Alkali Splash With pH 12 and a 20-Minute Wait for the Physician

This is a true ocular emergency: irrigation comes before paperwork, history, consent, and visual acuity. Alkali injuries worsen minute by minute.

Sequence:

1. Stop the paperwork and move him directly to the irrigation station. Have him sit or lie down and keep his hands away from the eye.
2. Instill topical proparacaine to break the blepharospasm and allow irrigation and lid manipulation. This is for the procedure only, not for home use.
3. Place a lid speculum if needed, evert the upper lid, and inspect the fornices for particulate matter; sweep it out. If using a Morgan lens, insert it and start normal saline.
4. Irrigate copiously with at least 1 L, typically over 30 minutes, or manually with saline from the inner to outer canthus while he looks in all directions.
5. Check pH every 5 minutes. Continue until pH is about 7.0-7.4. After stopping, wait 5-10 minutes and recheck, because the pH can rebound as retained chemical diffuses out; resume irrigation if it rises again.
6. Notify the physician immediately in parallel; do not wait 20 minutes to start. Technicians can initiate irrigation under standing protocol.

Do not let him go back to work, and do not give anesthetic to take home.

Alkalis cause liquefactive necrosis: they saponify cell membranes and penetrate deeply into the stroma, sometimes within seconds, so the injury can progress long after the splash. Acids tend to precipitate proteins, which can limit penetration, although strong acids are still serious. The pH of 12 here is severely alkaline, and the product is a drain cleaner, so the risk of limbal ischemia, corneal melting, perforation, and secondary glaucoma is real.

After irrigation, look for and document: corneal clarity and epithelial loss, limbal blanching or ischemia (a poor prognostic sign), conjunctival chemosis, visible particulate matter in the fornices, anterior chamber reaction or hypopyon, and intraocular pressure if it can be measured safely. Check visual acuity as soon as the lids can be opened. Fluorescein staining after irrigation maps the epithelial defect. Evert the upper lid again, because granular material can lodge there and continue releasing alkali.

Pain out of proportion, a white quiet eye, or a shrinking globe should prompt urgent physician review. Your job is to keep irrigating and reporting, not to decide that the eye "looks better" and stop early.

Explain that the numbing drop is a medication for the irrigation procedure and cannot be sent home or used repeatedly: it is toxic to the corneal epithelium, it hides worsening pain, and it can delay treatment of a melting cornea. He cannot return to work today; the eye needs a physician examination and likely follow-up within 24 hours. Give him written warning signs: increasing pain, decreasing vision, discharge, or a feeling that something is still in the eye.

Documentation: time of exposure, time of arrival, initial pH, time irrigation started, solution and volume used, pH readings with times, topical anesthetic administered, lid eversion and any foreign bodies removed, visual acuity when obtainable, fluorescein findings, physician notification times, and the patient's questions and your answers. Record that he was advised not to rub the eye and not to return to work.

Hand off verbally to the physician: exposure type, pH trend, volume irrigated, corneal and limbal findings, and the fact that he is still symptomatic. Ask whether tetanus status, topical antibiotics, cycloplegia, or pressure control is needed; those are physician decisions. Arrange the follow-up visit before he leaves, and ensure he has a way home, since driving after a severe chemical injury is unsafe.