Glaucoma in Patients With Ocular Chemical Burns
MICHELLE P. LIN, UMIT EKSIOGLU, RAGHU C. MUDUMBAI, MARK A. SLABAUGH, AND PHILIP P. CHEN
PURPOSE: To examine the development and manage-
ment of glaucoma in patients with ocular chemical burns.
DESIGN: Retrospective, observational case series.
METHODS: SETTING: University of Washington Eye
Clinics. PATIENT POPULATION: Twenty-nine eyes (18 pa-
tients) with ocular chemical burns seen between 1997 and
2010 with a minimum of 3 months of follow-up. OBSERVA-
TION PROCEDURE: Eyes were graded using the Roper-Hall
scale. MAIN OUTCOME MEASURES: Long-term use of glaucoma
medications (3 months or more) and need for glaucoma
surgery.
RESULTS: The mean age was 45 17 years, with a mean
follow-up of 75 47 months (median, 66 months).
Roper-Hall grade III or IV eyes (n 20) had significantly
higher intraocular pressure at presentation (35.9 vs 16.4
mm Hg; P .001) and over follow-up were more likely to
require long-term glaucoma medications (P .003) or to
undergo glaucoma surgery (P .016) than Roper-Hall
grade I or II eyes. Thirteen eyes (12 Roper-Hall grade III or
IV) underwent glaucoma surgery. Eight eyes underwent
glaucoma tube implant surgery; 4 required at least 1
revision. Seven eyes underwent diode laser cyclophotoco-
agulation; 4 required repeat treatment. Most (89%) eyes
had controlled intraocular pressure at the last follow-up.
However, 76% of eyes with visual acuity of 20/200 or
worse at initial evaluation did not have improved vision at
the last follow-up.
CONCLUSIONS: Eyes with Roper-Hall grade III or IV
ocular chemical burns were more likely to have glaucoma
and to require surgery for it. Outcomes of glaucoma
management generally were good, although tube implant
surgeries often had complications requiring revision.
(Am J Ophthalmol 2012;154:481 485. 2012 by
Elsevier Inc. All rights reserved.)
C
HEMICAL BURNS CONSTITUTE BETWEEN 8% AND 18%
of ocular trauma. Most victims are young males
between the ages of 16 and 45 years.13 Injuries are
often work related, and nearly 90% of injuries occur as a result
of accidents.4,5 Alkali burns are more common than acid
burns and are more severe.6 Many prognostic factors have
been examined in evaluating visual recovery after ocular
Accepted for publication Mar 21, 2012.
From the Department of Ophthalmology, University of Washington
School of Medicine, Seattle, Washington.
Umit Eksioglu is currently practicing at Department of Ophthalmol-
ogy, Ankara Training and Research Hospital, Ankara, Turkey.
Inquiries to Philip P. Chen, Department of Ophthalmology, University
of Washington, Box 359608, 325 Ninth Avenue, Seattle, WA 98104-
2499; e-mail: pchen@u.washington.edu
0002-9394/$36.00 2012 BY ELSEVIER INC. ALL
http://dx.doi.org/10.1016/j.ajo.2012.03.026
chemical burns, including pH and concentration of the
chemical, duration of exposure, corneal stromal whitening,
and the extent of limbal ischemia.79 However, few studies
have examined glaucoma after ocular chemical burns. The
purpose of this study is to investigate the risk of, and risk
factors for, development of glaucoma after ocular exposure to
acid and alkali chemical agents and the outcomes of man-
agement for glaucoma in these cases.
METHODS
WE REVIEWED PATIENTS SEEN BETWEEN 1997 AND 2010 AT
the Eye Clinics of the University of Washington (Univer-
sity of Washington Medical Center and Harborview Med-
ical Center). Patients were identified by International
Classification of Disease, Ninth Edition, code search for
ocular burns (940.0 through 940.5). Patients with ocular
chemical burns with at least 3 months of follow-up were
included in the study. Although glaucoma usually is
assessed though evaluation of the optic nerve and visual
field, because of the type of injury and the resulting poor
corneal clarity, most patients did not have optic nerve
findings recorded or visual field testing performed during
follow-up. Therefore, we defined glaucoma as intraocular
pressure (IOP) of more than 21 mm Hg and requiring
treatment during management of ocular chemical burns.
Clinical data collected included type of chemical burn,
ocular pH, demographic data (age, sex, race), visual acuity,
IOP, glaucoma medications, and examination findings and
procedures performed at presentation and over follow-up.
Long-term medication use was defined as use of glaucoma
medications at or beyond 3 months after injury.
Roper-Hall classification9 was used, in some cases retro-
spectively, to grade the severity of the burns. In brief,
Roper-Hall grade I burns indicate corneal epithelial damage
without limbal ischemia. Grade II burns indicate corneal haze
with iris details visible and less than one third limbal
ischemia. Grade III burns indicate total epithelial loss, stro-
mal haze with iris details obscured, and one third to one half
limbal ischemia. Grade IV burns indicate dense stromal haze
with the iris and pupil obscured, and more than one half
limbal ischemia. Eyes also were stratified into 2 groups based
on presenting visual acuity: Snellen acuity of better than
20/200 and Snellen acuity of 20/200 or worse. Data were
entered into a spreadsheet (SPSS software version 16.0 for
Mac; SPSS, Inc, Chicago, Illinois, USA). Statistical analysis
was performed with chi-square and Fisher exact testing and
independent-samples, 2-tail t test.
RIGHTS RESERVED. 481
 482

