JMSCR Vol||07||Issue||06||Page 807-812||June 2019

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Index Copernicus Value: 79.54
ISSN (e)-2347-176x ISSN (p) 2455-0450
DOI: https://dx.doi.org/10.18535/jmscr/v7i6.134

Original Article
Incidence and Management of Chemical Injuries of Eye
Authors
Dr Bishnu Prasad Mishra , Dr Ankita Mahapatra2, Dr Santosh Kumar Sahu3*,
1

Dr Choubarga Naik4, Dr Subha Soumya Dany5

1
Ophthalmologist, District Headquarter Hospital, Balangir, Odisha.
2
Post-graduate student, Department of Ophthalmology, VIMSAR, Burla, Odisha
3
ENT Specialist, District Headquarter Hospital, Balangir, Odisha.
4
Assistant Professor, Department of Dentistry, VIMSAR, Burla, Odisha
5
Lecturer, Department of Public Health Dentistry, Hi-tech Dental College and Hospital, Bhubaneswar
*Corresponding Author
Dr Santosh Kumar Sahu
ENT Specialist, District Headquarter Hospital, Balangir, Odisha, India
Abstract
Introduction: Chemical injuries to the eyes are common and represent one of the true ophthalmic
emergencies. Practically any chemical (acid or alkali) can cause ocular irritation.
Usually Acid burns are less severe than that caused by alkali burn.
Purpose: To study the incidence, pattern and management of chemical injuries of eye in a tertiary health
care centre of Western Odisha
Method: A Hospital based study was undertaken in department of ophthalmology at between January 2017
to December 2018, which is a period of 2 years. A total of 102 patients were included in the study after
counselling; and written informed consent was also taken individually in each case. Basic demographic
data and history of chemical injury was noted. Treatment needed (according to degree and severity of
injury) was provided to the patients at the Department of Ophthalmology. Patients were followed up for any
complications for 6 months. Data obtained were subjected to descriptive statistics using SPSS 20.0.
Results: Out of all cases of ocular injuries; chemical injuries of eye were encountered in 13.04%of cases
during the study period. Males (73.5%) were more affected and 31-40 years age group was the most
vulnerable one. Most of the cases (59.8) presented with unilateral involvement of eye and 72 cases
(70.59%) of chemical injury were caused by alkalis. Grade II injury (35.6%) was most common finding and
some post-operative complications were also encountered during the follow-up.
Concussion: Chemical injuries to eyes maybe very few in number and minor in presentation but they also
need early attention and care to minimize morbidity related to it.
Keywords: Acid, alkali, chemical injuries, complications, morbidity.

Introduction assessment and management. These represent

Chemical injuries (alkali, acid) to the eyes between 11.5%-22.1% of ocular traumas1. About
represent one of the true ophthalmic emergencies two thirds occur in young men and children age 1-
which necessitate instantaneous and rigorous 2 years are particularly at risk. The vast majority
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of the injuries occur in the workplace as a result of Loss of goblet cells and conjunctival inflammation
industrial accidents. A minority of injuries occur can leave the ocular surface prone to dryness. Lid
in the home or secondary to assault. Practically malposition may be present due to symblepharon
any chemical can cause ocular irritation. Most of formation leading to cicatricial entropion or
these injuries are inconsequential and do not cause ectropion.4In severe cases phthisis bulbi may be
serious lesions (e.g. shampoos, defence sprays, the tragic endresult. Chemical injury is the one of
household cleaning solutions etc.) while other the true ophthalmic emergencies and it needs
may result in permanent morbidity. Common immediate management. Chemical burns have a
acids are sulphuric acid (car batteries), major impact in terms of long-term morbidity and
hydrofluoric acid (glass polishing), acetic acid, so is a matter of major socio-economic
hydrochloric acid and nitric acid (gold maker). importance. The sequels of chemical burn may
Common alkalis are lime (plaster), have significant detrimental visual and
ammonia/ammonium hydrochloride (cleaning psychological effects on the affected individual.
solution, drain cleaner), potassium hydrochloride, Proper management in the acute setting as well as
magnesium hydrochloride (fireworks). Alkali follow-up by an ophthalmologist is crucial in
injuries are usually more severe than acid injuries limiting adverse effects of ocular tissue damage
as the latter tends to remain confined to the ocular secondary to the chemicals. The aim of this study
surface and producing superficial damage.2 When was to find out the pattern of ocular injury, nature
acid comes in contact with corneal surface they of causative chemicals, the disabilities incurred
cause coagulation of tissue protein forming a and the outcome of treatment.
barrier, which prevents deep penetration. But
alkalis in contrast, cause saponification of cellular Methods
lipids disrupt the normal barrier of the cornea All the cases of chemical injuries attending to the
resulting in deep penetration to internal structures Ophthalmologyout-patient department (OPD) and
causing severe damage to the lens and anterior casualty of Bhima Bhoi Medical College and
uvea. Alkali injuries tend to be more common District Headquarter hospital, Bolangir, Odisha.
since they are extensively used in industries and in during the study period from 01.01.2017 to
various households as cleansing agent. Chemical 31.012.2018 were considered. A detailed clinical
trauma to the eye may vary in severity from mild history of each case was taken with reference to
irritation to complete destruction of the ocular name, age, sex, address and occupation. With
surface epithelium, cornea opacification, loss in particular reference to time since injury, place of
vision and rarely loss of the eye.3The damage to injury and the chemical involved in each case
the corneal and conjunctival epithelium from an made. Patient’s chief complaint, personal history
ocular burn may be so severe as to damage the and past history were also noted. Prior to a full
pluripotent limbal stem cell causing a limbal stem ophthalmic exam, the pH of both eyes checked,
cell deficiency. This may lead to opacification and irrigated to bring the pH to an appropriate range
neo-vascularization of the cornea. An acute IOP (between 7 and 7.2). A thorough ocular
rise occurrence due to shrinkage and contraction examination (including normal eye) was done.
of the cornea and sclera is possible. Long-term The conditions of ocular adnexa, conjunctiva,
IOP rises can occur from the accumulation of cornea, sclera, anterior chamber, iris, pupil and
inflammatory debris within the trabecular lens were evaluated by slit- lamp examination and
meshwork, as well as due to damage to the retained chemicals if any were removed. Distant
trabecular meshwork itself. Damage to the visual acuity was recorded by Snellen’s chart.
conjunctiva can cause extensive scarring, Intraocular pressure was recorded, especially in
perilimbal ischemia, and contracture of fornices. alkaline burns. Fundoscopy was done by direct

