Epidermal burns will heal without intervention in 5–7 days.
Superficial dermal burns often heal in 1–2 weeks with scarring or eyelid contracture a rare sequelae.
Deeper dermal burns require 2–3 weeks to heal and more often have scarring or contracture of the anterior lamella and loss of skin appendages such as hair follicles and sweat glands.
Full-thickness burns, owing to the damage to the deep regenerative dermis, heal from the wound edge inward. Contracture of the anterior lamella is near uniform and the consequence depends on the size of the burn.
- Cleanse affected skin with moist gauze.
- Topical antibiotic can be applied to 1st- and 2nd-degree burns:
- Topical povidone-iodine ointment, silver sulfadiazine cream, silver nitrate solution and mupirocin ointment are commonly used around the face.
- Polysporin ophthalmic ointment can be used on the lids.
- Apply a lubricated dressing such as Xeroform gauze or alginate dressing.
- Trim burnt eyelashes with ointment covered scissors.
- Ocular-specific care:
- Sweep fornices with moist cotton tip applicators.
- For all patients with eyelid burns, give frequent preservative-free lubricating drops or ointment.
- If there is corneal injury, but no ulcer, add topical fluoroquinolone to cover pseudomonas.
- If there is corneal ulcer, add fortified topical antibiotics.
- Consider moisture chambers fashioned using ointment and smooth, occlusive dressing (e.g., Tegaderm) or simple plastic-wrap dressing.
- Boston scleral lens therapy has been investigated as a means of adding a layer of well-oxygenated fluid to cover the cornea and could be used if available.
- Application of a negative pressure dressing can be useful in deeply damaged facial burns, but care should be taken to avoid direct exposure to the ocular surface.
Early surgical interventions are sometimes required for deeper burns:
- Suture tarsorrhaphy using bolsters to prevent cheese-wiring (IV tubing from a butterfly needle or pieces of a red rubber or Foley catheter are preferable to foam from a suture pack).
- A "draw-string" approach can be helpful to allow ophthalmic exam. It is fashioned by adding a second piece of bolstering material on the less-burned eyelid and leaving the tarsorrhaphy loose. The lids are kept closed by sliding the bolsters down and friction prevents them from sliding open.
- Suture tarsorrhaphy rarely holds in edematous or severely necrotic eyelids, and neither suture nor permanent tarsorrhaphies can prevent eyelid contracture from occurring, but are rather for protection of the globe.
- Lateral canthotomy and cantholysis should be performed in patients with orbital compartment syndrome with elevated intraocular pressure and/or afferent pupillary defects.
- In cases of loss of the eyelids or inability to perform tarsorrhaphy, temporizing measures to provide protection should be performed depending on the extent of the tissue damage, although these measures should not be considered permanent eyelid reconstructions.
- The ocular surface can be surgically covered with
- Any remaining viable conjunctiva. The peripheral bulbar or fornix conjunctiva can be mobilized and the upper and lower extent folded over and sewn to one another.
- Dual-layered amniotic membrane graft
- Split thickness dermal grafts
- Mobilized Tenon's capsule
- The reconstructed surface can be covered by a temporary substrate such as
- Fresh or banked cadaveric skin
- Processed porcine skin (xenograft)
- Synthetic membrane (Biobrane)
- The reconstructed surface can be covered by a permanent substrate such as
- A full-thickness or partial-thickness skin graft
- Cultured epidermal cell sheets
- Synthetic membrane (Integra)
Intermediate stage surgical management is often required to alleviate lagophthalmos, release contractures, prevent malpositions, and treat infections.
- Grafting, although it might need to be repeated, should be entertained at this intermediate stage (1–3 weeks).
- Excision of necrotic eschar can be performed to prevent infection and aid in release of tissue, but it should be performed later than in other places of the body; 2–3 weeks is recommended.
- Contracture release and grafting has not conclusively been shown to be a benefit early (i.e., at 1 week) and should be delayed until corneal exposure forces the issue or when healing is felt to be complete.
- Consider depth and natural history discussion above.
- Unless contracture has resulted in complete loss of the anterior lamella, i.e., the brow skin is within 1 cm of the lash line, an incision should be made at the desired lid crease height and wide undermining should be performed to release all lid margin tension.
- A traction suture is useful for counter tension during dissection.
- In a 3rd-degree or milder 4th-degree upper-eyelid burn, dense scarring in the septum should be released to allow some mobility of the upper eyelid.
- A skin graft should be applied. Full-thickness grafts contract less owing to the increased dermal integrity. The graft should be oversized relative to the recipient site to account for contraction. Harvest locations are chosen based on available undamaged tissue of an adequate size in the following order of preference:
- Contralateral upper eyelid skin
- Preauricular skin
- Postauricular skin
- Supraclavicular skin
- Inner upper arm skin
- Split thickness grafting if needed for size
- The skin graft should be placed in a manner to decrease bleeding from limiting basal vascular ingrowth.
- Small drainage holes can be created using a #11 blade with or without a drain placement.
- The graft can be quilted centrally using interrupted tacking sutures or incorporated in the pass of a suspending Frost suture tarsorrhaphy.
- The graft can be glued using fibrin sealant such as Evicel or Tisseel glue.
- The lids should be immobilized on traction for 3–5 days.
- Other malpositions that might need to be corrected include
- Horizontal laxity
- Canthal webs
- Composite eyebrow grafting
- Punctal stenosis
- Horizontal fissure shortening
Other management considerations
Corneal examination might dictate other ophthalmic interventions that need to be entertained. Corneal melting or chemical burn–related injuries might benefit from topical cyclosporine, topical doxycycline, or ascorbic acid.
Amniotic membrane transplantation for corneal epithelial defects is not necessary for mild burns. Its use in severe burns has been reviewed in a recent Cochrane review and not shown to have a clear benefit for corneal re-epithelialization.
Common treatment responses, follow-up strategies
In severe burns requiring early or intermediate grafting, multiple surgical procedures are common. Unless lagophthalmos is refractory and the globe is threatened, secondary grafting should be delayed 3–6 months.
Sun protection to burned skin of all types should be employed to limit the risk of scarring and secondary malignancy.
Burn- and surgical repair–related scars should be treated with massage, intralesional steroids such as triamcinolone 40 mg/mL, or intralesional antimetabolites such as 50 mg/ml 5-fluoruracil (off label).