Demographic and Clinical Profile of OcularChemical 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 ina 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, 1.2e15.5years); 63.4% were male. Sixty-nine patients (51.4%) belonged to the preschool (0e5 years) age group. Bilateralchemical 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%). Surgicalintervention was performed in 114 eyes (85%) in the form of amniotic membrane grafting (n ¼ 78), symblepharonrelease (n ¼ 56), limbal stem cell transplantation (n ¼ 26), and lamellar keratoplasty (n ¼ 14). The average numberof surgeries conducted per patient was 2.3 (range, 1e4). Median visual acuity at final follow-up (mean, 537�354days) was 3/60.

Conclusions: Chemical injuries in pediatric patients are more commonly encountered in the preschool agegroup and are associated with severe visual loss. Alkali injury from bursting of chuna packets was the mostcommon mode of injury in pediatric patients in our study. Ophthalmology 2014;121:377-380 ª 2014 by theAmerican Academy of Ophthalmology.

Chemical injuries to the eye represent an ophthalmicemergency that can result in extensive damage and signifi-cant ocular morbidity.1 The reported incidence of ocularchemical injuries in developing countries is approximately1.25% to 4.4%.2 Severe chemical burn can lead tocomplete destruction of the ocular surface, cornealopacification, permanent vision loss, and rarely loss of theeye.3 Alkalis cause significantly greater damage comparedwith acids.4 Epidemiologic data show that severe chemicaleye injuries are more common in male subjects,particularly those aged between 16 and 45 years.1,5e7 Themajority of these injuries occur as a result of accidents atwork or home or deliberately from an assault.4 Acutechemical eye injury treated immediately with expedientirrigation and removal of trapped debris is associated witha significantly better visual outcome.4 Early managementendeavors to preserve the globe integrity, whereassubsequent treatment is aimed at promoting ocular surfaceepithelial recovery, augmenting corneal repair, minimizingulceration, and controlling the inflammatory response.1

Surgery may be necessary in the acute setting if healing ofthe ocular surface is inadequate. In the chronic stages,features of limbal stem cell deficiency can manifest.8

� 2014 by the American Academy of OphthalmologyPublished by Elsevier Inc.

Long-term management aims to restore the visual functionby preserving tear production, managing limbal stem celldeficiency, and addressing associated complications, such aslid malposition, cataract, and glaucoma.8e10

Compared with adults, ocular chemical injuries in thepediatric population pose a greater challenge mainlybecause of the difficulty in timely diagnosis and adequatemanagement of complications in this age group. Thepurpose of this study was to evaluate the pattern, riskfactors, and visual outcomes of pediatric chemical eyeinjuries that required hospitalization in a tertiary eye carecenter in North India.

Methods

In this retrospective chart review, case records of pediatric patientswho were treated at a tertiary eye care hospital between March2006 and March 2011 with ocular chemical burns were analyzed.The study was approved by an institutional review board andadhered to the tenets of the Declaration of Helsinki. ModifiedRoper-Hall classification was used for grading of ocular burns.1

The management of patients depended on the severity of ocularinjury at the time of presentation. In the acute stage (within 1

377ISSN 0161-6420/14/$ - see front matterhttp://dx.doi.org/10.1016/j.ophtha.2013.06.044

Table 1. Demographic and Clinical Profile at Presentation inPediatric Patients With Ocular Chemical Injury (n ¼ 134)

SexMale 85 (63.4%)Female 49 (36.5%)

Mean age � SD (range) 8.95�4.89 yrs(1.2e15.5 yrs)

LateralityBilateral 24 (17.9%)Unilateral 110 (82.1%)

Grade of injury at presentation, nGrade 1 9 (6.7%)Grade 2 31 (23.1%)Grade 3 25 (18.6%)Grade 4 69 (51.4%)

Age distribution (yrs)�5 69 (51.4%)>5e�10 57 (42.5%)>10e15 8 (5.9%)

SD ¼ standard deviation.

Ophthalmology Volume 121, Number 1, January 2014

month of injury), patients were initially managed with conventionalmedical therapy, which included copious irrigation of the affectedeye with normal saline and removal of any particulate matter ordebris.1 Patients were administered topical antibiotics,corticosteroids, and cycloplegic eye drops for the initial 2 to 4weeks. In addition, sodium ascorbate 10% eye drops and sodiumcitrate 10% eye drops were given twice per hour, andpreservative-free artificial tears were instilled every 1 to 2 hours.Oral vitamin C tablets 1 to 2 g/day in 4 divided doses were givenfor 2 to 4 weeks. Antiglaucoma therapy, including timolol maleate0.5% eye drops and oral acetazolamide, was administered ifrequired. The treatment was modified according to the response.Amniotic membrane grafting was performed in acute cases withcryopreserved amniotic membrane using the overlay technique tohasten epithelialization.11 The amniotic membrane covered theentire ocular surface with the stromal side touching the ocularsurface. The membrane was anchored with the interrupted 8-0 Vicryl sutures (Ethicon Inc., Johnson & Johnson, Ahmedabad,India) to the underlying conjunctiva and the episclera around thelimbus, and in cases where the lids were involved, anchoringsutures also were applied to the lid margin. In the chronic stage(>1 month after injury), preservative-free artificial tears wereinstilled every 1 to 2 hours. Amniotic membrane grafting wasperformed in cases of partial limbal stem cell deficiency to helpin vivo expansion of limbal stem cells using a standardtechnique.12

