Commentary: Assessment of limbal ischemia in ocular burns

“What gets measured appropriately and accurately, serves as an important benchmark for process improvement” is often quoted in management parlance signifying the importance of comprehensive assessments. The quality of assessments becomes much more useful as a benchmarking tool, when it is reproducible and repeatable. This paper by Kam et al.[1] highlights the fact about the inadequacies of the current clinical evaluation of ocular burns and calls for a refinement in the existing assessment protocols.

Ocular burns are catastrophic emergencies that can lead to significant visual morbidity.[2] Recovery of ocular surface and the visual morbidity depend on the extent and severity of ocular surface involvement at the acute insult.[3] Treatment protocols also vary with the severity of the injury and are often decided by the initial clinical assessment, and hence, a comprehensive method of examination is extremely critical for the eventual visual recovery. Timely management with amniotic membrane transplant and limbal stem-cell transplant have improved the final outcomes of moderate-to-severe chemical injury.[4]

In the current study, Kam et al, use slit lamp photographs of patients with different grades of chemical injury and analyze the interobserver agreement of limbal ischemia among various ophthalmic professionals who attended an ocular surface workshop. The authors concluded that the interobserver agreement was poor even among the various ophthalmic professionals. While the classifications proposed by Roper-Hall and Dua et al. serve as the current guidelines, studies such as the current ones bring about the limitations of reproducibility of these measurements.[5,6] Although fluorescein staining can allow us to quantify the amount of limbal epithelial loss, limbal ischemia is still diagnosed and quantified on the basis of the area of blanching seen at the limbus in slit lamp biomicroscopy. Ancillary tests such as anterior segment angiography and optical coherence tomography (OCT) angiography have been used to assess the corneal neovascularization in chronic limbal stem-cell deficiency.[7,8] However, their use in acute settings has not been fully elucidated. Clearly, the development of newer objective modalities to assess ocular surface following chemical injuries is the need of the hour which will help rationalize appropriate therapy.