Photographs by The University of Iowa and EyeRounds.org (12) and ©2017 American Academy of Ophthalmology, reprinted with permission. (13, 14).

Better

- Evaluate ocular pH using a urine test strip and CTA.
- Do not place the test strip directly on the eye. Roll a
- CTA across the conjunctival surface and then onto the test strip. If pH ≠ 7, continue irrigation and recheck until pH = 7.

Best:

- Initiate real-time video telemedicine consultation; treatment duration for more significant chemical burns will vary depending on the injury and are best determined by an eye-care specialist
- Further treatments and need for evacuation will be directed by the grade of injury. Evaluation will require fluorescein strips to evaluate the corneal epithelium and a light source, preferably with a red-free option (i.e., green lens), for evaluation of limbal ischemia.

Grade I:

- Topical antibiotic ointment (e.g., erythromycin ophthalmic ointment) 3 times per day Cycloplegic eye drop (cyclopentolate 1%), 1 drop every 8 hours, if available, for photophobia
- Preservative-free artificial tears 3 times per day, alternating between ointment treatments

Grades II–IV:

- Moxifloxacin 0.5% eye drops, 1 drop every 8 hours
- Topical corticosteroid (e.g., tobramycin/dexamethasone or prednisolone acetate 1%) 1 drop every hour while awake
- Cycloplegic drop (cyclopentolate 1%), 1 drop every 8 hours, if available
- Doxycycline 100mg PO every 12 hours; this has anti-inflammatory and anticollagenase benefits for the ocular surface.
- The following have been shown to improve corneal healing with severe chemical burns; add to the treatment if available:
  - Vitamin C 2g 4 times per day.17
  - Supplemental oxygen (administer 100% for 1 hour twice daily).19 No data are available for the effectiveness of lower doses of oxygen.
- Reassess frequently until evacuation.
- No altitude restrictions for flight

7. PRESEPTAL AND ORBITAL CELLULITIS

Infection anterior to the orbital septum (usually involving the eyelid) is termed preseptal cellulitis. Preseptal cellulitis will present with tenderness, swelling, and erythema of the eyelids, with no orbital findings (e.g., no sign of proptosis, eye movement restriction, or change in vision). Preseptal cellulitis can generally be managed with oral antibiotics, but the possibility of methicillinresistant Staphylococcus aureus (MRSA) must be considered.

Infection in the orbit (posterior to the orbital septum) can occur as a result of adjacent sinusitis, skin infection, puncture wounds, or orbital foreign bodies. Multiple organisms, including staphylococcal, streptococcal, and gram-negative bacteria, are usually responsible. Orbital cellulitis has the potential to progress rapidly and may lead to irreversible loss of vision or intracranial extension. Orbital cellulitis presents with pain, proptosis, conjunctival injection, decreased vision, and loss of ocular mobility (which may cause double vision).

Goal

Recognize infection early and start oral antibiotics for preseptal cellulitis and IV antibiotics for orbital cellulitis. Evacuate to an eye surgeon as rapidly as possible if orbital cellulitis is suspected.

Preseptal cellulitis (Figure 15)

- Minimum
- Moxifloxacin 400mg PO daily or levofloxacin 750mg PO daily.
- Does not cover MRSA; follow closely for worsening condition.
- Initiate pain control as needed.
- Activate evacuation with goal of evaluation by an eye surgeon within 24 hours.
- Initiate teleconsultation with photographs.

Best

Trimethoprim sulfamethoxazole DS 1 tablet PO every 8 hours combined with amoxicillin/clavulanic acid 875mg every 12 hours.

Orbital cellulitis (Figure 16)

Minimum

- Prompt recognition of the condition and the need for rapid intervention
- Initiate pain control as needed.
- Initiate IV access with broad-spectrum IV antibiotics: ertapenem 1g IV/IO daily or levofloxacin 500mg IV once a day.
- Initiate pain control as needed.
- Activate evacuation with goal of evaluation by an eye surgeon within 24 hours.

Initiate teleconsultation with photographs (include full facial views).