TABLE 1. Initial and Final Visual Acuity and Intraocular Pressure, Glaucoma Medication Use, and Glaucoma Surgery Performed in 29 Eyes with Ocular Chemical Burns

No. of Months to
Eye Age Type of Follow-up Roper-Hall Initial Visual Initial IOP Final Visual Final IOP IOP Medications First Glaucoma Corneal Surgery
No. (years) Burn (months) Grade Acuity (mm Hg) Acuity (mm Hg) ( 3 months) Glaucoma Surgery Type Surgery Type

1 28 Alkalia 98 4 20/400 42 20/80 20 Yes Baerveldt, revision 1 26 KPro I, KPro II

2 28 Alkalia 98 4 CF 43 Enucleation NR N/A PKP
3 51 Alkali 151 4 20/200 23 20/60 5 Yes Ahmed, removal, 23 KPro II
cyclocryotherapy
4 51 Alkali 151 3 20/80 15 LP 10 Yes ECP, CPC 105 PKP 3, KPro I
5 28 Acida 58 3 20/200 30 20/40 10 No
6 28 Acida 58 3 20/400 17 20/200 9 No
AMERICAN JOURNAL

7 52 Acid 66 1 20/70 30 20/40 29 Yes Baerveldt 66

8 33 Alkali 53 4 HM 43 Enucleation 43 Yes PKP 2
9 47 Alkali 58 2 20/200 20 HM 14 No
10 47 Alkali 58 2 20/200 17 HM 13 No
11 24 Acid 18 4 20/400 25 HM 6 Yes CPC, Baerveldt, revision 1 3 PKP 2
12 45 Alkali 103 4 HM NR Enucleation 25 Yes Tube (type unknown) 60 PKP 2, KPro I
13 25 Alkali 10 3 NR 21 CF 6 Yes CPC 3 3 PKP
14 25 Alkali 10 3 NR 18 LP 6 Yes
OF

