Eye burns: clinical guidelines

List of Abbreviations

AB – ankylosing blepharorrhaphy AKP – autoconjunctival plasty AM – amniotic membrane

ATP – autotenonoplasty, tenoplasty, (total, circular, sectoral) IOP – intraocular pressure

SPG – secondary post-burn glaucoma HT – hypotensive therapy

LESC – limbal epithelial stem cells LT – limbal transplantation

ICD-10 – International Classification of Diseases 10th Revision SCL – soft contact lens

PB – simple (non-ankylosing) blepharorrhaphy OCT – optical coherence tomography

PKP – lamellar keratoplasty PKP – penetrating keratoplasty STE – sinusotrabeculectomy

TSL – transscleral diode laser cyclodestruction UBM – ultrasound biomicroscopy

EN – enzymatic necrectomy N – necrectomy

EP – electrophysiological studies ECCE – extracapsular cataract extraction

Terms and Definitions

Necrectomy is the conservative removal (excising) of clearly non-viable gray tissues of the ocular surface (corneal epithelium, conjunctiva, subconjunctiva, Tenon's capsule).

Conjunctival ischemia is a local reduction in blood supply caused by a burn factor (narrowing or complete occlusion of the arterial lumen), leading to temporary dysfunction or persistent tissue damage. Superficial ischemia is a decrease in or transient absence of pain sensitivity in the ischemic conjunctiva. Deep ischemia is the persistent absence of conjunctival sensitivity.

Necrosis of ocular tissues is the death of eye tissues resulting from a burn injury.

Revascularizing surgeries are interventions aimed at restoring blood circulation in the ocular tunics after necrectomy (typically, closing tunic defects with local viable tissues).

Tenonplasty is the surgical mobilization of Tenon's capsule anteriorly and suturing it to the perilimbal sclera to restore blood circulation in the anterior segment of the eye.

Simple (non-ankylosing) blepharorrhaphy is an operation to close the palpebral fissure using sutures without fusing the free margins of the eyelids.

Ankylosing blepharorrhaphy is an operation to close the palpebral fissure using sutures and fusing the deepithelialized free margins of the eyelids (ankyloblepharon).

Temporary covering of the ocular surface with an amniotic membrane graft is a surgical procedure aimed at optimizing corneal and conjunctival epithelialization processes, as well as maintaining limbal epithelial stem cells that partially survived the burn.

Amniotic membrane transplantation (as a substrate for the epithelium) is a procedure performed in addition to conjunctival plastic surgery for extensive mucosal defects.

Limbal transplantation is the transplantation of corneal epithelial stem cells.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Thermal eye burn is damage to eye tissues resulting from exposure to high-temperature factors. This also includes burns caused by radiant energy. [1-4]

Chemicaleye burnisdamage toeyetissuesresultingfromexposuretochemicallyactiveagents(acids,alkalis,someaggressive liquids)[1-5].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Thermal burns

1. The intensity of tissue heating depends on the temperature, physical characteristics of the acting agent, heat transfer method, and duration of heating.

2. At temperatures of 41 °C and above, irreversible thermal coagulation (denaturation) of tissue proteins and cell death occur [6, 7].

3. Heating the skin to 60 °C leads to the formation of a moist or colliquative eschar. Higher temperatures result in the formation of a dense dry or coagulation eschar [2, 6, 7]

Chemical burns

1. Alkalis are particularly aggressive because they possess both hydrophilic and lipophilic properties, causing coagulative necrosis (liquefaction necrosis) in tissues with the formation of unstable soluble alkaline albuminates, which allows them to rapidly overcome cell membranes.

2. Acid burns cause coagulation necrosis with the conversion of tissue proteins into denser acid albuminates, which to some extent hinders the further penetration of acid into the eye [6, 7]. Therefore, acids penetrate eye tissues relatively less effectively than alkalis.

3. Heating the skin to 60 °C leads to the formation of a wet or liquefactive eschar. In the case of higher heating, a dense dry or coagulative eschar is formed [2, 6, 7]

In burns, due to the disruption of the blood-ocular barrier, conditions are created for tissue antigens to enter the bloodstream, causing auto-intoxication and auto-sensitization of the body [2-4].