The primary surgical intervention and subsequent outcome ineach case were noted. For those patients who required surgicalinterventions, surgery was performed in the form of symblepharonrelease, amniotic membrane grafting, allograft or autograft stemcell transplantation, and large-diameter lamellar keratoplasty. Thedata collected included age, sex, nature of chemical, complicationsover the course of follow-up, and visual acuity at the final follow-up examination. Statistical analysis was performed using a statis-tical software package (SPSS for Windows, version 13.0; SPSS,Inc., Chicago, IL). Normal distribution data are shown as meanvalues � standard deviations.

Table 2. Complications of Ocular Chemical Injuries in thePediatric Age Group

Complications N (%)

Corneal opacification 98 (73.1)Symblepharon 63 (47)Entropion 27 (20.1)Glaucoma 29 (21.6)Phthisis 6 (4.4)

Results

A total of 134 patients (85 [63.4%] were male) with ocularchemical 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 ¼ 69, 51.4%) of thepatients in the 0- to 5-year-old age group (Table 1). The highestmale-to-female ratio was seen in the 6- to 10-year-old age groupwith a ratio of 3.2:1, whereas the youngest age group (0e5years) 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 iscommonly used as an additive to tobacco chewing in this part ofthe world. Other chemicals included toilet cleaner (20, 14.9%),caustic soda (9, 6.7%), and organic acids (7, 5.2%). The nature ofthe chemical was unknown in 10 cases (7.4%). The time intervalbetween injury and presentation to our hospital was 68.3 days(range, 1e365 days). Approximately 28.3% of the patients had notreceived any eye irrigation immediately after the injury. Fortypatients (29.8%) sought treatment in the acute stage (within 1month), and 94 patients (70.2%) sought treatment in the chronicstage (after 1 month). A large proportion of the patients (n ¼ 94,70.1%) had severe ocular burn (grades 3 and 4). The ocularcomplications of chemical injuries are summarized in Table 2.

Surgical intervention was performed in 114 eyes (85%) in theform of amniotic membrane grafting (n ¼ 78), symblepharon

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release (n ¼ 56), limbal stem cell transplantation (n ¼ 26), andlamellar keratoplasty (n ¼ 14). The average number of surgeriesconducted per patient was 2.3 (range, 1e4). The age-wise distri-bution of clinical characteristics and surgical interventions isshown in Table 3.

Visual acuity at presentation ranged from 6/6 to perception oflight (median, light perception with projection). Mean decimalvisual acuity at final follow up was 0.05�0.04 (range, no lightperception to 6/9).The mean follow-up was 537 days (range, 3months to 5 years). The best-corrected visual acuity in the finalfollow-up is shown in Table 4.

Discussion

Chemical ocular burns are potentially blinding becauseextensive limbal ischemia impairs ocular surface healing,eventually causing corneal opacification, which is difficultto treat with conventional corneal transplantation tech-niques.13 Although alkalis cause more severe chemicalinjuries compared with acids,14e16 acidic agents such ashydrofluoric acid are known to produce severe injuriesbecause of rapid penetration into the eye.17 Management ofsevere ocular chemical injuries typically requires a longperiod of treatment for restoration of visual acuity. Inocular trauma in the pediatric age group, there is anadditional risk of development of amblyopia. In this study,we analyzed the cause, management, and outcomes of

Table 3. Age-wise Distribution of Clinical Characteristics andSurgical Interventions in Pediatric Patients With Ocular Chemical

Injuries

Clinical Characteristics0e5 Yrs(n[69)

>5e10 Yrs(n[57)

>10e15 Yrs(n[8)

Grade of injuryGrade 1 4 2 3Grade 2 12 17 2Grade 3 14 10 1Grade 4 39 28 2

Causative chemical agentLime 46 38 4Toilet cleaner 13 6 1Organic acid 4 3 0Caustic soda 3 6 0Others/unknown 3 4 3

Surgical treatmentSymblepharon release 21 34 1Amniotic membrane grafting 56 20 2Limbal stem cell transplantation 8 18 0Lamellar keratoplasty 5 9 0