15 66 Alkali 114 1 20/50 17 20/30 13 No

OPHTHALMOLOGY

16 60 Acid 43 1 20/30 NR 20/20 14 No

17 77 Alkali 96 1 20/40 10 20/30 16 No
18 77 Alkali 96 1 20/50 8 20/25 14 No
19 44 Alkali 157 3 LP 50 HM 10 Yes CPC 13 PKP
20 44 Alkali 157 3 LP 60 20/40 10 Yes Ahmed CPC 10 KPro II
21 19 Alkali 17 2 20/40 23 20/20 18 No
22 19 Alkali 17 3 20/40 16 20/25 18 No
23 70 Alkali 16 4 HM 21 20/200 20 Yes PKP, KPro I
24 51 Alkali 27 4 20/200 42 HM 14 Yes Baerveldt 25 PKP
25 51 Alkali 27 4 NLP NR NLP 41 Yes
26 46 Alkali 109 4 20/400 40 HM 15 Yes Baerveldt 2, revision 4 4 PKP, KPro I
27 46 Alkali 109 2 20/20 12 20/25 15 Yes
28 52 Alkali 97 3 20/400 47 HM 20 Yes CPC 2 12 Declined
29 52 Alkali 97 4 20/400 87 LP 20 Yes CPC 3 11 Declined

CF counting fingers; CPC transscleral cyclophotocoagulation; ECP endoscopic cyclophotocoagulation; HM hand movements; IOP intraocular pressure; KPro Boston
SEPTEMBER

