Demographic and Clinical Prole 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 prole, 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 78), symblepharon
release (n 56), limbal stem cell transplantation (n 26), and lamellar keratoplasty (n 14). The average number
of surgeries conducted per patient was 2.3 (range, 1e4). Median visual acuity at nal 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 2014 by the
American Academy of Ophthalmology.

Chemical injuries to the eye represent an ophthalmic

emergency that can result in extensive damage and signicant 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
opacication, permanent vision loss, and rarely loss of the
eye.3 Alkalis cause signicantly 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 signicantly 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 inammatory 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 deciency can manifest.8

 2014 by the American Academy of Ophthalmology

Published by Elsevier Inc.

Long-term management aims to restore the visual function

by preserving tear production, managing limbal stem cell
deciency, 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 difculty 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. Modied
Roper-Hall classication 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

ISSN 0161-6420/14/$ - see front matter

http://dx.doi.org/10.1016/j.ophtha.2013.06.044

377

Ophthalmology

Volume 121, Number 1, January 2014

month of injury), patients were initially managed with conventional

medical therapy, which included copious irrigation of the affected
eye with normal saline and removal of any particulate matter or
debris.1 Patients were administered topical antibiotics,
corticosteroids, and cycloplegic eye drops for the initial 2 to 4
weeks. In addition, sodium ascorbate 10% eye drops and sodium
citrate 10% eye drops were given twice per hour, and
preservative-free articial tears were instilled every 1 to 2 hours.
Oral vitamin C tablets 1 to 2 g/day in 4 divided doses were given
for 2 to 4 weeks. Antiglaucoma therapy, including timolol maleate
0.5% eye drops and oral acetazolamide, was administered if
required. The treatment was modied according to the response.
Amniotic membrane grafting was performed in acute cases with
cryopreserved amniotic membrane using the overlay technique to
hasten epithelialization.11 The amniotic membrane covered the
entire ocular surface with the stromal side touching the ocular
surface. The membrane was anchored with the interrupted 80 Vicryl sutures (Ethicon Inc., Johnson & Johnson, Ahmedabad,
India) to the underlying conjunctiva and the episclera around the
limbus, and in cases where the lids were involved, anchoring
sutures also were applied to the lid margin. In the chronic stage
(>1 month after injury), preservative-free articial tears were
instilled every 1 to 2 hours. Amniotic membrane grafting was
performed in cases of partial limbal stem cell deciency to help
in vivo expansion of limbal stem cells using a standard
technique.12
The primary surgical intervention and subsequent outcome in
each case were noted. For those patients who required surgical
interventions, surgery was performed in the form of symblepharon
release, amniotic membrane grafting, allograft or autograft stem
cell transplantation, and large-diameter lamellar keratoplasty. The
data collected included age, sex, nature of chemical, complications
over the course of follow-up, and visual acuity at the nal followup examination. Statistical analysis was performed using a statistical software package (SPSS for Windows, version 13.0; SPSS,
Inc., Chicago, IL). Normal distribution data are shown as mean
values
standard deviations.

Table 1. Demographic and Clinical Prole at Presentation in

Pediatric Patients With Ocular Chemical Injury (n 134)
Sex
Male
Female
Mean age
SD (range)
Laterality
Bilateral
Unilateral
Grade of injury at presentation, n
Grade 1
Grade 2
Grade 3
Grade 4
Age distribution (yrs)
5
>5e10
>10e15

85 (63.4%)
49 (36.5%)
8.95
4.89 yrs
(1.2e15.5 yrs)
24 (17.9%)
110 (82.1%)
9
31
25
69

(6.7%)
(23.1%)
(18.6%)
(51.4%)

69 (51.4%)
57 (42.5%)
8 (5.9%)

SD standard deviation.

release (n 56), limbal stem cell transplantation (n 26), and

lamellar keratoplasty (n 14). The average number of surgeries
conducted per patient was 2.3 (range, 1e4). The age-wise distribution of clinical characteristics and surgical interventions is
shown in Table 3.
Visual acuity at presentation ranged from 6/6 to perception of
light (median, light perception with projection). Mean decimal
visual acuity at nal follow up was 0.05
0.04 (range, no light
perception to 6/9).The mean follow-up was 537 days (range, 3
months to 5 years). The best-corrected visual acuity in the nal
follow-up is shown in Table 4.

