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Three Part Question

In [adults or children who present with chemical eye burns], is [diphoterine eye wash better than normal saline] at [improving or preserving visual outcomes]?

Clinical Scenario

35 year old builder presented to A&E after having bleach spashed into eyes. Does the new solution Diphoterine offer better visual outcome compared to normal saline when used to irrigate acutely contaminated eyes?

Search Strategy

PubMed interface on world wide web. 1950 to present.
("diphoterine"[Supplementary Concept] OR "diphoterine"[All Fields]) AND ("J Mol Catal A Chem"[Journal] OR "chemical"[All Fields]) AND ("eye burns"[MeSH Terms] OR ("eye"[All Fields] AND "burns"[All Fields]) OR "eye burns"[All Fields]) AND ("emergencies"[MeSH Terms] OR "emergencies"[All Fields] OR "emergency"[All Fields]) AND ("humans"[MeSH Terms] OR "humans"[All Fields] OR "human"[All Fields])

Search Outcome

4 articles

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Chau JP, Lee DT, Lo SH Aug 2012 Hong Kong	Adults or children with ocular chemical burns	Systematic review of randomized, quasi-randomized controlled trials and observational studies comparing the effectiveness of eye irrigation methods among adults or children as an active form of emergency treatment for ocular chemical burns.	Time elapsed to reepithelialization	Signifcantly shorter in the dophoterine group compared with the normal saline group for grade 1 and grade 2 burns (Hugh's classification)	1. Language bias: only articles that were published in English and Chinese were included in the search 2. A total of 115 potential studies were identified but only four studies were included after the assessment of two indendent reviewers 3. Only one study had children included in their study population 4. Selected studies are not tested for homogeneity
			Time elapsed to reepithelialization	No signficant difference between he dophoterine group compared with the normal saline group in grade 3 burns
			Final visual acuity	No significant difference between the dophoterine group for grade 1,2,3 burns
Merle H, Donnio A, Ayeboua L, Michel F, Thomas F, Ketterle J, Leonard C, Josset P, Gerard M March 2005 France	Patients with alkali ocular burns who were treated with either a physiological solution or amphoteric solution (Diphoterine*) as rinising solutions at the University Hospital Center of Fort de France in Martinique	Case series	Time elapsed to reepithelialization in grade 1 burns	Significantly shorter when Diphoterine was used days versus (1.9 ± 1 days vs 11.1 ± 1.4 days p=<0.05	1. Participants are not randomised into groups. ( Patients from 01/01/1988 - 31/12/1999 were treated with physiological solution; patients from 01/01/2000-31/12/2001 were treated with Diphoterine) 2. Data collection is subject to bias as there was no blinding 3. Sample size is not calculated 4. Results may not be generalised to all severity of ocular burns as 80% of the cases were grade 1 or grade 2 burns
			Time elapsed to reepithelialization in grade 2 burns	Significantly shorter when Diphoterine was used days versus (5.6 ± 4.9 days vs 10 ±9.2 days p=0.02
			Complications	No complications in either group in grade 1 burns
			Final visual acuity	No significant difference between the 2 groups in all grades of ocular burn
Hall AH, Blomet J, Mathieu L Aug 2002 USA	N/A	Review	Safety	No irritation when 0.1 mL of Diphoterine was instilled into conjuctival sac of rabbit eye	1. Potential conflict of interest ( the review was funded by Laboratoire Prévor, producer of diphoterine) 2. Method of literature search was not clearly stated 3. Review included in vitro studies 4. Only case reports were used in human studies 5. Lack of scoring system to rate studies 6. Presentation of results were poor without statistical data
			Stromal oedema	To lesser extend when diphoterine used
			Cornal epithelial cell damage	Completely destroped when water was used; partially destroyed when isotonic artifical tears solution used; only morphologic variationis with few cells destroyed when Diphoterine used
			Lost in work time	Significant reduction when Diphoterine was used as the initial decontamination method compared to acetic acid solutioin or water
Gerard M, Merle H, Chiambaretta F, Rigal D, Schrage N Nov 2002 France	Woman being attacked with chemical product to eyes and face, who sustain severe ocular injury with opaque cornea and visual acuity of 2/20 on immediate examintation	Single case report	Stomal oedema	No oedema was noted after using rinsing with Diphoterine following serious ocular burn	Single case report Subject to observer bias relatively low hierarchy of evidence No comparison of outcome to control
			Further treatment	No further treatment or surgery required as ocular burn healed with conservative treatment only

Comment(s)

The biochemical propteries of Diphoterine suggests it may be a superior irrigating solution for ocular chemical burns: It is an amphoteric solution which can bind with both acids or bases without altering the pH of the environment. These chemical reactions are non-exothermic and will not cause further damage. It is hypertonic which impedes chemical tissue penetration. Diphoterine and its acid/base decontaminant residues do not irritate the eyes. However, there is a lack of robust clinical trials to compare the effectiveness between Diphoterine and normal saline solution.

Clinical Bottom Line

Ocular chemical burns should be irrigated as soon as possible regardless of the type of solution used. Current studies suggest Diphoterine has a shorter time elasped to reepithelization in grade 1 & 2 burns but not overall improvement in final visual acuity compared to normal saline use.

References

1. Chau JP, Lee DT, Lo SH A systematic review of methods of eye irrigation for adults and children with ocular chemical burns. Worldviews Evid Based Nurs 2012 Aug;9(3):129-38
2. Merle H, Donnio A, Ayeboua L, Michel F, Thomas F, Ketterle J, Leonard C, Josset P, Gerard M Alkali ocular burns in Martinique (French West Indies) Evaluation of the use of an amphoteric solution as the rinsing product. Burns 2005 Mar;31(2):205-11
3. Hall AH, Blomet J, Mathieu L Diphoterine for emergent eye/skin chemical splash decontamination: a review Vet Hum Toxicol 2002 Aug;44(4):228-31
4. Gerard M, Merle H, Chiambaretta F, Rigal D, Schrage N An amphoteric rinse used in the emergency treatment of a serious ocular burn. Burns 2002 Nov;28(7):670-3