keratoprosthesis (type I or II); LP light perception; N/A not applicable; NLP no light perception; NR not recorded; PKP penetrating keratoplasty.
a
Suspected methamphetamine manufacture.
2012
 Roper-Hall classification resulted in 5 eyes (17.2%) with grade
TABLE 2. Clinical Findings during Follow-up in Eyes with I ocular chemical burns, 4 eyes (13.8%) with grade II ocular
Ocular Chemical Burns (n 29) chemical burns, 9 eyes (31.0%) with grade III ocular chemical
burns, and 11 eyes (37.9%) with grade IV ocular chemical burns.
Roper-Hall Roper-Hall
Findings Grade I/II Grade III/IV P Value
One eye (3.4%) was enucleated after 10 days because of
endophthalmitis after corneal perforation and was not included
Age (years) 54 20 41 14 .153a
in the analysis of glaucoma development or treatment.
Follow-up (mos) 73 33 75 53 .895a
Higher Roper-Hall grade was associated significantly with
Chemical: alkali/acid 7/2 17/3 .633b
initial visual acuity of 20/200 or worse. Higher Roper-Hall
(eyes)
Eyes requiring glaucoma
grade also was associated with worse initial visual acuity (P
medication .016, analysis of variance), but not with higher initial IOP
Initial 1/9 (11%) 18/20 (90%) .001b (P .055, analysis of variance), unless Roper-Hall grade III
Long term 2/9 (22%) 16/19 (84%) .003b and IV eyes were combined and compared with Roper-Hall
No. of long-term 0.4 1.0 1.8 1.4 .018a grade I and II eyes (P .001; Table 2). Higher Roper-Hall
medications grade also was associated significantly with any glaucoma med-
Glaucoma surgery (eyes) 1/9 (11%) 12/19 (63%) .016b ication use (P .001), long-term glaucoma medication use (P
Other surgery (eyes) 1/9 (11%) 17/20 (85%) .001b .010), need for any ophthalmic surgery (P .003), and visual
Visual acuity
acuity of 20/200 or worse at final visit (P .020). Most eyes that
Initial
required long-term glaucoma medication use had elevated IOP
logMAR 0.46 0.34 1.90 1.18 .001a
20/200 (eyes) 7/9 (77%) 2/19 (11%) .001b
by the first week after injury (15/18 eyes; 83%).
Final
A comparison of eyes with alkali versus acid burns showed
logMAR 0.61 0.96 2.49 1.72 .001a that among eyes with alkali burns, 16 (70%) of 23 and 11 (48%)
20/200 7/9 (77%) 5/19 (26%) .014b of 23 required long-term glaucoma medication and surgery,
Intraocular pressure respectively, which was not significantly different than the 2
(mm Hg) (40%) of 5 eyes with acid burns that required both long-term
Initial 17.1 7.3 35.6 18.8 .001a glaucoma medications and glaucoma surgery (P .315). Final
Final 16.2 5.0 14.5 9.2 .601a visual acuity was 20/200 or worse in 15 (63%) of 24 eyes with
alkali burns and in 2 (40%) of 5 eyes with acid burns.
logMAR logarithm of the minimal angle of resolution.
a
Thirteen eyes (46% of all eyes; 5/9 Roper-Hall grade III and
Independent sample t test, 2 tailed.
b 7/10 Roper-Hall grade IV) required glaucoma surgery for IOP
Fisher exact test, 2 tailed.
control; all were treated medically for glaucoma before any type
of glaucoma surgery. Eyes with Roper-Hall grade III or IV ocular
chemical burns were significantly more likely to need long-term
RESULTS glaucoma medications (P .003) and glaucoma surgery (P
.016) compared with eyes with Roper-Hall grade I or II ocular
TWENTY-NINE EYES (18 PATIENTS) WITH OCULAR CHEMI- chemical burns (Table 2). Four eyes underwent glaucoma surgery
cal burns were identified and met inclusion criteria (Table at the same time as penetrating keratoplasty or Boston kerato-
1). The mean patient age was 45.4 16.7 years (range, 19 prosthesis surgery, and 3 eyes underwent glaucoma surgery after
to 77 years), and mean follow-up was 75 47 months such procedures. Three eyes underwent glaucoma surgery before
(median, 66 months; range, 10 to 157 months). Most penetrating keratoplasty, and 3 eyes that underwent glaucoma
patients were male (15/18; 83%) and white (15/18; 83%). surgery had no corneal transplantation procedures performed.
Twenty-four eyes (83%) had alkali burns with a mean pH The Kaplan-Meier estimate for need for glaucoma surgery was
of 9.38, whereas 5 eyes (17%) had acid burns. Among eyes 58.6% (95% confidence interval, 34.0% to 83.2%) at 3 years for
with alkali burns, 68% (15/22) had visual acuity of 20/200 Roper-Hall grade III and IV eyes, which was significantly worse
or worse, compared with 60% (3/5) in eyes with acid burns. (P .002, log-rank test) than that for Roper-Hall grade I and II
In 2 eyes (7%) with alkali burns, the initial visual acuity eyes (0%).
was unknown because the patient was intubated at the Eight eyes (28%) underwent glaucoma drainage tube implant
time of initial evaluation. In 1 eye (3.4%), the initial surgery (5 Baerveldt procedures, 2 Ahmed procedures, and 1
visual acuity was no light perception because of prior unknown procedure). Four (3 Baerveldt procedures and 1
damage from long-standing angle-recession glaucoma, Ahmed procedure) required revision surgery during follow-up: 1
which was well controlled with medications before the had the tube tied off because of hypotony in an eye that had not
chemical injury; this eye was not included in evaluation of had prior cyclodestruction; 1 underwent 2 revisions for tube
visual acuity during follow-up. Four eyes (14%; all with corneal contact, with eventual tube placement in the pars plana
initial visual acuity of 20/200 or worse; 2 patients) were after pars plana vitrectomy; 1 required 4 revisions, 2 for tube
injured in accidents involving suspected methamphet- blockage and 2 for tube exposure; and 1 required implant
amine manufacture. removal, with subsequent cyclocryotherapy treatment. One