Discussion
Results
A total of 134 patients (85 [63.4%] were male) with ocular
chemical injury were seen between March 2006 and March 2011.
The mean age at the time of injury was 8.95
4.89 years (range,
1.2e15.5 years), with approximately half (n 69, 51.4%) of the
patients in the 0- to 5-year-old age group (Table 1). The highest
male-to-female ratio was seen in the 6- to 10-year-old age group
with a ratio of 3.2:1, whereas the youngest age group (0e5
years) showed a relatively lower male-to-female ratio of 1.4:1.
Bilateral chemical injuries were seen in 24 patients (17.9%).
Lime was the most commonly involved chemical in 88 cases
(65.6%). This was in the form of chuna packet injury, which is
commonly used as an additive to tobacco chewing in this part of
the world. Other chemicals included toilet cleaner (20, 14.9%),
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
(range, 1e365 days). Approximately 28.3% of the patients had not
received any eye irrigation immediately after the injury. Forty
patients (29.8%) sought treatment in the acute stage (within 1
month), and 94 patients (70.2%) sought treatment in the chronic
stage (after 1 month). A large proportion of the patients (n 94,
70.1%) had severe ocular burn (grades 3 and 4). The ocular
complications of chemical injuries are summarized in Table 2.
Surgical intervention was performed in 114 eyes (85%) in the
form of amniotic membrane grafting (n 78), symblepharon

378

Chemical ocular burns are potentially blinding because

extensive limbal ischemia impairs ocular surface healing,
eventually causing corneal opacication, which is difcult
to treat with conventional corneal transplantation techniques.13 Although alkalis cause more severe chemical
injuries compared with acids,14e16 acidic agents such as
hydrouoric acid are known to produce severe injuries
because of rapid penetration into the eye.17 Management of
severe ocular chemical injuries typically requires a long
period of treatment for restoration of visual acuity. In
ocular trauma in the pediatric age group, there is an
additional risk of development of amblyopia. In this study,
we analyzed the cause, management, and outcomes of
Table 2. Complications of Ocular Chemical Injuries in the
Pediatric Age Group
Complications
Corneal opacication
Symblepharon
Entropion
Glaucoma
Phthisis

N (%)
98
63
27
29
6

(73.1)
(47)
(20.1)
(21.6)
(4.4)

Vajpayee et al

Ocular Chemical Injuries in the Pediatrics

Table 3. Age-wise Distribution of Clinical Characteristics and

Surgical Interventions in Pediatric Patients With Ocular Chemical
Injuries
Clinical Characteristics
Grade of injury
Grade 1
Grade 2
Grade 3
Grade 4
Causative chemical agent
Lime
Toilet cleaner
Organic acid
Caustic soda
Others/unknown
Surgical treatment
Symblepharon release
Amniotic membrane grafting
Limbal stem cell transplantation
Lamellar keratoplasty

0e5 Yrs >5e10 Yrs >10e15 Yrs

(n[69) (n[57)
(n[8)
4
12
14
39

2
17
10
28

3
2
1
2

46
13
4
3
3

38
6
3
6
4

4
1
0
0
3

21
56
8
5

34
20
18
9

1
2
0
0

ocular chemical burns in children. Approximately two thirds

of all patients in our study were male. A study from Egypt
on ocular trauma in the pediatric age group reported that
69% of patients were male.18 In another report from the
United States, boys constituted 58.8% of the total number
of patients treated in the emergency department after
injury with household cleaning products.19 These ndings
are presumably related to the high physical contact and
aggressive nature of play among young boys.
Furthermore, the most commonly affected age group was
the preschool (0e5 years) age group in our study, perhaps
because this age group has relatively immature motor
skills and a natural curiosity for objects with emphasis on
general inquisitiveness about their environment. Children
aged 1 to 3 years accounted for 72.0% of all cases in
a report of injuries associated with household articles in
the pediatric age group.19
In our study, lime was the most common offending agent
in the form of chuna, which is mainly used by adults and
can cause collateral damage in children.20 Chuna is an
alkaline, edible calcium hydroxide paste that is added to
chewing tobacco in India and other regions of Southeast
Asia. It causes epithelial abrasions in the oral mucosa that
increase the penetration of chemical compounds released
from tobacco. In India, chuna is sold in polythene packets
Table 4. Best-Corrected Visual Acuity at Final Follow-up After
Ocular Chemical Injuries in Pediatric Age Group
Visual Acuity
6/18
<6/18e3/60
<3/60
Unknown*

N (%)
16
26
86
6

(11.9)
(19.4)
(64.2)
(4.4)

*These patients were not cooperative during assessment of visual acuity.

