Demographic and Clinical Profile of Ocular

Chemical Injuries in the Pediatric Age Group

Rasik B. Vajpayee, FRCS (Edin), FRANZCO,1,2 Himanshu Shekhar, MD,2 Namrata Sharma, MD,2
Vishal Jhanji, MD, FRCS1,3

Objective: To review the risk factors, management, and visual outcomes of pediatric chemical eye injuries in
a tertiary care hospital in North India.
Design: Retrospective hospital-based study.
Participants: Patients aged <16 years with ocular chemical burns.
Methods: Case records of patients with ocular chemical injury who presented to the Dr. Rajendra Prasad
Centre for Ophthalmic Sciences were reviewed over a 5-year period.
Main Outcome Measures: Demographic profile, nature of chemical injury, complications, and visual
outcomes after chemical injury.
Results: A total of 134 pediatric patients with a history of ocular chemical burns were seen between March
2006 and March 2011. The mean age of patients at the time of injury was 8.95
4.89 years (range, 1.2e15.5
years); 63.4% were male. Sixty-nine patients (51.4%) belonged to the preschool (0e5 years) age group. Bilateral
chemical injuries were seen in 24 patients (17.9%). Lime (“chuna”) was the most commonly involved chemical (88,
65.6%) followed by toilet cleaner (20, 14.9%). The mean time between injury and presentation was 68.3 days
(range, 1e365 days). Severe (grade 3 and 4) ocular chemical injury was seen in 94 patients (70.1%). Surgical
intervention was performed in 114 eyes (85%) in the form of amniotic membrane grafting (n ¼ 78), symblepharon
release (n ¼ 56), limbal stem cell transplantation (n ¼ 26), and lamellar keratoplasty (n ¼ 14). The average number
of surgeries conducted per patient was 2.3 (range, 1e4). Median visual acuity at final follow-up (mean, 537
354
days) was 3/60.
Conclusions: Chemical injuries in pediatric patients are more commonly encountered in the preschool age
group and are associated with severe visual loss. Alkali injury from bursting of chuna packets was the most
common mode of injury in pediatric patients in our study. Ophthalmology 2014;121:377-380 ª 2014 by the
American Academy of Ophthalmology.

Chemical injuries to the eye represent an ophthalmic
emergency that can result in extensive damage and signifi-
cant ocular morbidity.1 The reported incidence of ocular
chemical injuries in developing countries is approximately
1.25% to 4.4%.2 Severe chemical burn can lead to
complete destruction of the ocular surface, corneal
opacification, permanent vision loss, and rarely loss of the
eye.3 Alkalis cause significantly greater damage compared
with acids.4 Epidemiologic data show that severe chemical
eye injuries are more common in male subjects,
particularly those aged between 16 and 45 years.1,5e7 The
majority of these injuries occur as a result of accidents at
work or home or deliberately from an assault.4 Acute
chemical eye injury treated immediately with expedient
irrigation and removal of trapped debris is associated with
a significantly better visual outcome.4 Early management
endeavors to preserve the globe integrity, whereas
subsequent treatment is aimed at promoting ocular surface
epithelial recovery, augmenting corneal repair, minimizing
ulceration, and controlling the inflammatory response.1
Surgery may be necessary in the acute setting if healing of
the ocular surface is inadequate. In the chronic stages,
features of limbal stem cell deficiency can manifest.8
Long-term management aims to restore the visual function
by preserving tear production, managing limbal stem cell
deficiency, and addressing associated complications, such as
lid malposition, cataract, and glaucoma.8e10
Compared with adults, ocular chemical injuries in the
pediatric population pose a greater challenge mainly
because of the difficulty in timely diagnosis and adequate
management of complications in this age group. The
purpose of this study was to evaluate the pattern, risk
factors, and visual outcomes of pediatric chemical eye
injuries that required hospitalization in a tertiary eye care
center in North India.
Methods
In this retrospective chart review, case records of pediatric patients
who were treated at a tertiary eye care hospital between March
2006 and March 2011 with ocular chemical burns were analyzed.
The study was approved by an institutional review board and
adhered to the tenets of the Declaration of Helsinki. Modified
Roper-Hall classification was used for grading of ocular burns.1
The management of patients depended on the severity of ocular
injury at the time of presentation. In the acute stage (within 1

