Hexafluorine for hydrofluoric acid burns to the eye

Date First Published:
May 30, 2012
Last Updated:
August 17, 2012
Report by:
Katherine Atley, Medical student (Emergency Department, Salford Royal Hospital)
Three-Part Question:
In [patients with hydrofluoric acid burns to the eye] is the use of [Hexafluorine more effective than the conventional treatment of water irrigation or calcium gluconate] at [reducing severity and improving outcome]?
Clinical Scenario:
A 31-year-old man was working in a local chemical factory when he splashed himself with hydrofluoric acid to the eye. He attends the emergency department and you arrange for copious water irrigation and oral pain relief. You have the heard about the Hexafluorine antidote solution and wonder whether there is any evidence for its use.
Search Strategy:
Calcium gluconate versus water irrigation
Medline search from 1946-06/2012 using the OVID interface.
Searched – {(Hydrofluoric acid OR Hydrofluoric acid burn* OR HF) AND (eye* OR ocular) AND (calcium gluconate).mp.} LIMIT (English)

Embase search from 1974-06/2012 using the OVID interface.
Searched – {(Hydrofluoric acid OR Hydrofluoric acid burn* OR HF) AND (eye* OR ocular) AND (calcium gluconate).mp.} LIMIT (English)

The Cochrane Library
Searched – (Hydrofluoric acid) AND (calcium gluconate)

Hexafluorine versus calcium gluconate versus water irrigation
Medline search from 1946-06/2012 using the OVID interface.
Searched – {(Hydrofluoric acid OR Hydrofluoric acid burn* OR HF) AND (eye* OR ocular) AND (Hexafluorine).mp.} LIMIT (English)

Embase search from 1974-06/2012 using the OVID interface.
Searched – {(Hydrofluoric acid OR Hydrofluoric acid burn* OR HF) AND (eye* OR ocular) AND (Hexafluorine).mp.} LIMIT (English)

The Cochrane Library
Searched – (Hydrofluoric acid) AND (Hexafluorine)
Outcome:
Calcium gluconate versus water irrigation – 20 papers were found of which 4 were relevant.
Using the references of the papers already found, another 2 papers were also found to be relevant.

