Ralph Numerical Classification for Ocular Chemical Burns

Clinical Finding

Points

perilimbal hyperemia

0

chemosis

1

spotty perilimbal ischemia

1

clouded epithelium

1

spotty denudation of epithelium

1

up to 50% epithelial loss

2

mild stromal haze, iris details visible

2

vertically oval, fixed pupil

2

iridocyclitis

2

perilimbal ischemia less than one third circumference

2

complete epithelial loss

3

moderate stromal haze, iris details barely visible

3

perilimbal ischemia one third to one half of circumference

3

sustained increase of intraocular pressure during first 24 hours

3

severe stromal haze of opacity, no iris details visible

4

perilimbal ischemia greater than one half the circumference

4

Parameter

Finding

Points

perilimbal change

hyperemia

0

spotty ischemia

1

ischemia less than one third of circumference

2

ischemia from one third to one half of circumference

3

ischemia greater than one half of circumference

4

epithelium

no change

0

clouded

1

up to 50% loss

2

complete epithelial loss

3

stromal haze in cornea

none

0

mild, with iris details visible

2

moderate, with iris details barely visible

3

severe and opaque, with no iris details visible

4

chemosis

none

0

present

1

pupil

no change

0

vertically oval, fixed pupil

2

iridocyclitis

absent

0

present

2

intraocular pressure

normal

0

transient increase

0

sustained increase during first 24 hours

3

Score

Injury

Interpretation

0 – 3

insignificant

Rapid recovery without sequelae.

4 – 6

mild

Rapid replacement of damaged epithelium with clearing of any stromal haze. Return of visual acuity to the baseline usually occurs within 1-2 weeks.

7 – 9

moderate

Usually with a delay of 1-3 weeks in complete re-epithelialization. Some reduction in visual acuity may result from persistent haze of the stroma. A mild pannus stabilizing at 1-2 mm onto the cornea is common.

10 – 12

severe

Sluggish regrowth of epithelium and frequent development of pannus. A furrow from collagenolytic activity in advance of the pannus is common. Perforation is a definite possibility. Evan at best, the final visual acuity will remain low because of pannus and a lingering stromal haze.

>= 13

very severe

These are the worst burns initially and those with the poorest long term prognosis. The early inflammatory response subsides only after several months. A dense pannus develops, especially from above. Invariably there is active collagenolysis, often with perforation. A cataract is expected. After many months or years the most fortunate patients end up with dense corneal scarring and vascularization, along with frequent secondary glaucoma.