 2014 by the American Academy of Ophthalmology ISSN 0161-6420/14/$ - see front matter 377
Published by Elsevier Inc. http://dx.doi.org/10.1016/j.ophtha.2013.06.044

Downloaded for Yohanes Firmansyah (yohanesfirmansyah28@gmail.com) at Universitas Tarumanagara from ClinicalKey.com by Elsevier on May 10, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
 Ophthalmology Volume 121, Number 1, January 2014

month of injury), patients were initially managed with conventional Table 1. Demographic and Clinical Profile at Presentation in
medical therapy, which included copious irrigation of the affected Pediatric Patients With Ocular Chemical Injury (n ¼ 134)
eye with normal saline and removal of any particulate matter or
debris.1 Patients were administered topical antibiotics, Sex
corticosteroids, and cycloplegic eye drops for the initial 2 to 4 Male 85 (63.4%)
weeks. In addition, sodium ascorbate 10% eye drops and sodium Female 49 (36.5%)
citrate 10% eye drops were given twice per hour, and Mean age
SD (range) 8.95
4.89 yrs
(1.2e15.5 yrs)
preservative-free artificial tears were instilled every 1 to 2 hours.
Laterality
Oral vitamin C tablets 1 to 2 g/day in 4 divided doses were given
Bilateral 24 (17.9%)
for 2 to 4 weeks. Antiglaucoma therapy, including timolol maleate Unilateral 110 (82.1%)
0.5% eye drops and oral acetazolamide, was administered if Grade of injury at presentation, n
required. The treatment was modified according to the response. Grade 1 9 (6.7%)
Amniotic membrane grafting was performed in acute cases with Grade 2 31 (23.1%)
cryopreserved amniotic membrane using the overlay technique to Grade 3 25 (18.6%)
hasten epithelialization.11 The amniotic membrane covered the Grade 4 69 (51.4%)
entire ocular surface with the stromal side touching the ocular Age distribution (yrs)
surface. The membrane was anchored with the interrupted 8- 5 69 (51.4%)
0 Vicryl sutures (Ethicon Inc., Johnson & Johnson, Ahmedabad, >5e10 57 (42.5%)
India) to the underlying conjunctiva and the episclera around the >10e15 8 (5.9%)
limbus, and in cases where the lids were involved, anchoring
sutures also were applied to the lid margin. In the chronic stage SD ¼ standard deviation.
(>1 month after injury), preservative-free artificial tears were
instilled every 1 to 2 hours. Amniotic membrane grafting was
performed in cases of partial limbal stem cell deficiency to help
in vivo expansion of limbal stem cells using a standard release (n ¼ 56), limbal stem cell transplantation (n ¼ 26), and
technique.12 lamellar keratoplasty (n ¼ 14). The average number of surgeries
The primary surgical intervention and subsequent outcome in conducted per patient was 2.3 (range, 1e4). The age-wise distri-
each case were noted. For those patients who required surgical bution of clinical characteristics and surgical interventions is
interventions, surgery was performed in the form of symblepharon shown in Table 3.
release, amniotic membrane grafting, allograft or autograft stem Visual acuity at presentation ranged from 6/6 to perception of
cell transplantation, and large-diameter lamellar keratoplasty. The light (median, light perception with projection). Mean decimal
data collected included age, sex, nature of chemical, complications visual acuity at final follow up was 0.05
0.04 (range, no light
over the course of follow-up, and visual acuity at the final follow- perception to 6/9).The mean follow-up was 537 days (range, 3
up examination. Statistical analysis was performed using a statis- months to 5 years). The best-corrected visual acuity in the final
tical software package (SPSS for Windows, version 13.0; SPSS, follow-up is shown in Table 4.
Inc., Chicago, IL). Normal distribution data are shown as mean
values
standard deviations.
Discussion
Results Chemical ocular burns are potentially blinding because
A total of 134 patients (85 [63.4%] were male) with ocular extensive limbal ischemia impairs ocular surface healing,
chemical injury were seen between March 2006 and March 2011. eventually causing corneal opacification, which is difficult
The mean age at the time of injury was 8.95
4.89 years (range, to treat with conventional corneal transplantation tech-
1.2e15.5 years), with approximately half (n ¼ 69, 51.4%) of the niques.13 Although alkalis cause more severe chemical
patients in the 0- to 5-year-old age group (Table 1). The highest injuries compared with acids,14e16 acidic agents such as
male-to-female ratio was seen in the 6- to 10-year-old age group hydrofluoric acid are known to produce severe injuries
with a ratio of 3.2:1, whereas the youngest age group (0e5 because of rapid penetration into the eye.17 Management of
years) showed a relatively lower male-to-female ratio of 1.4:1. severe ocular chemical injuries typically requires a long
Bilateral chemical injuries were seen in 24 patients (17.9%).
period of treatment for restoration of visual acuity. In
Lime was the most commonly involved chemical in 88 cases
(65.6%). This was in the form of “chuna” packet injury, which is ocular trauma in the pediatric age group, there is an
commonly used as an additive to tobacco chewing in this part of additional risk of development of amblyopia. In this study,
the world. Other chemicals included toilet cleaner (20, 14.9%), we analyzed the cause, management, and outcomes of
caustic soda (9, 6.7%), and organic acids (7, 5.2%). The nature of
the chemical was unknown in 10 cases (7.4%). The time interval
between injury and presentation to our hospital was 68.3 days Table 2. Complications of Ocular Chemical Injuries in the
(range, 1e365 days). Approximately 28.3% of the patients had not Pediatric Age Group
received any eye irrigation immediately after the injury. Forty
patients (29.8%) sought treatment in the acute stage (within 1 Complications N (%)
month), and 94 patients (70.2%) sought treatment in the chronic
Corneal opacification 98 (73.1)
stage (after 1 month). A large proportion of the patients (n ¼ 94, Symblepharon 63 (47)
70.1%) had severe ocular burn (grades 3 and 4). The ocular Entropion 27 (20.1)
complications of chemical injuries are summarized in Table 2. Glaucoma 29 (21.6)
Surgical intervention was performed in 114 eyes (85%) in the Phthisis 6 (4.4)
form of amniotic membrane grafting (n ¼ 78), symblepharon

