How to irrigate the eye and perform eyelid tipping

By Cristiano Antonino On Mar 9, 2022

Eyelid inversion: eye irrigation is used to remove particles and harmful chemicals from the conjunctiva and cornea

Eyelid eversion is used to expose the upper eyelid conjunctiva and fornix so that foreign bodies can be identified in these areas

Eyelid eversion and eyelid irrigation are often performed together to ensure that both particulate matter and chemical irritants are removed from the entire ocular surface.

Indications for eye irrigation and eyelid eversion

Chemical eye injuries (caustic chemical burns are a medical emergency; irrigation should begin as soon as possible, with on-site flushing with any available water, even before a doctor arrives)
Removal of a small particle from the eye
Treatment of foreign body sensation when no particles are visible (sometimes successfully)

Contra-indications to eye irrigation and lid tipping

Absolute contraindications:

Absent

Relative contraindications:

If perforation of the eye is suspected, irrigation should be postponed until a formal eye examination can be performed.

If the cornea may have deep wounds or foreign bodies, irrigation with a scleral lens may cause further injury and should not be performed. Irrigate the eye manually, gently and with great care.

Complications of eye irrigation and eyelid eversion

The cornea or conjunctiva may be mechanically abraded by the tip of the EV tube, the scleral lens or an irrigation current aimed directly at the cornea.

Eye irrigation and eyelid eversion equipment

Irrigation solution, e.g., normal saline (0.9%), lactated Ringer’s, heated when possible; several litres may be required for prolonged irrigation
Intravenous cannula and EV infusion rod
Drainage basin and towels to collect irrigation fluid runoff
Face/eye protection, gloves and shirts for operator(s)
Local anaesthetic (e.g., proparacaine 0.5% eye drops); sometimes for prolonged irrigations, add 10 mL of 1% lidocaine to each litre of irrigation solution
pH test strips or extended pH paper
Swabs, eyelid retractors
Cotton-tipped applicators (swabs)
Scleral lenses (irrigation)

Additional considerations to eyelid eversion

Patients exposed to chemicals may have other severe chemical burns in addition to ocular burns. Ocular burns should be treated at the same time as these other serious injuries.
Seek urgent ophthalmological advice for severe ocular burns, particularly those involving deep corneal injury, but do not delay irrigation while waiting for the ophthalmologist.
If you are unsure of the severity of an eye injury from chemical exposure, irrigate the eye.

Positioning for eye irrigation and eyelid eversion

Place the patient supine on the bed or gurney.
Hang irrigation fluid bags with saline solution one metre or more above the patient’s head (proper fluid flow depends on this height).
Place a plastic drainage basin under the patient’s eye to collect the irrigation fluid and towels on the stretcher.
An assistant can help retract the eyelids during irrigation and should be on the opposite side of the stretcher.

