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Three Part Question

In [patients with alkali eye burns] do [ascorbate drops] [reduce short-term symptoms and long-term sequelae]?

Clinical Scenario

A 22 year old man has been cleaning out an old chemical drum. He attends the emergency department with severe burning in his eyes. He says the drum was marked as NaOH 20%. You arrange for copious irrigation and oral pain relief. You contact the duty opthamologist who asks to start mydriatics, antibiotic ointement and ascorbate drops. You do not have the ascorbate drops and wonder whether there is any evidence for their use.

Search Strategy

Medline 1966-06/03 using the OVID interface.
{[(injury.mp OR exp "wounds and injuries" OR exp burns OR burn$.mp) AND (eye$.mp OR exp eye)] OR (eye injury.mp OR eye injuries.mp OR exp eye injuries OR eye burn$.mp OR exp eye burns)} AND (alkali$.mp OR exp alkalies) AND (ascorbate$.mp OR ascorbic acid.mp OR exp ascorbic acid OR vitamin C.mp)

Search Outcome

Altogether 33 papers found of which 1 was relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Brodovsky SC et al, 2000, Australia	121 patients with 177 alkali burnt eyes over 11 years. Standard alkali protocol (antibiotics, intensive topical steroids, ascorbate, citrate and antibiotics) vs conservative protocal (antibiotics, short course of steroids)	Retrospective clinical comparison	Time to re-epithelialisation	Delay in grade 2 burns. Trend for longer in 1, shorter in 3 and no difference in 4	Uncontrolled. Very few conservatively treated patients Conclude that ascorbate and citrate are the effective agent for grade 3 burns without considering the effect of intensive steroid alone
			Final visual acuity	Better in grade 3 burns. No difference in 1, 2 and 4

Comment(s)

Ascorbate (and citrate) treatment have been extensively investigated in rabbits but there is no appropriate human data. A randomised controlled trial is mentioned as being underway in papers in 1980, but has not been reported.

Clinical Bottom Line

There is no good evidence for the use of ascorbate in alkali burns in humans. A well designed randomised controlled trial should be performed.

References

1. Brodovsky SC, McCarty CA, Snibson G et al. Management of alkali burns: an 11-year retrospective review. Opthamol 2000;107(10):1829-35.