3.1 Chemical Injury, Conjunctival

eyes.nhs.scot/
Eyecare Guidelines/
Section 3 - Conjunctiva/
3.1 Chemical Injury, Conjunctival

Date of last review:

7/9/2026

Date of next review:

7/9/2028

Date of publication:

16/9/2026

Differential diagnosis ⁽¹⁾ 

Corneal abrasion
Other causes of acute red eye (history should aid the diagnosis)

Possible management by optometrist

Advice ⁽¹⁾

Time to irrigation is critical and has a major impact on prognosis
Irrigation should:
- Begin immediately at the scene of the accident with any available non-toxic liquid (e.g. tap water)
- Continue on presentation to clinical care with copious irrigation using sterile saline (≥1 litre initially), or water if saline unavailable
Continue irrigation for:
- 15–30 minutes, or
- Until ocular surface pH returns to physiological range (approx. 6.5–7.6)
When measuring pH:
- Pause irrigation
- Wait 5-10 minutes (7)
- Test the fornix using universal indicator paper
- Once pH returns to normal, recheck after a further 30 minutes
Advise no contact lens wear until resolution

Examination ⁽¹⁾

Instil topical anaesthetic if required to facilitate irrigation and examination
Evert lids (including double eversion where possible), to:
- Identify and remove retained particulate matter by sweeping fornices with a moistened cotton bud
Ascertain which chemical caused the injury
Assess and record visual acuity (even if challenging to do so)

Treatment 

Severe Injury (e.g. limbal ischaemia, corneal opacity) ⁽¹⁾

No pharmacological treatment in primary care
Emergency referral after irrigation

Mild Injury

Ocular lubricants (preferably preservative-free) to aid epithelial healing and symptomatic relief as required (drops/gel for use during the day ± unmedicated ointment for use at bedtime) ⁽¹⁾ Refer to local formularies for suitable options ⁽⁶⁾
Consider topical antibiotic prophylaxis if ⁽¹⁾:
- Significant epithelial defect
- Risk of contamination
Consider cycloplegia (e.g. cyclopentolate) for ciliary spasm ⁽¹⁾
Recommend simple over the counter pain relief with advice from pharmacist if needed^(1,7)and light protection (e.g. sunglasses) ⁽¹⁾

Typical dosage/duration

(Blue text = IP, black text = non-IP)

Chloramphenicol 0.5% eye drops (preservative free) ^(1,5) (POM, off-label): One drop every 2 (waking⁽⁷⁾) hours for 48 hours. After this period, treatment should be every 4 hours during waking hours. Eye drops may be supplemented by 1% ointment at night. The course of treatment should be 5 days (even if symptoms improve) ^(2,3)
Chloramphenicol 1% eye ointment (preservative free) ^(1,5) (POM, off-label): Apply at night (if eye drops used during the day), alternatively apply 3–4 times daily, if ointment used alone. The course of treatment should be 5 days (even if symptoms improve) ^(2,3)
Cyclopentolate 1% eye drops (preservative free) ^(1,5) (POM): One drop up to 3 times daily, consider reducing (or stopping) as condition improves ^(6,7) (consult local guidance as they may vary on timescales)

NB. Chloramphenicol 0.5% eye drops and 1% eye ointment are available via the NHS Pharmacy First service for the treatment of infected eye conditions only and not for prophylactic use in this condition. Where prophylactic antibiotic treatment is clinically indicated, chloramphenicol can be supplied by a prescription or written order. In an emergency situation chloramphenicol (0.5% & 1%) can be supplied to the patient from practice stock if there is no alternative as above ⁽⁷⁾

Regimens should be adjusted according to severity and patient factors (e.g. age, weight, pregnancy, renal function). Prescribing should follow local formulary and national guidance where available ⁽⁷⁾

In cases of known sensitivities, please consult local formularies for alternative options ⁽⁷⁾.

Further management options

Treatment may be provided within available locally enhanced schemes, or by community IP optometrists/OMPs, as appropriate⁽⁷⁾

Severe Chemical Injury ⁽¹⁾

First aid (immediate irrigation) followed by emergency referral to A&E / HES
Contact receiving unit to ensure the patient is expected and prioritised

Mild Chemical Injury ⁽¹⁾

Alleviation / palliation
Usually no referral required, provided close monitoring and resolution

Possible management in secondary care or local/community pathways where available

See Further management options ^(1,7)
Continued irrigation ⁽¹⁾
Inpatient care for severe cases ⁽¹⁾
Medical therapy may include ⁽¹⁾:
- Topical antibiotics and corticosteroids
- Ascorbic acid (topical/systemic)
- Sodium citrate
- Oral tetracyclines
- Systemic IOP-lowering therapy if required
Additional interventions (1):
- Bandage contact lens
- Amniotic membrane transplantation
- Limbal stem cell transplantation
- Surgical reconstruction in severe cases

College of Optometrists Clinical Management Guideline⁽¹⁾ 

Trauma (chemical) - College of Optometrists *

* With special thanks to The College of Optometrists for providing the evidence framework for diagnosis and management from the Clinical Management Guidelines (CMGs) for this condition. All references to the College/CMGs are included where appropriate and form the basis of the Community Eyecare Guidelines.

Guidance is informed by the following sources

College of Optometrists Clinical Management Guidelines Clinical Management Guidelines - College of Optometrists
Advisory alignment with the College of Optometrists Formulary Optometrists' Formulary - College of Optometrists
Advisory alignment with the BNF BNF (British National Formulary) | NICE
Advisory alignment with the Summary Product Characteristics taken from the EMC Home - electronic medicines compendium (emc)
Advisory alignment with Scottish Health Board formularies (where a clear majority is present) *
Advisory alignment with expert consensus (CEGG), informed by sources 2-5 above
Advisory alignment with expert consensus (CEGG)
“Annex C of the Statement” https://www.eyes.nhs.scot/for-professionals/legislation/

* Scottish formularies should be available within the Prescribing section of your Health Board pages on the eyes.nhs.scot website. If unavailable, contact your local Health Board for further information; Health Boards landing page

If you have a query relating to this page, please email NSS.ComEyecareGuidelineGroup@nhs.scot

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