Comments: in burns, depending on the depth of penetration of the damaging agent into the eye tissues, the corneal and conjunctival epithelium, nerve endings, lacrimal glands, corneal stroma and endothelium, aqueous humor outflow pathways, sclera, iris, lens, and ciliary body may be damaged. As a result of damage to nerve receptors and pathways in the eyelid skin, conjunctiva, and cornea, their sensitivity in the affected areas may be reduced or completely absent.

The basal cells of the corneal limbal epithelium are oligopotent stem cells of the corneal phenotypic epithelium, ensuring the continuous replenishment of the normal corneal epithelial cover. The death of these limbal epithelial stem cells (LESC) during an eye burn clinically manifests as a condition termed limbal stem cell deficiency. This typically presents as persistent or recurrent corneal erosion with the ingrowth of conjunctival epithelium, invasion of superficial and deep vessels into the stroma, and the formation of a total vascular leucoma as the healing outcome [3, 5, 7, 8].

Tissues of the ocular surface necroticized by a burn are the cause of persistent inflammation and may contain particles of the burning agent. They can also serve as a source of antigenic information, leading to the development of autoimmune reactions.

Inflammation is accompanied by infiltration of the peripheral cornea by neutrophils and monocytes, with their secretion of destructive proteases that threaten rapid corneal ulceration and perforation. This can also be facilitated by a superimposed bacterial infection. Repair of the stroma damaged by the burn occurs due to collagen production by keratocytes (stromal fibroblasts) [6, 7, 8].

The inactivation of tissue proteases (which cause the destruction of burned tissues) is carried out by certain blood factors, as well as tissue protease inhibitors, which are also produced by keratocytes. The death of keratocytes and the loss of limbal vascularization due to necrosis in a severe burn create favorable conditions for corneal ulceration and perforation [5, 7].

Damage to tear-producing glands during ocular surface burns leads to inadequate moisturization, which negatively affects the epithelialization of the burned cornea [5, 9].

Autoimmunization against antigens of the affected tissues is the cause of secondary immunodeficiency developing after severe and extremely severe eye burns of various etiologies [2, 3, 4, 8].

Despite major differences in the mechanisms of ocular tissue damage caused by various burning agents, the clinical presentation of the developing process in most of these injuries is very similar and depends largely on the severity of the lesion.

1.3 Epidemiology of the Disease or Condition

The incidence of eye burns ranges from 6.1% to 38.4% of all eye injuries. Chemical burns predominate, accounting for about 60–80% of all ocular burns. In industrial regions, at least 65–75% of eye burns are occupational, while the rest are domestic or resulting from assault [4, 5]. Statistical data on the prevalence of eye burns in Russia and other countries are scarce in the specialized literature.

1.4 Features of Coding the Disease or Condition

Thermal and chemical burns confined to eye and adnexa

(T26) 

T26.0 Thermal burn of eyelid and periocular area

T26.1 Thermal burn of cornea and conjunctival sac

T26.2 Thermal burn resulting in rupture and destruction of eyeball T26.3 Thermal burn of other parts of eye and adnexa

T26.4 Thermal burn of eye and adnexa, unspecified location T26.5 Chemical burn of eyelid and periocular area

T26.6 Chemical burn of cornea and conjunctival sac

T26.7 Chemical burn resulting in rupture and destruction of eyeball T26.8 Chemical burn of other parts of eye and adnexa

T26.9 Chemical burn of eye and adnexa, unspecified location

1.5 Classification of the disease or condition

The system of the Russian Ministry of Health adopts the classification of eye burns by N.A. Puchkovskaya and V.M. Nepomnyashchaya (1973), which divides burns according to the depth of lesion into 4 degrees (I, II, III, and IV) and 4 categories (mild, moderate, severe, and extremely severe). See Table 1 [2, 3, 4].

