Go with the flow during an eye emergency

Nursing, Aug 2000 by Ramponi, Denise

Learn how to flush dangerous chemicals from your patient's eye by performing continuous irrigation through this special lens.

YOU'RE WORKING in the emergency department and receive a call from the lab: A technologist in the chemistry department has splashed acetic acid solution in her right eye and is on her way down. You quickly grab your eyeemergency equipment.

When someone gets a chemical in her eye, you can help prevent damage to the cornea by irrigating the eye and restoring its normal pH. You could do this by prying open her eyelids and administing a flush solution through intravenous (LV) tubing, but this technique calls for constant attention and the use of both hands. Fortunately, you have another option.

In this article, I'll review how to use the Morgan lens, a molded plastic device that fits over the eye and through which you can flush irrigating solution. When properly placed, the Morgan lens rests between the cornea and the eyelid and solution instilled through the attached tubing irrigates both surfaces. Continuously bathed with fluid, the cornea remains untouched by the lens itself (For tips on eye emergencies, see Eye on Incidentals. )

Getting started

Alkaline substances, such as lye or ammonia, can quickly damage the cornea; although acids don't generally penetrate as deeply, both call for immediate treatment. To use the Morgan lens, gather the following equipment:

clean gloves

litmus paper

topical ocular anesthetic

tape

sterile package containing the Morgan lens with

attached tubing

I.V. tubing

I.V. solution: lactated Ringer's or 0.9% sodium chloride solution.

Take your patient to a quiet area and have her lie supine. As you prepare the equipment, tell her what you're about to do and take a quick history. Ask the following:

When did the injury occur?

What substance was involved? (As soon as you know, ask someone to call the poison control center or chemical manufacturer to learn the fluid's PH.)

Is she wearing contact lenses?

Does she take any medication or have any allergies?

Was she wearing safety glasses when the injury occurred?

Does she have any other injuries?

Did she have any treatment before you arrived?

Is her tetanus immunization up-to-date?

Wash your hands and put on clean gloves. If your patient is wearing contact lenses, remove them. Quickly assess the pH of her eye fluid by touching litmus paper to it. Even if you can't readily determine the pH or if the substance is neutral, irrigate the eye immediately.

1. Instill a topical ocular anesthetic, as shown, unless your patient is allergic to any of the ingredients.

Select an isotonic flush solution. Tears have a pH of 7.1, so lactated Ringer's solution (pH, 6.0 to 7.5) is recommended. You could also use 0.9/a sodium chloride solution, but its pH ranges from 4.5 to 7.0, so prolonged infusion could cause discomfort, such as a burning sensation. Attach the I.V. tubing to the solution and to the lens tubing.

2. Slowly begin instilling the solution through the lens tubing. Have your patient look down. As shown, hold her upper eyelid back and carefully insert the lens under her upper lid. Then have her look up while you retract her lower lid and gently drop the lens into place. (To keep the irrigation tubing in place, consider taping it to her forehead.) Administer the irrigation fluid at a wideopen rate.

3. Secure a fluid collection device or a towel to the side of your patient's face, as shown, to collect the fluid flowing from her eye. After 15 minutes of irrigation, again touch litmus paper to the fluid in her eye to assess the pH. Continue irrigating the eye until the fluid pH reaches 6.9 to 7.2. Generally, 500 ml of solution is needed to neutralize an acid solution; 2,000 ml, for an alkaline solution. If you don't know the pH, infuse 2,000 mt.

4. Confide irrigating with the desired amount of solution at a wide-open rate. After 10 minutes, check the pH again to make sure the chemical isn't leaching out of the ocular tissue. If the pH is still neutral, prepare to remove the lens. Slow the flow of the irrigation solution and ask your patient to look up. As shown, retract the lower lid.

5. Slide the lens out, stop the irrigation, and dry your patient's face with a towel. Dispose of the lens in an appropriate container. Examine the eye for signs of corneal abrasion. Evaluate her visual acuity with correction and document the resuits. Follow the physician's orders for medications, restrictions, and patient referral to an ophthalmologist.

Document what your patient told you about the accident and what actions you took. Include the device name, the type and amount of infusate, the number and readings of pH tests, duration of the infusion, any followup, and your signature.

Eye on

incidentals

Consider storing eyeemergency supplies in one place, such as a clean tackle box, to keep them organized and available.

If your patient feels a foreign body in her eye but you can't see it, directly flush the eye with 20 ml of irrigating fluid rather than using the Morgan lens.

Continuous irrigation of the eye may dilute the topical ocular anesthetic, so repeat the application if necessary. But don't apply an anesthetic more frequently than once every 20 minutes because it could damage the eye.