VOL. 154, NO. 3 GLAUCOMA AFTER CHEMICAL BURNS 483

other tube (type unknown) was considered to be marginally
functional at the time of enucleation. Seven eyes underwent
diode laser cyclophotocoagulation, 3 of which needed multiple
procedures. One eye underwent endoscopic diode laser cyclo-
photocoagulation, followed by transscleral diode laser cyclopho-
tocoagulation; the other eyes all underwent transscleral diode
laser cyclophotocoagulation only.
Three eyes (10.3%) were enucleated, one at 10 days after
ocular chemical burn injury resulting from endophthalmitis after
corneal perforation, and 1 each at 4 and 8 years after injury for
intractable pain; glaucoma was considered the cause in 1 of those
cases, in an eye that had not undergone glaucoma surgery. For
the total group, the IOP was considered controlled at last
follow-up in 25 (89%) of 28 eyes. Among the 7 eyes (24%) with
recorded cup-to-disc ratio, the mean ratio at last visit was 0.57
0.20; 2 of 7 eyes (29%) had cupping consistent with some degree
of optic nerve damage (0.75 and 0.90). Optic disc pallor was
noted in 4 of 7 eyes (57%).
Eighteen eyes (62%; 17/20 Roper-Hall grade III or IV)
underwent any kind of ocular surgery during follow-up.
Fourteen of 18 eyes (78%) had corneal surgery, 10 of 18 eyes
(56%) had cataract extraction, 4 of 18 eyes (22%) had pars
plana vitrectomy, and 13 of 18 eyes (72%) had oculoplastic
surgery during follow-up. Of the 13 who had undergone 1 or
more corneal transplant surgeries, 9 (69%) underwent pene-
trating keratoplasty, 4 (31%) subsequently underwent at least
1 repeat penetrating keratoplasty, and 7 (54%) underwent
keratoprosthesis surgery (5 of Boston type I and 3 of Boston
type II; 1 received both types). Seven of 18 eyes (39%)
underwent amniotic membrane graft(s), and 5 of 18 eyes (28%)
underwent limbal stem cell transplantation.
At the last follow-up visit, 4 of 19 eyes with initial visual
acuity of 20/200 or worse (21%; 2 each of Roper-Hall grade III
and IV) had improved to better than 20/200; 3 of these (alkali
injuries) had undergone Boston type II keratoprosthesis, and 1
(acid injury) required only eyelid reconstructive surgery. One of
9 eyes with initial visual acuity better than 20/200 (11%;
Roper-Hall grade III, alkali injury) had declined to 20/200 or
worse at the final follow-up. The remaining 15 eyes (76%) with
visual acuity of 20/200 or worse at the initial visit did not have
visual acuity better than 20/200 at the final follow-up or had
undergone enucleation. In all of these eyes, the clarity of the
cornea alone could have accounted for the visual acuity noted,
although the relative contribution of glaucoma damage to the
measured acuity could not be ascertained because the optic nerve
and visual field could not be evaluated.
DISCUSSION
SEVERE OCULAR CHEMICAL BURNS REMAIN A CHALLENG-
ing area for both visual rehabilitation and glaucoma
treatment, although improvements have been made in the
management of ocular chemical burns in recent years.10,11
Vision loss from chemical burns is not limited to the direct
causative injury to the ocular surface, but may also occur as
484 AMERICAN JOURNAL
a result of acute and chronic optic nerve damage from
uncontrolled IOP. Glaucoma as a result of alkali burns may
be immediate or delayed.12 In 1946, Hughes documented
several cases of elevated IOP 1 month after alkali burns.13
Kuckelkorn and associates reviewed 66 cases (90 eyes) of
severe ocular chemical burns14; early glaucoma occurred in
14 (15.6%) eyes and late (months) glaucoma occurred in
20 (22.2%) eyes.14 Tsai and associates found glaucoma
in 18 (55%) of 33 eyes after ocular chemical or thermal
burns that caused severe ocular surface disease.15 However,
these reports did not include evaluation of risk factors for
glaucoma development, nor outcomes of management.
We found glaucoma after ocular chemical burns to be
associated with more severe burns: 16 (84%) of 19 eyes
with Roper-Hall grade III or IV ocular chemical burns
required long-term glaucoma medication. We found only a
small proportion of eyes that had initially low IOP later
demonstrated elevated IOP requiring glaucoma medica-
tions; 15 (83%) of 18 eyes that required long-term glau-
coma treatment had elevated IOP within 1 week of
presentation. This is perhaps not surprising, given the
pathophysiology of chemical burns on the ocular surface.