Table 1

Classification of eye burn severity based on the depth and extent of tissue involvement

The authors also conventionally distinguish two phases (primary damage to eye tissues and development of the main pathological links) and four stages of the burn process:

1. stage of primary necrosis;

2. stage of acute inflammation;

3. stage of pronounced trophic disorders followed by vascularization;

4. stage of scarring and late dystrophies [3, 4].

Comments: N.A. Puchkovskaya and V.M. Nepomnyashchaya do not provide specific figures for the duration of the burn disease stages in this classification, explaining that this duration in each specific case can vary greatly as it depends on a large number of factors and the nature of treatment. They also indicate that mild and moderate burns may not go through the last two stages at all.

New knowledge about the role of limbal epithelial stem cells (LESCs) in the pathogenesis of burn disease has prompted scientists worldwide (McCulley J.P., Wagoner M.D., Dua H.S., Schrage N.F., Kuhn F., etc.) to improve classification frameworks. Taking these data into account, in 2020 a group of authors from the Department of Ophthalmology of the Military Medical Academy (A.N. Kulikov, V.F. Chernysh, S.V. Churashov) proposed a new interpretation of the classification of eye burns (Table 2).

Classification of eye burns

Phases of clinical course: 1. Direct action; 2. Acute (up to 7 days post-burn); 3. Early reparative (8-21 days); 4. Late reparative (from day 22).

* – The perilimbal zone of the bulbar conjunctiva, determining the trophism of limbal epithelial stem cells – in a band up to 3 mm wide from the limbus.

** – Intraocular changes: iris depigmentation, pupil deformation and immobility, turbidity of the anterior chamber fluid, lens, and vitreous body – may be accompanied by ocular hypertension or hypotony;

In the classification, the severity of ocular surface burn injury is assessed by the degree of damage to limbal epithelial stem cells (LESCs). The latter is judged by the severity of perilimbal conjunctival ischemia – superficial or deep.

Each burn severity grade implies a specific type of ocular surface healing:

Mild burns (type I healing) – complete recovery.

Moderate burns (type II) – partial conjunctivization of the cornea.

Severe burns (type III) – total fibrovascular pannus and corneal stromal neovascularization with possible symblepharon formation and eyelid scarring.

Extremely severe burns (type IV) – sterile corneal ulceration with persistent absence of epithelialization of the cornea and proximal conjunctiva, combined with signs of ischemia and necrosis in the limbus and conjunctiva.

Comments: The diagnosis is formulated for each eye separately. At the same time, the assessment of overall eye burn severity is based on the maximum severity of damage to the eyelids, cornea, or conjunctiva. For example, a severe chemical (alkali) grade III burn of the cornea, grade II of the conjunctiva and eyelids in the second phase of burn disease of the right eye.

1.6 Clinical presentation of the disease or condition

Immediately after the burn, the patient is concerned about pain and aching in the eyes, as well as decreased visual acuity. Corneal syndrome develops immediately (lacrimation, photophobia, and blepharospasm). Pain may be a transient symptom and is often inversely proportional to the severity of the lesion [2 - 5, 10].

In subsequent hours, in mild, moderate, and severe burns, pain somewhat decreases, but corneal syndrome persists. In the case of an extremely severe burn, pain in the eye, as well as photophobia, lacrimation, and blepharospasm may be completely absent due to a sharp impairment of ocular surface tissue sensitivity [1, 2, 4, 5].

Severe and extremely severe burns are accompanied by the development of burn disease with a protracted course and autoimmunization of the body by antigens of damaged tissues, complicating the healing processes [2, 4, 11].

2. Diagnostics, medical indications and contraindications for diagnostic methods

Criteria for establishing the diagnosis/condition: e.g., based on pathognomonic data:

1. medical history data;

2. physical examination;

3. laboratory testing;

4. instrumental examination.

2.1 Complaints and Anamnesis

Comments: complaints are described in the section "Clinical picture of the disease or condition". Special attention requires identifying the time and circumstances of the eye burn, the type and duration of the damaging agent's action on the patient, and prior therapeutic measures in the anamnesis.

