penetration Alkaline substances tend to cause more damage as they cause saponification of fatty acids and can essentially “melt” the cornea and gain access to the internal structures of the eye Goals of Treatment Chemical injury to the eyeball is a true ocular emergency requiring immediate assessment and intervention by ED personnel Copious irrigation, even prior to ocular examination in many cases, is necessary to minimize damage to the ocular surface and is the mainstay of treatment if exposure is suspected Emergency management may be the most important factor in determining long-term visual outcome Clinical Considerations Clinical Recognition Often, there is a clear history of a noxious substance coming in contact with the ocular surface It may also be that the event is not witnessed and a parent may not be certain of the caustic exposure Thus, the ED clinician must maintain a high index of suspicion in children presenting with photophobia or an irritated, red or painful eye of acute onset A prompt pH test done by touching a litmus strip to the eye can be useful in detecting acidic or alkaline conditions It is also important to determine whether particulate matter may have been deposited on the ocular surface Smoke can cause chemical conjunctivitis, particularly in housefires when chemicals are liberated into the air from burning plastics and other substances Foreign bodies such as ashes and other particulate matter in smoke are not uncommon The examiner must also assess the degree of exposure If a child has no symptoms (e.g., pain, photophobia) or signs (e.g., red eye, epiphora, conjunctival swelling) and a weak history of actual chemical exposure to the eye it may be acceptable to avoid lavage Clinical Assessment A thorough clinical examination of the eye is often deferred until after irrigation if there is confirmation, or strong suspicion of, chemical exposure Immediate intervention is essential to improving the patient’s prognosis Management Any patient with sufficient history should be immediately placed in the supine position so ocular lavage may be started This procedure can often be frightening and anxiety provoking for a child, and some level of restraint is often needed Sedation and topical anesthetic may be helpful, but the physician should