and are often easily accessible by children, who tend to

play with them. These chuna packets can burst even when
squeezed lightly, resulting in a spill of alkali in the eyes,
causing severe chemical injury. Furthermore, these packets
have no statutory warning labeling them as a hazardous
substance, and there is no legislation to restrict their use.
Previous reports from India have shown devastating
outcomes after ocular injury involving chuna packets.
Chuna packets caused grade 4 injuries in the majority of
the eyes, and 68% of the eyes were treated surgically,
with a nal median visual acuity of 1/60.21
The severity of damage after ocular chemical injury
mostly depends on the contact time of the chemical with the
surface of the eye and on the promptness of the management
of injury. Immediate irrigation after chemical eye injury is
the single most important intervention, inuencing the
outcome more than any other therapeutic approach.1,22
Approximately one third of our patients did not receive
immediate irrigation at the time of injury. Consequently,
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
injury.
The complications of ocular chemical injuries in our
study were similar to those of a previous large case series
of adult patients reported from Shanghai.23 The most
common complication seen in our study was central
corneal opacication followed by symblepharon,
entropion, and elevated intraocular pressure. A high
proportion of patients (85%) required surgical
intervention. This may be related to the severity of
injury, which may be further affected by delayed initial
presentation (mean time of presentation was >2 months
after injury). A multitude of operative procedures are
needed for patients with ocular chemical injury to
salvage the eye and restore visual function. Most
commonly performed surgical procedures include
amniotic membrane graft, limbal stem cell graft, oral
mucosa graft, and fornix reconstruction.1 In our study,
amniotic membrane transplantation was performed in 78
eyes (58.2%). Amniotic membrane transplantation
promotes corneal epithelization, prevents conjunctival
adhesions, and helps restore the ocular surface.5,10,13,21
Most cases in our study required more than 1 surgery,
resulting in an overall suboptimal visual outcome. Only
12% of the cases achieved a visual acuity of 6/18,
whereas 64% of the patients had a visual acuity of <3/60 in
our study. A previous study from India showed that 30 of
145 eyes had a nal visual acuity of <6/60 and that 10% of
these eyes became blind after chemical injury.24

Study Limitations
The main limitation of our study is its retrospective design.
Because all cases were collected from a tertiary care
hospital, there is a potential referral bias. We limited our
ndings to the last recorded visual acuity. It is possible that
some patients might have experienced a subsequent
improvement in their vision. Also, few patients would have

379

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:
275313.
2. Xie YF, Tan YY, Tang S. Epidemiology of 377 patients with
chemical burns in Guangdong province. Burns 2004;30:
56972.
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;218:6629.
4. Arffa R. Graysons Diseases of the Cornea. In: Arffa R, ed.
Chemical Injuries. 3rd ed. St. Louis, MO: Mosby-Year Book;
1991:64965.
5. Kuckelkorn R, Keller GK, Redbrake C. Emergency treatment
of chemical and thermal eye burns. Acta Ophthalmol Scand
2002;80:410.
6. Morgan SJ. Chemical burns of the eye: causes and management. Br J Ophthalmol 1987;71:8547.
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
ndings [in German]. Klin Monbl Augenheilkd 1993;203:
3442.

8. Harun S, Srinicasan S, Hollingworth K, et al. Modication of

classication of ocular chemical injuries [letter]. Br J Ophthalmol 2004;88:13534; author reply 1354e5.
9. Dua HS, Azuara-Blanco A. Limbal stem cells of the corneal
epithelium. Surv Ophthalmol 2000;44:41525.
10. Azuara-Blanco A, Pillai CT, Dua HS. Amniotic membrane
transplantation for ocular surface reconstruction. Br J Ophthalmol 1999;83:399402.
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;112:19639.
12. Anderson DF, Ellies P, Pires RT, Tseng SC. Amniotic
membrane transplantation for partial limbal stem cell deciency. Br J Ophthalmol 2001;85:56775.
13. Chiou AG, Florakis GJ, Kazim M. Management of conjunctival cicatrizing diseases and severe ocular surface dysfunction. Surv Ophthalmol 1998;43:1946.
14. Pster RR. The effect of chemical injury on the ocular surface.
Ophthalmology 1983;90:6019.
15. Pster RR. Chemical corneal burns. Int Ophthalmol Clin
1984;24:15768.
16. Pster RR. Chemical injuries of the eye. Ophthalmology
1983;90:124653.
17. Schultz G, Henkind P, Gross EM. Acid burns of the eye. Am J
Ophthalmol 1968;66:6547.
18. El-Mekawey HE, Abu El Einen KG, Abdelmaboud M, et al.
Epidemiology of ocular emergencies in the Egyptian population: a ve-year retrospective study. Clin Ophthalmol
2011;5:95560.
19. DSouza AL, Nelson NG, McKenzie LB. Pediatric burn
injuries treated in US emergency departments between 1990
and 2006. Pediatrics 2009;124:142430.
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
hydrouoric acid exposures. J Occup Med 1983;25:8613.
23. Hong J, Qiu T, Wei A, et al. Clinical characteristics and visual
outcome of severe ocular chemical injuries in Shanghai.
Ophthalmology 2010;117:226872.
24. Saini JS, Sharma A. Ocular chemical burnseclinical and
demographic prole. Burns 1993;19:679.

Footnotes and Financial Disclosures

Originally received: April 7, 2013.
Final revision: June 22, 2013.
Accepted: June 25, 2013.
Available online: August 13, 2013.

Presented in part as a poster at: the Annual Meeting of the American

Academy of Ophthalmology, November 10e13, 2012, Chicago, Illinois.
Manuscript no. 2013-563.

Centre for Eye Research Australia, University of Melbourne, Melbourne,

Australia.

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of
Medical Sciences, New Delhi, India.

Department of Ophthalmology and Visual Sciences, The Chinese

University of Hong Kong, Hong Kong SAR.

380

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.