Comments: Special attention is required to identify concomitant acute or chronic diseases in order to determine the strength of the damaging factor, the somatic status of the patient, and the quality and timeliness of medical care provided, if any.

2.2 Physical Examination

2.3 Laboratory Diagnostics

There are no diagnostic criteria for eye burns based on clinical laboratory test data.

2.4 Instrumental Diagnostics

Comments: visometry in children under three years of age is performed approximately – determining whether the child has object vision. In children three years of age and older, it is performed using charts: from 3 years of age using a children's silhouette picture chart, from 5 years of age visometry is performed using Landolt rings or "E" tests. Such results are most accurate. In adults, visual acuity is examined using standard visometric charts (Golovin-Sivtsev, etc.) or "E" tests. The visual acuity value is taken as the chart row in which all signs are correctly recognized.

Depending on the severity of the burn, visual acuity is impaired to varying degrees. Thus, in a mild burn, visual acuity decreases slightly or is not affected at all. In a moderate burn, visual acuity may be reduced to a few tenths (≥ 0.5). Severe and extremely severe burns are accompanied by a significant and often persistent decrease in visual acuity (≤ 0.4) down to blindness.

Comments: when assessing the degree (depth) of corneal damage, it is recommended to proceed from the state of its epithelium (edema, erosion), stroma (edema, intensity of opacity, thinning), and Descemet's membrane (folds). When assessing the conjunctiva, it is recommended to consider the severity of its hyperemia, de-epithelialization, chemosis, ischemia, or necrosis, and when assessing the sclera – its exposure and thinning. Special attention should be paid to the state of the anterior chamber structures and the lens (presence or absence of exudate, changes in the iris pattern, pupil deformation, cataract). In severe and even extremely severe chemical eye burns, corneal transparency and visual acuity may remain quite high in the first days and even weeks and thus are not reliable criteria for assessing the severity of these burns. In these cases, an important aid for making such a diagnosis can be : sharp impairment or absence of corneal and limbal sensitivity, perilimbal conjunctival ischemia, damage to anterior chamber structures and lens opacity, as well as (indirectly) the absence of complaints of lacrimation, photophobia, and aching in the eye. Examination of the conjunctival fornices is recommended to be performed under conditions of double eversion of the upper eyelid (preferably) using an eyelid elevator.

Comments: The area of corneal and conjunctival de-epithelialization should be assessed by its yellowish-green staining.

Comments: The results of the palpatory measurement method should be recorded as: Tn (normal pressure), T+1 (moderately elevated), T+2 (high), T+3 (severely elevated - the eye is hard "like stone"); accordingly, for decreased ophthalmotonus: T-1 (moderately decreased), T-2 (low), and T-3 (severely decreased)

Comments: the diagnostic value of new ultrasound and laser research methods in determining the surgical strategy for treating complications of burn disease is indisputable. Both methods (ultrasound biomicroscopy (UBM) and optical coherence tomography (OCT)) provide a clear understanding of the anatomy and topography of the anterior chamber (UBM and OCT), as well as the posterior chamber and pars plana of the ciliary body (UBM) of the eyeball. If UBM is not feasible due to the presence of burn wounds and symblepharon, anterior segment OCT is still possible in such cases.

2.5 Other Procedures

Other diagnostic methods are not indicated.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 Emergency Care

Emergency care for eye burns should primarily aim to eliminate contact between the damaging agent and the eye [1, 2, 13].

In case of chemical burn

The ophthalmologist's assistance should be based on the assumption that any prior eye irrigation performed immediately after the burn was insufficient.

Comments: Clarifying complaints and medical history details or taking any other actions is recommended to be carried out only after the initial irrigation or during the process.

In an eye with an open eyeball injury, preference should be given to irrigation, while wound closure should be performed afterwards.

Given that the epithelial stem cells of the corneal limbus are relatively protected (located deep within the multilayered epithelial layer), there remains hope that they have not yet been damaged or have been partially preserved, and timely irrigation can still prevent their injury. This primarily applies to fresh chemical burns, but even if hours have passed since the burn, irrigation improves the prognosis.