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and indirect ophthalmoscope wherever possible. Result
General examination and systemic examination, In this study 102 cases of chemical injury of eye
routine investigations were done in each case. All were considered. They were of different age group
the patients were graded according to the severity and mostly were unilateral. Different varieties of
of injury by Roper Hall (Modified Hughes) injurious agents and mode of injuries were noted.
Grading of Ocular Chemical Injuries (Table 1).5,6 All the injuries were classified according to Roper
All the patients were treated by available Hall grading and they were managed as
therapeutic measures in best possible conservative aforementioned. The visual improvement in each
way. Patients of grade 1 and grade2 injuries were and every case during the follow up period a
treated in the line of following conventional maximum of 6 months was observed and
technique. compared with the initial visual acuity.
1. Immediate removal of chemical by Table 2 shows out of 782 cases of ocular trauma
thorough wash with normal saline and 102 cases (13.04%) of chemical injuries of eye
normalization of Ph were encountered during the study period. Out of
2. Topical antibiotic ointment, drops total 102 cases of chemical injury, 75 cases
3. Preservative free artificial tear drops , (73.5%) were found to be male and 27 cases
Topical NSAIDs (26.5%) were female.
4. Steroid to be used cautiously and Atropine In this study the incidence of chemical injury in
(1%) patients according to age group (Table 3) shows
5. Systemic antibiotics, Doxycycline (to be following trends: below 10 years was 4 (3.9%)
avoided in children) anti-inflammatory and between 11 to 20 years, it was 19 (18.6%) and
agent and vitamin-C. between 21 to 30 years 31 cases (30.4%) were
6. Conjunctival epithelium debridement from observed. 34 cases (33.3%) were encountered in
corneal surface the age group of 31 to 40 years which was the
7. Acetazolamide, anti-glaucoma drops in highest so far and 9 cases (8.9%) were in the age
cases of elevated IOP group of 41 to 50 years. In the group of 51 to 60
8. Glass rod passed in the fornix in suspected years of age, 5 cases (4.9%) of chemical injuries
cases of development of symblepharon of eye were found.
For G-III, IV non-healing injuries, following extra In total 143 eyes were involved in the 102 cases
measures were taken, as per the suitability of the taken into account; out of which 61 cases (59.8%)
case had unilateral and 41 cases (40.2%) had bilateral
1. Bandage soft contact lens involvement of eyes.
2. Patching of the eye, tarsorrhaphy, Amniotic Table 5 shows the following observations:
membrane graft 1. Out of 26 eyes having the grade – 1 injury,
3. Systemic ascorbate the pre-treatment VA was 6/6 in 4 eyes
4. Tenonplasty (15.3%) and 6/9 in 22 eyes (84.7%). After
5. Autohemotherapy, subconjunctival injection receiving treatment, the best corrected VA
of 0.5 cc of the patient’s own blood was given became 6/6 in all 26 cases. The success rate
and repeated every alternate day as necessary in visual improvement was 100%.
All the patients were followed up for a variable 2. Out of 51 eyes having grade-2 injury, the
period of time extending from 1 week to 6 initial VA was 6/9 in18 eyes (35.2%) 6/12 or
months, according to the grade of injury. In each 6/18 in 24 eyes (47.05%) and in rest 9 eyes
follow up visit ocular condition was thoroughly (17.6%) VA was better than 6/60 but worse
examined and distant visual acuity was recorded. than 6/18. The best corrected VA after
Long-term follow up for glaucoma, dry eye done. treatment was 6/6 in 44 eyes. Success rate

