye in running tap water and continuously open/close the eyelid. Turn the head so the affected eye is lower to avoid contaminating the unaffected eye
- In hospital/ED: use sterile normal saline, lactated Ringer's, or balanced salt solution (BSS) - preferred over tap water due to hypotonicity concerns
- Instill topical anaesthetic (e.g. proparacaine) before/during irrigation - dramatically improves compliance and cooperation
- A lid speculum may be helpful to keep the eye open
- Irrigate at least 2 litres over the first 30 minutes continuously
- A Morgan lens can be used; if used, replace between each litre to avoid trapping chemical
Critical additional step: Double-evert the upper eyelid and sweep the fornices with a moist cotton bud to remove any retained cement particles. Cement is particulate and fragments lodge in the fornices, continuing to leach alkali long after irrigation.
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After 2 L, check conjunctival pH with litmus paper
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Continue irrigating until pH reaches 7.0-7.4 (neutral)
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Recheck pH every 15-30 minutes; normalization typically takes 30-60 minutes
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Debride any necrotic corneal epithelium at the slit lamp to remove residual chemical
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Harriet Lane Handbook, p. 74; Kanski's Clinical Ophthalmology 10th ed., p. 945; Rosen's Emergency Medicine
STEP 2 - Assessment
| Assessment | Method |
|---|---|
| Visual acuity | Test and trend from outset |
| Conjunctival pH | Litmus paper - before and after irrigation |
| Slit-lamp exam | Corneal clarity, fluorescein staining, limbal ischaemia |
| IOP | Check intraocular pressure |
| Fundus | If penetrating injury suspected |
STEP 3 - Grading (Roper-Hall Classification)
| Grade | Cornea | Limbal Ischaemia | Prognosis |
|---|---|---|---|
| 1 | Clear (epithelial damage only) | None | Excellent |
| 2 | Hazy, iris detail visible | <1/3 | Good |
| 3 | Haze obscures iris detail | 1/3 to 1/2 | Guarded |
| 4 | Opaque | >1/2 | Poor |
The Dua classification (6 grades based on clock hours of limbal involvement + % conjunctival involvement) provides better prognostic discrimination, especially for severe cases.
- Kanski's Clinical Ophthalmology 10th ed., p. 945
STEP 4 - Medical Treatment
Mild injuries (Grade 1-2)
- Topical antibiotic ointment for ~1 week (e.g. chloramphenicol 4x daily)
- Topical steroids + cycloplegics if necessary
Moderate-severe injuries (Grade 3-4) - use preservative-free drops
All the below aim to reduce inflammation, promote re-epithelialisation, and prevent corneal ulceration:
| Drug | Rationale | Regimen |
|---|---|---|
| Topical corticosteroids | Reduce inflammation and neutrophil infiltration; treat anterior uveitis | 4-8x daily initially; taper off at 7-10 days (risk of sterile corneal ulceration) |
| Cycloplegics (e.g. atropine 1%) | Pain relief, prevent posterior synechiae | Twice daily |
| Topical antibiotics (e.g. chloramphenicol) | Prophylaxis against infection | 4x daily |
| Sodium ascorbate 10% topical + oral Vitamin C 1-2 g QID | Promotes mature collagen synthesis by corneal fibroblasts | Every 2 hours topically |
| Sodium citrate 10% topical (Grade 3-4) | Potent neutrophil inhibitor; inhibits collagenase; targets the "second wave" of phagocytes ~7 days post-injury | Every 2 hours for ~10 days; also oral (2 g QID) |
| Tetracyclines / doxycycline | Collagenase inhibitor; reduce corneal melting | Topical ointment 4x/day + oral doxycycline 100 mg BD |
| Acetylcysteine 10% | Alternative anticollagenase | 6x daily topically |
| IOP management (oral acetazolamide if raised) | Raised IOP is common in severe burns | Avoid topical drops to reduce ocular surface burden |
- Prevent symblepharon formation by daily lysis of developing adhesions with a sterile glass rod or damp cotton bud
- Kanski's Clinical Ophthalmology 10th ed., p. 945
STEP 5 - Referral and Admission
- Urgent ophthalmology referral for: significant vision loss, uncontrolled pain, persistent pH abnormality, significant mucosal injury, or Grade 3-4 injuries
- Hospital admission is usually required for Grade 3-4 injuries to ensure adequate drop instillation in the early stages
- Consider dermatology opinion if periocular skin is involved
- Harriet Lane Handbook, p. 74
Key Points to Remember
- Cement = alkali = deeper and more dangerous than acid burns (liquefactive necrosis vs. coagulative)
- Particulate matter (cement fragments) must be physically removed from the fornices - irrigation alone is insufficient
- Steroids must be tapered by day 7-10 to avoid sterile corneal ulceration
- Early ophthalmology involvement is essential for all but the most trivial exposures
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