Conjunctival sac irrigation is recommended to be performed with retraction of the lower eyelid and mandatory double eversion of the upper eyelid, preferably using an eyelid elevator. It is recommended to evert the eyelids again for inspection and (if found) thoroughly remove (and excise if necessary) any remaining particles of the burning agent on the mucosal tissue, and continue the procedure.

In case of thermal burn

Comments: for at least 15 minutes, while washing out residues of the burning agent or foreign bodies (if any) from the conjunctival sac, or removing them with a cotton swab or tweezers if this proves ineffective.

Regardless of the causative agent

Comments: the possible development of allergic reactions should be kept in mind: fever, itching, rash, arthralgia, anaphylactic shock. Anti-shock therapy equipment should be prepared prior to administering tetanus antitoxin**. It is not used if the patient has hypersensitivity (allergy) to any of the components included in the medicinal product.

3.2. Conservative treatment

Comments: if corneal epithelialization is not complete by the end of the second week post-burn, adjustment of the aforementioned initial therapy is recommended by reducing the use of corticosteroids (ATX code S01BA) and switching to a short-term course (within two weeks) of non-steroidal anti-inflammatory drug instillations (ATX code S01BC) or using surgical methods (amniotic membrane transplantation or simple blepharorrhaphy). After complete corneal epithelialization, corticosteroid instillations (ATX code S01BA) should be continued, gradually tapering them until inflammatory phenomena in the eye subside.

Comments: in accordance with the instructions for 2 weeks, then switch to other antimicrobial agents (ATX code S01AX) until complete corneal epithelialization.

Comments: depending on the severity of the burn, topical forms of drugs are prescribed for a prolonged period until complete corneal epithelialization, in combination with intramuscular or intravenous injections.

Not used if the patient has hypersensitivity (allergy) to any of the components of the medicinal products.

GGR CLOC 5Grade of Recommendation C (Level of Evidence – 5).

Comments: prescribed (if well tolerated by the patient) until complete corneal epithelialization. It is important to strictly follow care rules and permissible wearing periods.

Comment: it is necessary to perform a preliminary test – administering a small amount of the drug (1 ml) 10 minutes prior to the main administration – to identify potential anaphylactic or allergic reactions.

Comments: instillations are prescribed in sufficient dosages and combinations to achieve the target intraocular pressure (IOP) level. If complete corneal re-epithelialization has not yet occurred, it is recommended to refrain from topical use of beta-blockers (ATC code S01ED) that cause corneal epithelial edema and negatively affect its epithelialization.

3.3. Surgical treatment

Objectives of surgical treatment:

• Clearing the burn surface of non-viable tissues.

• Prevention of circulatory disorders and restoration of tissue blood supply.

• Prevention and treatment of infection.

• Restoration of the integrity of the ocular surface and skin integument via surgical plastic closure of tissue defects.

• Achieving an optimal functional and aesthetic outcome, maximizing the restoration of the patient's quality of life.

Comments: it is necessary to perform an inspection of the conjunctival fornices in the first 24 hours after the burn, and early adequate necrectomy (if necessary) 2 to 3 days after the burn, when demarcation of necrotic areas becomes apparent.

Comments: performed in combination with necrectomy (if the bulbar conjunctiva is partially preserved, with its mobilization).

Comments: usually performed in combination with amniotic membrane (AM) transplantation, ATP, simple or ankylosing blepharorraphy.

Comments: AM coverage is possible both from the first day after the burn upon detection of partial, subtotal, or suspected total loss of epithelial stem cells, and in the late period in the absence of signs of corneal epithelium regeneration and the development of persistent corneal erosion. It also helps maintain the viability (a form of resuscitation) of corneal epithelial stem cells that survived immediately after the burn. Without such coverage, these partially damaged stem cells may perish under the conditions of post-burn inflammation and scarring processes of the ocular surface.

AM coverage is performed using suture or sutureless fixation; the optimal duration of its placement on the corneal surface is 7–10 days, after which repeated coverage is possible if the epithelial defect persists.