378

Downloaded for Yohanes Firmansyah (yohanesfirmansyah28@gmail.com) at Universitas Tarumanagara from ClinicalKey.com by Elsevier on May 10, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
 Vajpayee et al 
Ocular Chemical Injuries in the Pediatrics

Table 3. Age-wise Distribution of Clinical Characteristics and and are often easily accessible by children, who tend to
Surgical Interventions in Pediatric Patients With Ocular Chemical play with them. These chuna packets can burst even when
Injuries squeezed lightly, resulting in a spill of alkali in the eyes,
causing severe chemical injury. Furthermore, these packets
0e5 Yrs >5e10 Yrs >10e15 Yrs
Clinical Characteristics (n[69) (n[57) (n[8)
have no statutory warning labeling them as a hazardous
substance, and there is no legislation to restrict their use.
Grade of injury Previous reports from India have shown devastating
Grade 1 4 2 3 outcomes after ocular injury involving chuna packets.
Grade 2 12 17 2
Grade 3 14 10 1
Chuna packets caused grade 4 injuries in the majority of
Grade 4 39 28 2 the eyes, and 68% of the eyes were treated surgically,
Causative chemical agent with a final median visual acuity of 1/60.21
Lime 46 38 4 The severity of damage after ocular chemical injury
Toilet cleaner 13 6 1 mostly depends on the contact time of the chemical with the
Organic acid 4 3 0 surface of the eye and on the promptness of the management
Caustic soda 3 6 0
Others/unknown 3 4 3
of injury. Immediate irrigation after chemical eye injury is
Surgical treatment the single most important intervention, influencing the
Symblepharon release 21 34 1 outcome more than any other therapeutic approach.1,22
Amniotic membrane grafting 56 20 2 Approximately one third of our patients did not receive
Limbal stem cell transplantation 8 18 0 immediate irrigation at the time of injury. Consequently,
Lamellar keratoplasty 5 9 0 many of these patients had severe chemical injuries at the
time of presentation. The severity of damage in our cases
also may be attributed to the delay in presentation, with
70.2% of the patients presenting more than 1 month after the
ocular chemical burns in children. Approximately two thirds injury.
of all patients in our study were male. A study from Egypt The complications of ocular chemical injuries in our
on ocular trauma in the pediatric age group reported that study were similar to those of a previous large case series
69% of patients were male.18 In another report from the of adult patients reported from Shanghai.23 The most
United States, boys constituted 58.8% of the total number common complication seen in our study was central
of patients treated in the emergency department after corneal opacification followed by symblepharon,
injury with household cleaning products.19 These findings entropion, and elevated intraocular pressure. A high
are presumably related to the high physical contact and proportion of patients (85%) required surgical
aggressive nature of play among young boys. intervention. This may be related to the severity of
Furthermore, the most commonly affected age group was injury, which may be further affected by delayed initial
the preschool (0e5 years) age group in our study, perhaps presentation (mean time of presentation was >2 months
because this age group has relatively immature motor after injury). A multitude of operative procedures are
skills and a natural curiosity for objects with emphasis on needed for patients with ocular chemical injury to
general inquisitiveness about their environment. Children salvage the eye and restore visual function. Most
aged 1 to 3 years accounted for 72.0% of all cases in commonly performed surgical procedures include
a report of injuries associated with household articles in amniotic membrane graft, limbal stem cell graft, oral
the pediatric age group.19 mucosa graft, and fornix reconstruction.1 In our study,
In our study, lime was the most common offending agent amniotic membrane transplantation was performed in 78
in the form of “chuna,” which is mainly used by adults and eyes (58.2%). Amniotic membrane transplantation
can cause collateral damage in children.20 Chuna is an promotes corneal epithelization, prevents conjunctival
alkaline, edible calcium hydroxide paste that is added to adhesions, and helps restore the ocular surface.5,10,13,21
chewing tobacco in India and other regions of Southeast Most cases in our study required more than 1 surgery,
Asia. It causes epithelial abrasions in the oral mucosa that resulting in an overall suboptimal visual outcome. Only
increase the penetration of chemical compounds released 12% of the cases achieved a visual acuity of 6/18,
from tobacco. In India, chuna is sold in polythene packets whereas 64% of the patients had a visual acuity of <3/60 in
our study. A previous study from India showed that 30 of
Table 4. Best-Corrected Visual Acuity at Final Follow-up After
145 eyes had a final visual acuity of <6/60 and that 10% of
Ocular Chemical Injuries in Pediatric Age Group these eyes became blind after chemical injury.24