Vajpayee et al � Ocular Chemical Injuries in the Pediatrics

ocular chemical burns in children. Approximately two thirdsof all patients in our study were male. A study from Egypton ocular trauma in the pediatric age group reported that69% of patients were male.18 In another report from theUnited States, boys constituted 58.8% of the total numberof patients treated in the emergency department afterinjury with household cleaning products.19 These findingsare presumably related to the high physical contact andaggressive nature of play among young boys.Furthermore, the most commonly affected age group wasthe preschool (0e5 years) age group in our study, perhapsbecause this age group has relatively immature motorskills and a natural curiosity for objects with emphasis ongeneral inquisitiveness about their environment. Childrenaged 1 to 3 years accounted for 72.0% of all cases ina report of injuries associated with household articles inthe pediatric age group.19

In our study, lime was the most common offending agentin the form of “chuna,” which is mainly used by adults andcan cause collateral damage in children.20 Chuna is analkaline, edible calcium hydroxide paste that is added tochewing tobacco in India and other regions of SoutheastAsia. It causes epithelial abrasions in the oral mucosa thatincrease the penetration of chemical compounds releasedfrom tobacco. In India, chuna is sold in polythene packets

Table 4. Best-Corrected Visual Acuity at Final Follow-up AfterOcular Chemical Injuries in Pediatric Age Group

Visual Acuity N (%)

�6/18 16 (11.9)<6/18e3/60 26 (19.4)<3/60 86 (64.2)Unknown* 6 (4.4)

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

and are often easily accessible by children, who tend toplay with them. These chuna packets can burst even whensqueezed lightly, resulting in a spill of alkali in the eyes,causing severe chemical injury. Furthermore, these packetshave no statutory warning labeling them as a hazardoussubstance, and there is no legislation to restrict their use.Previous reports from India have shown devastatingoutcomes after ocular injury involving chuna packets.Chuna packets caused grade 4 injuries in the majority ofthe eyes, and 68% of the eyes were treated surgically,with a final median visual acuity of 1/60.21

The severity of damage after ocular chemical injurymostly depends on the contact time of the chemical with thesurface of the eye and on the promptness of the managementof injury. Immediate irrigation after chemical eye injury isthe single most important intervention, influencing theoutcome more than any other therapeutic approach.1,22

Approximately one third of our patients did not receiveimmediate irrigation at the time of injury. Consequently,many of these patients had severe chemical injuries at thetime of presentation. The severity of damage in our casesalso may be attributed to the delay in presentation, with70.2% of the patients presenting more than 1 month after theinjury.

The complications of ocular chemical injuries in ourstudy were similar to those of a previous large case seriesof adult patients reported from Shanghai.23 The mostcommon complication seen in our study was centralcorneal opacification followed by symblepharon,entropion, and elevated intraocular pressure. A highproportion of patients (85%) required surgicalintervention. This may be related to the severity ofinjury, which may be further affected by delayed initialpresentation (mean time of presentation was >2 monthsafter injury). A multitude of operative procedures areneeded for patients with ocular chemical injury tosalvage the eye and restore visual function. Mostcommonly performed surgical procedures includeamniotic membrane graft, limbal stem cell graft, oralmucosa graft, and fornix reconstruction.1 In our study,amniotic membrane transplantation was performed in 78eyes (58.2%). Amniotic membrane transplantationpromotes corneal epithelization, prevents conjunctivaladhesions, 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. Only12% of the cases achieved a visual acuity of �6/18,whereas 64% of the patients had a visual acuity of <3/60 inour study. A previous study from India showed that 30 of145 eyes had a final visual acuity of <6/60 and that 10% ofthese 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 carehospital, there is a potential referral bias. We limited ourfindings to the last recorded visual acuity. It is possible thatsome patients might have experienced a subsequentimprovement in their vision. Also, few patients would have

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continued their follow-ups with a local or primaryphysician.

In conclusion, our study highlights the perils of ocularchemical injuries in the pediatric age group, particularly inthe preschool age category. The data presented in this studydemonstrate a need for primary prevention and controlmeasures. Legislature on the sale and distribution of strongacids and alkalis, public education, parental education, andvigilance at home should be applied stringently, especiallyin the developed world. Also, tobacco chewers should beeducated about the dangers of tobacco chewing, includingthe dangers associated with keeping these chuna packets athome. The importance of rinsing the eyes immediately afterchemical injury10 should be an integral part of publiceducation forums on chemical injuries.

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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.

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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 ofMedical Sciences, New Delhi, India.3 Department of Ophthalmology and Visual Sciences, The ChineseUniversity of Hong Kong, Hong Kong SAR.

Presented in part as a poster at: the Annual Meeting of the AmericanAcademy of Ophthalmology, November 10e13, 2012, Chicago, Illinois.

Financial Disclosure(s):The author(s) have no proprietary or commercial interest in any materialsdiscussed in this article.

Correspondence:Rasik B. Vajpayee, FRCS (Edin), FRANZCO, Centre for Eye ResearchAustralia, University of Melbourne, 32 Gisborne Street, East Melbourne,Victoria 3002, Australia. E-mail: rasikv@unimelb.edu.au.