Early direct chemical injury may cause tissue shrinkage and
disruption of the trabecular meshwork and outflow chan-
nels.16,17 Subsequent chronic inflammation may lead to
synechiae and angle closure, perhaps offset in part by
ciliary body necrosis in alkali burns.16 Other mechanisms,
such as long-term use of topical corticosteroids after ocular
procedures, also may contribute to later IOP elevation.
Glaucoma may occur after corneal surgeries required for
visual rehabilitation, with reported rates of 10% to 53%,
including after newer procedures such as Boston kerato-
prosthesis placement.18 20 In our study, glaucoma surgery
often was associated with corneal transplant procedures
and was required after penetrating keratoplasty or kerato-
prosthesis surgery in 3 (23%) of 13 eyes, and in another 4
eyes (31%), the procedure was performed at the same time
as penetrating keratoplasty or keratoprosthesis surgery.
However, in all 7 of these eyes, medically treated glaucoma
predated the corneal transplant surgery.
In 14 patients with ocular chemical burns and glaucoma,
Kuckelkorn and associates noted that glaucoma drainage im-
plant surgery had a high complication rate (6 of 9 eyes) and
concluded that transscleral laser cyclophotocoagulation may be
preferred in such patients.21 Our findings, albeit in a similarly
small sample, are in agreement, with 4 of 8 eyes that received a
glaucoma tube implant requiring at least 1 revision, and 1 other
that was considered suboptimally functional at the time of
enucleation. In some eyes, scarred and friable conjunctiva, the
difficulty of accurate tube placement because of poor corneal
clarity, and uncertain ciliary body health and aqueous produc-
tion render glaucoma tube shunt placement relatively problem-
atic. When tube implant surgery is performed as an adjunct to
keratoprosthesis surgery, tube placement in relation to the
cornea becomes less critical, and several reports have noted good
results in these cases with tube implants.19 However some
OF OPHTHALMOLOGY SEPTEMBER 2012
authors have noted a relatively high frequency of tube-related
complications in these patients, such as tube erosion,22 and
others have reported that concurrent or subsequent cyclophoto-
coagulation may be necessary.23
Our study has several limitations. Glaucoma was defined
only by IOP, because most patients did not have optic nerve
and visual field assessment during follow-up because of cor-
neal opacity. This makes it difficult to ascertain with confi-
dence the relative contribution of glaucoma to the final visual
state of many of the eyes studied, although most eyes had
controlled IOP. The retrospective nature of our study design
prevented us from gathering all clinically relevant data on all
subjects because of incomplete medical recording and non-
standardized follow-up regimens. In addition, a larger sample
size would enhance the strength of the conclusions made.
ALL AUTHORS HAVE COMPLETED AND SUBMITTED THE ICMJE FORM FOR DISCLOSURE OF POTENTIAL CONFLICTS OF
interest and none were reported. Publication of this article was supported in part by an unrestricted departmental grant from Research to Prevent
Blindness, Inc, New York, New York, and by the University of Washington Glaucoma Research Fund, Seattle, Washington, including an unrestricted
research grant from Allergan, Inc, Irvine, California. Involved in study design and conduct (R.C.M., P.P.C.); data collection (M.P.L., U.E., M.A.S.,
P.P.C.); data management and analysis (P.P.C.); data interpretation (R.C.M., M.A.S., P.P.C.); and preparation, review, or approval of manuscript
(M.P.L., U.E., R.C.M., M.A.S., P.P.C.). The Human Subjects Division of the University of Washington, Seattle, Washington, approved this
retrospective review of patient data.
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AFTER CHEMICAL BURNS 485
 Biosketch
Michelle Lin is a medical student at the University of Washington School of Medicine, Seattle, Washington. She received
her MPH degree from the Dartmouth Institute for Health Policy & Clinical Practice. Michelle is passionate about
outcomes research, innovation and technology development in vision science. She is currently pursuing a research
fellowship at the Cleveland Clinic/Cole Eye Institute.

VOL. 154, NO. 3 GLAUCOMA AFTER CHEMICAL BURNS 485.e1

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.