Visual Acuity N (%) Study Limitations

6/18 16 (11.9)
<6/18e3/60 26 (19.4)
The main limitation of our study is its retrospective design.
<3/60 86 (64.2) Because all cases were collected from a tertiary care
Unknown* 6 (4.4) hospital, there is a potential referral bias. We limited our
findings to the last recorded visual acuity. It is possible that
*These patients were not cooperative during assessment of visual acuity. some patients might have experienced a subsequent
improvement in their vision. Also, few patients would have

379

Downloaded for Yohanes Firmansyah (yohanesfirmansyah28@gmail.com) at Universitas Tarumanagara from ClinicalKey.com by Elsevier on May 10, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
 Ophthalmology Volume 121, Number 1, January 2014
continued their follow-ups with a local or primary
physician.
In conclusion, our study highlights the perils of ocular
chemical injuries in the pediatric age group, particularly in
the preschool age category. The data presented in this study
demonstrate a need for primary prevention and control
measures. Legislature on the sale and distribution of strong
acids and alkalis, public education, parental education, and
vigilance at home should be applied stringently, especially
in the developed world. Also, tobacco chewers should be
educated about the dangers of tobacco chewing, including
the dangers associated with keeping these chuna packets at
home. The importance of rinsing the eyes immediately after
chemical injury10 should be an integral part of public
education forums on chemical injuries.
References
1. Wagoner M. Chemical injuries of the eye: current concepts in
pathophysiology and therapy. Surv Ophthalmol 1997;41:
275–313.
2. Xie YF, Tan YY, Tang S. Epidemiology of 377 patients with
chemical burns in Guangdong province. Burns 2004;30:
569–72.
3. Viestenz A, Kuchle M. Retrospective analysis of 417 cases of
contusion and rupture of the globe with frequent avoidable
causes of trauma: the Erlangen Ocular Contusion-Registry
(EOCR) 1985e1995 [in German]. Klin Monbl Augenheilkd
2001;218:662–9.
4. Arffa R. Grayson’s Diseases of the Cornea. In: Arffa R, ed.
Chemical Injuries. 3rd ed. St. Louis, MO: Mosby-Year Book;
1991:649–65.
5. Kuckelkorn R, Keller GK, Redbrake C. Emergency treatment
of chemical and thermal eye burns. Acta Ophthalmol Scand
2002;80:4–10.
6. Morgan SJ. Chemical burns of the eye: causes and manage-
ment. Br J Ophthalmol 1987;71:854–7.
7. Kuckelkorn R, Luft I, Kottek AA, et al. Chemical and thermal
eye burns in the residential area of RWTH Aachen. Analysis of
accidents in one year using a new automated documentation of
findings [in German]. Klin Monbl Augenheilkd 1993;203:
34–42.
Footnotes and Financial Disclosures
Originally received: April 7, 2013.
Final revision: June 22, 2013.
Accepted: June 25, 2013.
Available online: August 13, 2013. Manuscript no. 2013-563.
1
Centre for Eye Research Australia, University of Melbourne, Melbourne,
Australia.
2
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of