Eyelid eversion: step-by-step description of procedures and key teaching points

Immediate initiation of irrigation is the primary goal in the treatment of chemical eye burns. Postpone other parts of the assessment and treatment, even the normal preliminary assessments, including external examination of the eye and basic assessment of visual acuity, until after irrigation.
Whenever possible, check the pH of the eye before irrigation by touching the lower fornix with a pH card or pH strip used for measurement in urine. If pH strips are not immediately available, check the pH as soon as possible after the start of irrigation. The normal pH of the eye measured with litmus paper is approximately 7.0.
Ask the patient to look upwards and then insert a drop of topical ocular anaesthetic into the lower fornix of the affected eye. Explain to the patient to keep the eyes closed until irrigation begins in order to retain the drug. It may be necessary to reintroduce drops every 5-10 minutes during irrigation.
If particulate material may be in the eyes and significant chemical exposure is unlikely, sweep up particles with a moist cotton-tipped applicator before irrigating. Clean both lower and upper fornices.
In one hand, hold the end of the EV tube approximately 3-5 cm from the eye. Open the tube fully to obtain optimal irrigation flow.
Direct the irrigation flow over the entire surface of the eye, including the lower and upper fornices and the cornea. The flow should run over the surface and should never be aimed directly at the cornea.
Retract the eyelids to adequately irrigate the fornices. Use the hand not holding the EV tube; or an assistant with gauze in each hand can retract the eyelids. An eyelid retractor may also be used, particularly if blepharospasm is present. An eyelid retractor may cause pain that requires treatment (usually treatable with topical proparacaine).
During treatment of a chemical burn, the skin surfaces of the eyelids and periorbital area should also be quickly flushed to remove persistent chemicals.
The duration of flushing depends on the clinical scenario and should continue until the pH normalises. In many cases 15 to 20 minutes of irrigation is required and many litres of irrigant are often used. In acid burns and, in particular, alkali burns, some experts suggest 1 to 2 h of irrigation. With alkali burns, irrigation may have to continue for several hours.
For prolonged irrigation (e.g. > 15 min), consider using a scleral lens. Consider adding 10 mL of 1% idocaine to each litre of irrigation fluid to provide anesthesia and switching to a commercially available irrigation fluid in place of saline or Ringer’s lactate.
Check the pH of the eye(s) at the end of irrigation. If the pH is not normal, continue irrigation. If the pH is normal, check it again after another 20 minutes to see if irrigation should be started again because chemicals may continue to leak from the tissue and alter what appeared to be a normalised pH.

Eyelid eversion

When irrigation is complete, turn the upper eyelid upside down to make sure there is no residue in the upper conjunctiva.
First, press gently on the upper eyelid with a cotton-tipped applicator. Then manually lift the margin of the upper eyelid, bending it backwards over the applicator (i.e. upwards and backwards towards the patient’s forehead).
Hold the inverted eyelid in place by positioning the applicator over the inverted conjunctiva.
In particular, if the presence of foreign bodies or objects is suspected, expose the upper fornix using double eyelid eversion (i.e., first everting the eyelid and then inserting a wad under the everted eyelid and lifting it until the fornix is visible)
Brushing both the lower and upper fornices to remove any visible particles and residual particles that cannot be seen.

The scleral lens

Use a scleral lens if prolonged irrigation is required, such as in patients with significant alkaline burns. As scleral lenses do not irrigate vigorously and may not fully irrigate the fornices, they should only be used after manual irrigation with at least one litre of saline. If the eye may be punctured, or if the cornea may have a deep wound or foreign body, irrigation with a scleral lens may cause further injury and should not be done.
Apply a topical anaesthetic before inserting the lens.
Attach the lens to the saline tube and open the intravenous tube so that fluid flows slowly through the device.
Ask the patient to look down and insert the lens under the upper eyelid. Then, ask the patient to look up and insert the other half of the lens under the lower eyelid.
Once the lens is in position, increase the flow of saline through the tube.
Scleral lenses can be used to irrigate both eyes at the same time.

Aftercare for eye irrigation and eyelid eversion treatment

Perform an ophthalmological examination, including visual acuity assessment, intraocular pressure measurement, and slit-lamp examination of the cornea and conjunctiva with fluorescein, to assess corneal abrasion.
If necessary (e.g., severe chemical burns), seek ophthalmological advice for continued care or 24-hour follow-up.
Prescribe lubricants (preservative-free artificial tears and ointment) and topical antibiotics (e.g., moxifloxacin 0.5% drops 3 times/day for approximately 3 days) for patients with mild corneal damage from minor chemical exposures.
Consider the use of a patch or systemic analgesics for pain relief, as well as a cycloplegic (homatropine 5% or cyclopentolate 1% 2 times/day, avoid phenylephrine as it can cause vasoconstriction and increase ischaemia).
Ask the patient to return to the emergency department within 24 h if symptoms do not improve or worsen.

Eye Burns: What They Are, How To Treat Them

Corneal Abrasions And Foreign Bodies In The Eye: What To Do? Diagnosis And Treatment

Wound Care Guideline (Part 2) – Dressing Abrasions And Lacerations

Contusions And Lacerations Of The Eye And Eyelids: Diagnosis And Treatment

Source:

MSD