Comments: an eye burn frequently leads to the development of dry eye syndrome and cicatricial changes of the eyelids, preventing their complete closure (including during sleep); therefore, this method of surgical treatment neutralizes the pathological impact of these phenomena. Combining this with AM corneal coverage is especially effective.

Comments: performed no earlier than the end of the second week after the burn (usually in combination with simple or ankylosing blepharorraphy).

3.4. Other Treatment

No other treatment methods are performed.

Diet therapy

Not applicable.

4. Medical Rehabilitation and Sanatorium-Resort Treatment

4.1 Medical and Psychological Rehabilitation

4.2 Surgical Rehabilitation

The question of visual rehabilitation in patients with corneal opacities should be considered only after the restoration of normal eyelid closure, elimination of cicatricial pathology of the eyelids and conjunctiva, correction of tear drainage and ocular surface moisturization disorders, as well as normalization of intraocular pressure.

Comments: if it is necessary to eliminate cicatricial pathology and incomplete eyelid closure, trichiasis, symblepharon, restore tear drainage or ocular surface moisturization, as well as for visual rehabilitation, these procedures are initiated no earlier than 6 months after severe thermal burns, 9 months after severe chemical burns, and 1 year after extremely severe burns.

Comments: performed no earlier than 1 year after the burn trauma.

In cases of cicatricial lesions that relatively quickly lead to severe complications (marked ectropion with visual impairment, extensive symblepharon limiting eyeball mobility, secondary glaucoma, etc.), the timing of surgical interventions may be earlier.

Comments: these reconstructive surgeries are performed 1 year after the trauma.

Comments: these reconstructive surgeries are performed 1 year after the trauma.

Comments: this is performed provided that the corneal epithelial phenotype is restored.

Comment: before deciding on limbal stem cell transplantation, it is recommended to confirm the diagnosis of total limbal stem cell deficiency.

The presence of goblet cells within the epithelium covering the leukoma is recommended to be considered a reliable sign of the conjunctival phenotype epithelium and, consequently, of limbal deficiency. The phenotype of the epithelium covering the leukoma should be determined using impression cytology and confocal microscopy methods [6, 26]. If deep stromal opacity of the cornea persists after successful limbal transplantation, optical keratoplasty is recommended to be performed no earlier than three months after the first surgery.

In the event of ulceration or microperforation developing on a post-burn leukoma or corneal graft, closure of the corneal defect with a multi-layered amniotic membrane graft or autoconjunctival pedicle flap is recommended as a tectonic procedure.

5. Prevention and Dispensary Observation

5.1 Prevention

Prevention of eye burns at home and in the workplace involves strict adherence to occupational safety regulations and careful handling of caustic substances at home. There is no prevention for criminal (assault-related) burns.

5.2 Dispensary monitoring

Comment: intraocular pressure, the state of the vitreous body, and ocular tunics are monitored.

6. Organization of Medical Care

• Indications for hospitalization in a medical organization: all moderate, severe, and extremely severe burns.

• Indications for patient discharge from a medical organization

1. completion of treatment or one of the stages of specialized, including high-tech, medical care in a 24-hour or day hospital setting, provided there are no treatment complications requiring drug correction and/or medical interventions in an inpatient setting;

2. Refusal of the patient or their legal representative from specialized, including high-tech, medical care in a 24-hour or day hospital setting, established by a medical board (consilium) of the medical organization;

3. Need to transfer the patient to another medical organization.

7. Additional Information

7.1 Secondary Post-Burn Glaucoma

Comments: as a rule, glaucoma develops after severe chemical burns in 61.4% of cases. The corresponding figure for thermal burns is 20%. The incidence of secondary glaucoma increases proportionally to the severity of the trauma. In severe burns, it is 52.63%, and in extremely severe burns, it is 72%. Most often, secondary glaucoma manifests at the 2nd and 3rd stages of surgical rehabilitation, accounting for a total of 79.3% of cases.

Comments: it is possible to reduce the dose or discontinue corticosteroids (ATX code S01BA) in case of IOP decompensation [2].