Medical Sciences, New Delhi, India.
3
Department of Ophthalmology and Visual Sciences, The Chinese
University of Hong Kong, Hong Kong SAR.
380
Downloaded for Yohanes Firmansyah (yohanesfirmansyah28@gmail.com) at Universitas Tarumanagara from ClinicalKey.com by Elsevier on May 10, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
8. Harun S, Srinicasan S, Hollingworth K, et al. Modification of
classification of ocular chemical injuries [letter]. Br J Oph-
thalmol 2004;88:1353–4; author reply 1354e5.
9. Dua HS, Azuara-Blanco A. Limbal stem cells of the corneal
epithelium. Surv Ophthalmol 2000;44:415–25.
10. Azuara-Blanco A, Pillai CT, Dua HS. Amniotic membrane
transplantation for ocular surface reconstruction. Br J Oph-
thalmol 1999;83:399–402.
11. Tamhane A, Vajpayee RB, Biswas NR, et al. Evaluation of
amniotic membrane transplantation as an adjunct to medical
therapy as compared with medical therapy alone in acute
ocular burns. Ophthalmology 2005;112:1963–9.
12. Anderson DF, Ellies P, Pires RT, Tseng SC. Amniotic
membrane transplantation for partial limbal stem cell defi-
ciency. Br J Ophthalmol 2001;85:567–75.
13. Chiou AG, Florakis GJ, Kazim M. Management of conjunc-
tival cicatrizing diseases and severe ocular surface dysfunc-
tion. Surv Ophthalmol 1998;43:19–46.
14. Pfister RR. The effect of chemical injury on the ocular surface.
Ophthalmology 1983;90:601–9.
15. Pfister RR. Chemical corneal burns. Int Ophthalmol Clin
1984;24:157–68.
16. Pfister RR. Chemical injuries of the eye. Ophthalmology
1983;90:1246–53.
17. Schultz G, Henkind P, Gross EM. Acid burns of the eye. Am J
Ophthalmol 1968;66:654–7.
18. El-Mekawey HE, Abu El Einen KG, Abdelmaboud M, et al.
Epidemiology of ocular emergencies in the Egyptian pop-
ulation: a five-year retrospective study. Clin Ophthalmol
2011;5:955–60.
19. D’Souza AL, Nelson NG, McKenzie LB. Pediatric burn
injuries treated in US emergency departments between 1990
and 2006. Pediatrics 2009;124:1424–30.
20. Agarwal T, Vajpayee R. A warning about the dangers of chuna
packets [letter]. Lancet 2003;361:2247.
21. Agarwal T, Vajpayee RB, Sharma N, Tandon R. Severe ocular
injury resulting from chuna packets. Ophthalmology
2006;113:961.
22. Trevino MA, Herrmann GH, Sprout WL. Treatment of severe
hydrofluoric acid exposures. J Occup Med 1983;25:861–3.
23. Hong J, Qiu T, Wei A, et al. Clinical characteristics and visual
outcome of severe ocular chemical injuries in Shanghai.
Ophthalmology 2010;117:2268–72.
24. Saini JS, Sharma A. Ocular chemical burnseclinical and
demographic profile. Burns 1993;19:67–9.
Presented in part as a poster at: the Annual Meeting of the American
Academy of Ophthalmology, November 10e13, 2012, Chicago, Illinois.
Financial Disclosure(s):
The author(s) have no proprietary or commercial interest in any materials
discussed in this article.
Correspondence:
Rasik B. Vajpayee, FRCS (Edin), FRANZCO, Centre for Eye Research
Australia, University of Melbourne, 32 Gisborne Street, East Melbourne,
Victoria 3002, Australia. E-mail: rasikv@unimelb.edu.au.