Severe alkali burns from beer line cleaners warrant mandatory safety guidelines

To the Editor: Two patients at our tertiary referral eye hospital had received severe alkali burns to the face and eyes while cleaning beer lines. In hotels, pubs and clubs, beer lines are cleaned weekly using strong alkaline solutions at high pressure. In an accident, alkali released under high pressure can produce blinding damage.

Our patients were young, typical of workers at these venues, and their injuries have had major impacts on their lives. One incident involved the face (60%–80% of facial skin) and both eyes (grade IV1) of a 23-year-old man (Box) using a commercially available beer line cleaner (potassium hydroxide; pH, 14). His eyes were immediately irrigated with water. His initial visual acuity was hand movements in the right eye and light perception in the left eye. He had bilateral corneal opacification and ocular ischaemia with hypotony in the left eye. He was treated according to burns protocol,1 but a non-healing right corneal ulcer developed, requiring multiple operations. Bilateral reconstructive eyelid surgery was also needed.2 His vision is currently light perception and no light perception with hypotony, respectively, in his right and left eyes. He requires further surgery to preserve his remaining vision, as well as ongoing psychological and social support.

The second patient received a grade IV injury to her left eye in 2006. Multiple operations were needed to heal the ocular surface, along with psychological and social support. After 4 years of treatment, her final visual acuity was light perception. She returned to limited work late in 2010.

Alkali injuries to the eye are devastating as they cause liquefactive necrosis and pass rapidly through the cornea to the eye's internal structures.3 Damage to the stem cells of the ocular surface and intraocular structures produces permanent, difficult-to-treat and often blinding ocular disease. First aid should include copious ocular irrigation with water before referral to an emergency department.

Neither patient was wearing safety glasses. We found there are no mandatory safety guidelines in Australia (http://www.safeworkaustralia.gov.au), the United Kingdom (http://www.hse.gov.uk) or the United States (http://www.osha.gov), and perhaps worldwide, for beer line cleaning. Although the product information recommends use of safety equipment, this is not enforced and the equipment is usually not sufficient. Most workplaces provide safety glasses, but these offer suboptimal protection from a splash injury. Non-vented safety goggles are needed for adequate protection and should be worn throughout the cleaning procedure, from set-up to clean-up. We suggest that mandatory guidelines are indicated, as although such injuries are uncommon, they are severe and debilitating in the working-age group, with significant costs to the individual, health system and society.

Severe facial and ocular burns soon after injury

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A: Image shows the limbal and scleral ischaemia of the left eye and bilateral opaque corneas. The sunken appearance of the left eye, indicative of hypotony, is a very poor prognostic sign. B: A close-up view of the left eye, showing the cloudy cornea and limbal ischaemia. 