Hexafluorine versus calcium gluconate versus water irrigation- 8 papers found of which 3 were relevant.
1 other relevant paper was found in the references.
Relevant Paper(s):
Study Title Patient Group Study type (level of evidence) Outcomes Key results Study Weaknesses
Ocular Hydrofluoric Acid Burns: Animal Model, Mechanism of Injury and Therapy McCulley JP 1990 USA Rabbits Experimental animal study Conjunctival inflammation Minimal = Saline, Minimal-moderate = MgSO4, MgCl2, Hyamine, Moderate-severe = CaCl2, Severe = Zephiran, calcium gluconate injections Uncontrolled.
Not human data.
Results are based on subjective clinical observations.
Conjunctival chemosis Minimal = Hyamine, Saline, Moderate = MgSO4, MgCl2, Moderate-severe = CaCl2, calcium gluconate injections
Corneal stromal opacification Minimal = Saline, MgCl2, Moderate = CaCl2, Moderate-severe = MgSO4, Severe = Hyamine, Zephira
Corneal stromal oedema Minimal = Saline, Moderate = MgSO4 , MgCl2, Hyamine, Severe = CaCl2, Zephiran, calcium gluconate injections
The efficacy of calcium gluconate in ocular hydrofluoric acid burns. Beiran I et al. 1997 Israel 38 rabbits Experimental animal study Corneal erosion Group 2, 3 and 4 had smaller area of erosion than group 1 after day 1, but after 2 weeks no significant difference except group 4 was significantly worse. Uncontrolled.
Not human data.
Results are based on subjective clinical observations.
Does not have a group irrigated with calcium gluconate eye drops without the addition of saline.
Corneal haziness No significant difference between all groups, but after 2 weeks haziness markedly deteriorated in group 4.
Conjunctival damage No significant difference between all groups, but after 2 weeks conjunctival damage increased in group 4.
Acidity After HF exposure, pH – 2.5 and after rinsing with all groups, pH – 6 – 6.5
The role of Calcium Gluconate in the Treatment of Hydrofluoric Acid Eye Burn Bentur Y et al. 1993 Israel One male patient Case report
Ocular Hydrofluoric Acid Burns. Rubinfeld RS et al. 1992 USA Two male patients Case reports Not known what initial treatment was on one of the patients.
Hydrofluoric Acid Burns of the Eye: Report of Possible Delayed Toxicity. Hatai JK et al. 1986 USA One female patient Case report Does not compare with calcium gluconate.
Hydrofluoric Acids Burns of the Eye. McCulley JP et al. 1983 USA Rabbits and one male patient Experimental animal study and a case report Corneal ulceration CaCl2 irrigation and injections caused an increase in corneal ulceration. Uncontrolled.
Not human data.
Toxicity MgSO4, Zephiran, Hyamin and subconjunctival 10% calcium gluconate injections were all too toxic for the eyes. Water, saline and MgCl2 were found to be non-toxic.
Analysis of Hydrofluoric Acid Penetration and Decontamination of the Eye by means of Time-Resolved Optical Coherence Tomography. Spöler F et al. 2008 Germany Rabbits Experimental animal study Penetration depth of the acid Tap water and 1% calcium gluconate managed to slow the acid but couldn’t prevent full penetration; however Hexafluorine stopped the acid penetration. Uncontrolled.
Not human data.
It did not take into account the concentration of HF.
Opacification of the cornea Tap water and 1% calcium gluconate increase cornea opacification whereas the cornea remained clear after rinsing with Hexafluorine.
An Improved Method for Emergent Decontamination of Ocular and Dermal Hydrofluoric Acid Splashes. Soderberg K et al. 2004 Sweden 16 patients with HF exposure over 2 years, 5 patients with ocular exposure Series of cases Does not compare with water or calcium gluconate irrigation.
Efficacy of Hexafluorine for Emergent Decontamination of Hydrofluoric Acid Eye and Skin Splashes. Mathieu L et al. 2001 France 11 patients with HF exposure over 4 years, 2 patients with ocular exposure Series of cases Does not compare with water or calcium gluconate irrigation.
Hexafluorine for Emergent Decontamination of Hydrofluoric Acid Eye/Skin Splashes. Hall AH et al. 2000 France One male patient In vitro study and case report In vitro pH Water – no effect, 10% calcium gluconate final pH - 4.5, Hexafluorine final pH - 6.5 Does not answer my three part question about HF exposure to the eye specifically.
Not human data.

Does not compare with water or calcium gluconate irrigation.
In vitro pF Water – no effect, 10% calcium gluconate final pF - 3, Hexafluroine final pF - 6
Author Commentary:
Different decontamination solutions have been investigated using rabbit’s eyes but there is little appropriate human data. Nevertheless, using in vitro studies, in vivo experimental animal studies and previously reported human clinical cases, Hexafluorine has demonstrated to be the most efficacious irrigator for reducing severity and improving the outcome after HF exposure to the eye.
Bottom Line:
It is imperative to rinse a HF ocular burn as soon as possible in order to prevent or minimise subsequent injury. Hexafluorine has been shown to be the most effective decontamination solution.
Level of Evidence:
Level 3: Small numbers of small studies or great heterogeneity or very different population
References:
  1. McCulley JP. Ocular Hydrofluoric Acid Burns: Animal Model, Mechanism of Injury and Therapy
  2. Beiran I et al.. The efficacy of calcium gluconate in ocular hydrofluoric acid burns.
  3. Bentur Y et al.. The role of Calcium Gluconate in the Treatment of Hydrofluoric Acid Eye Burn
  4. Rubinfeld RS et al.. Ocular Hydrofluoric Acid Burns.
  5. Hatai JK et al. . Hydrofluoric Acid Burns of the Eye: Report of Possible Delayed Toxicity.
  6. McCulley JP et al.. Hydrofluoric Acids Burns of the Eye.
  7. Spöler F et al.. Analysis of Hydrofluoric Acid Penetration and Decontamination of the Eye by means of Time-Resolved Optical Coherence Tomography.
  8. Soderberg K et al.. An Improved Method for Emergent Decontamination of Ocular and Dermal Hydrofluoric Acid Splashes.
  9. Mathieu L et al.. Efficacy of Hexafluorine for Emergent Decontamination of Hydrofluoric Acid Eye and Skin Splashes.
  10. Hall AH et al.. Hexafluorine for Emergent Decontamination of Hydrofluoric Acid Eye/Skin Splashes.