Comments: the use of hypotensive therapy allows maintaining normal IOP throughout the entire observation period in 39.6% of cases; as the stages of surgical rehabilitation progress, repeated IOP decompensations are possible, which requires correction of hypotensive therapy and/or the use of various surgical treatment methods for secondary glaucoma in the same eye (for example: lens extraction at stage 1, sinustrabeculectomy or TSCPC at stage 2, anti-glaucoma drainage implantation at stage 3, keratoplasty with anterior chamber reconstruction and TSCPC at stage 4).

To perform TSCPC, a diode laser with a wavelength of 810 nm is used, with a single pulse energy of 1.0–2.0 W and an exposure of 1 s; the session ends when 16–24 coagulates are applied. The efficacy of TSCPC is 87.1%. IOP compensation one year or more after the procedure is maintained in 45.2% of cases. The only "negative" consequence of the procedures is the possible absence of a hypotensive effect; no other complications associated with TSCPC have been identified.

Comments: cryodestruction of the ciliary body has a minor hypotensive effect and can be recommended as the procedure of choice when TSCPC is not feasible [2].

Comments: the immediate hypotensive effect of STE occurs in all cases, but in 71.4% of cases it does not last longer than half a year.

Comments: overall, drainage implantation is a highly effective method of surgical treatment for secondary glaucoma in cases where none of the used methods provide IOP compensation. However, in the early postoperative period after drainage implantation, simultaneous transplantation of mucosal flaps significantly increases the risk of infectious complications, and if fornixplasty is impossible, there is a high probability of damaging drainage elements at subsequent stages of rehabilitation. IOP decompensation or manifestation of secondary glaucoma at intermediate stages of rehabilitation in burn patients is a consequence of planned surgical interventions associated with surgical trauma to the limbal zone and ciliary body; the reliably high frequency of IOP compensation after various treatment methods is offset by its relatively short duration and the need in most cases to undertake another surgical intervention every 6–12 months (until the patient's rehabilitation stages are completed).

7.2 Post-Burn Cataract

Comments: intraocular lens implantation is inappropriate during the treatment stages of acute burn trauma and its complications. At the functional rehabilitation stage, the issue of intraocular correction is decided on a case-by-case basis, taking into account the potential for achieving high visual acuity, considering that in the aftermath of burns, an inflammatory response to surgery and implantation always occurs and tends to be severe.

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Chentsova E.V., Doctor of Medical Sciences, Professor – Head of the Group, Member of the Association of Ophthalmologists;

2. Makarov P.V., Doctor of Medical Sciences, Member of the Association of Ophthalmologists;

3. Kulikov A.N., Doctor of Medical Sciences, Professor, Member of the Association of Ophthalmologists

4. Chernysh V.F., Candidate of Medical Sciences, Associate Professor;

5. Churashov S.V., Doctor of Medical Sciences, Member of the Association of Ophthalmologists;

Conflict of interest: none.

Appendix A2. Methodology for Developing Clinical Guidelines

Methods used for collecting/selecting evidence: search in electronic databases, library resources. Description of methods used for collecting/selecting evidence: the evidence base for the recommendations consists of publications included in the Cochrane Library, EMBASE and MEDLINE databases, as well as monographs and articles in leading specialized peer-reviewed domestic medical journals on the topic. The search depth was 10 years. Methods used for assessing the quality and strength of evidence: expert consensus, significance assessment in accordance with the rating scale.

Target audience for these clinical guidelines:

1. Ophthalmologists

2. General practitioners (family physicians);

3. Ambulance doctors

4. Nursing staff

Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

Table 2. Scale for assessing the levels of evidence (LE) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

Table 3. Scale for grading grades of recommendation (GR) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

These clinical guidelines were developed taking into account the following regulatory legal documents:

1. Order of the Ministry of Health of the Russian Federation No. 442n dated October 25, 2012 (as amended by Orders of the Ministry of Health of the Russian Federation No. 114n dated February 21, 2020, No. 746n dated July 27, 2020) "On Approval of the Procedure for Providing Medical Care to Children with Diseases of the Eye, Its Adnexa and Orbit".

2. Order of the Ministry of Health of the Russian Federation No. 902n dated November 12, 2012 (as amended by Orders of the Ministry of Health of the Russian Federation No. 558n dated June 9, 2020, No. 44n dated February 1, 2022) "On Approval of the Procedure for Providing Medical Care to the Adult Population with Diseases of the Eye, Its Adnexa and Orbit".

3. Order of the Ministry of Health dated September 10, 2021 No. 920n "On Approval of the Standard of Medical Care for Adults with Eye Burns (Diagnosis, Treatment, and Follow-up Care)".

4. Order of the Ministry of Health of the Russian Federation No. 203n dated May 10, 2017 "On Approval of Criteria for Assessing the Quality of Medical Care"

5. Decree of the Government of the Russian Federation No. 2406-r dated October 12, 2019 (as amended on June 9, 2023) "On Approval of the List of Vital and Essential Medicines, as well as Lists of Medicinal Products for Medical Use and the Minimum Assortment of Medicinal Products Required for the Provision of Medical Care".

6. Order of the Ministry of Health of the Russian Federation No. 103n dated February 28, 2019 "On Approval of the Procedure and Timelines for the Development of Clinical Guidelines, Their Revision, the Standard Form of Clinical Guidelines and Requirements for Their Structure, Composition, and Scientific Validity of Information Included in Clinical Guidelines"

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

Burns are one of the most severe injuries to the visual organ and a major cause of visual impairment. The degree of chemical burn depends on the properties of the damaging agents, as well as the duration of exposure of the chemical substance to the surface of the eyeball. A characteristic feature of eye burns is the spread of pathological processes far beyond the boundaries of the initially traumatized zone of the eyeball. Currently, the incidence of burn injuries remains significant, ranging from 6.1% to 38.4% of all eye injuries, and about 50% of the victims become disabled in visual groups I-2. Among burn patients, the overwhelming majority are young men of working age.

Prevention of eye burns in adults primarily involves compliance with general safety precautions, adherence to necessary occupational safety rules, and the use of personal protective equipment when required for work.

Preventive measures directed at children's eye burns require special attention.

• Children should not be left unattended in areas where they are at risk of sustaining a burn (kitchen, bathroom, boiler room, utility room).

• Hot cookware should be placed on rear burners or handles turned away from the edge of the stove.

• Hot liquids (tea, soup, boiling water) should be kept out of the reach of children.

• Children should be kept at a safe distance from open fire (e.g., when cooking on a grill during a picnic).

• Children should not be taught to use matches and lighters until there is certainty that they understand their potential danger. These items must be stored in a place inaccessible to children.

• Household chemicals must be stored in a place inaccessible to children.

Treatment for eye burns must be initiated from the very first day following the injury.

This is necessary to prevent the development of severe and sometimes irreversible complications.

It is extremely vital to flush the eyes thoroughly with running water during the first minutes after the injury, and then seek immediate specialist care.

What not to do

• Waste time searching for an antidote.

• Use warm liquids for irrigation.

• Rub the eyes with hands, a tissue, or any other non-sterile material.

• Delay visiting a doctor if normal visual function is preserved, as preserved visual function does not rule out an ongoing pathological process in the ocular tissues.

Treatment of moderate, severe, and extremely severe burns involves prolonged conservative therapy and often requires multiple surgical interventions aimed at saving the eye as an organ.

After discharge from the hospital, the patient must continue regular follow-up with an ophthalmologist and receive courses of anti-inflammatory and reparative therapy.

As a rule, elective reconstructive surgeries to restore eye function can only be performed one year after severe and particularly severe burns. Such treatment is classified as specialized high-tech care utilizing complex optical equipment:

• removal of a cataractous lens

• lamellar keratoplasty

• penetrating keratoplasty

• mucosal flap plasty of the fornices using labial mucosa

• keratoprosthesis and reinforcement of corneal leukoma in particularly severe cases

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Rating scales, questionnaires, and other patient assessment tools for eye burns are not used.