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was 86.2% Rest 7 eyes (13.8%) improved to in 7 eyes (14.58%) best corrected VA
6/9 – 6/12. improved to better than 1/60.
3. Total No of eyes with grade-3 injury were 48. 4. Out of 18 eyes with grade – 4 injury, the VA
Out of this, initial VA was better than 6/60 before treatment was HM in 12 eyes
but worse than 6/18 in 14 eyes (29.16%), (66.67%) and perception of light in 6 eyes
better than 1/60 but worse than 6/60 in 31 (33.33%). After treatment the best corrected
eyes(64.5%) and HM only was present in 3 VA was CF in 3 eyes (16.67%) HM in 3 eyes
eyes (6.25%).After treatment, the best (16.67) and PL in 9 eyes (50%). In 3 eyes,
corrected VA was improved to 6/18 or better there was perforation followed by infection
in 29 eyes (60.4%). In 12 eyes (25%) which was finally eviscerated.
corrected VA improved to 6/60 or better and

Table 1: Roper Hall (Modified Hughes) Grading of Ocular Chemical Injuries.5,6

GRADE CORNEA LIMBAL ISCHEMIA PROGNOSIS
I EPITHELIAL DAMAGE NIL EXCELLENT
II HAZE, IRIS DETAILS VISIBLE <1/3 GOOD
III TOTAL LOSS OF EPITHELIUM, STROMAL 1/3 - 1/2 GUARDED
HAZE, IRIS DETAILS OBSCURED
IV OPAQUE, IRIS AND PUPIL OBSCURED >1/2 POOR

Table 2: Incidence Of Chemical Injury In Relation To Total Number Of Ocular Trauma

TOTAL NO OF OCULAR TRAUMA TOTAL NO OF CHEMICAL INJURY PERCENTAGE
782 102 13.04%

Table 3: Chemical Injury in different age group:

AGE NUMBER OF PATIENTS PERCENTAGE
0-10 4 3.9
11-20 19 18.6
21-30 31 30.4
31-40 34 33.3
41-50 9 8.9
51-60 5 4.9

Table 4: Severity of chemical injuries:

GRADE NO OF EYES PERCENTAGE
I 26 18.1
II 51 35.6
III 48 33.5
IV 18 12.6

Table 5: Visual outcome in relation to grades of injury

GRADE OF TOTAL NO VISUAL ACUITY NO. OF PRETREATMENT NO. OF POSTTREATMENT
INJURY OF EYES EYES (%) EYES (%)
6/6 4(15.3) 26(100)
I 26
6/9 22(84.7) -
6/6 -- 44(86.2)
6/9 18(35.2) 7(13.8)
II 51
6/12 or 6/18 24(47.05)
>6/60 and <6/18 9(17.6)
6/18 or BETTER -- 29(60.4)
>6/60 and <6/18 14(29.16) 12(25)
III 48
>1/60 and <6/60 31(64.5) 7(14.58)
HM 3(6.25) --
CF -- 3(16.67)
IV 18 HM 12(66.67) 3(16.67)
PL 6(33.3) 9(50)

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Table 6: Complications
COMPLICATIONS NO OF CASES PERCENTAGE
CORNEAL SCARRING 54 37.76
DRY EYE 46 32.16
LID DIFORMITY 23 16
SYMBLEPHARON 9 6.29
GLAUCOMA 42 29.3
CATARACT 16 11.1
PERFORATION 3 2.09

Discussion The lowest incidence of 3.9% was encountered in

The present study was conducted in the Dept. of the age group below 10 years. Higher percentage
Ophthalmology, between 1st January 2017 to 31st of chemical injury was observed in the age group
December 2019.Out of the total 782 cases of of 31 to 40 years (33.3%) and 21 to 30 years
ocular trauma attending the OPD and casualty, (30.4%).This is due to the fact that, people of this
102 cases of chemical injury of the eye were age group are the main working member of the
accounted. All the cases were studied in detail and society. P.Singh et al4 (2013) also studied and
they were graded according to Modified Hughes found that the chemical injury patients are mostly
grading system. The best possible and available found in age group between 20 to 40yrs.
conservative methods of treatments was given to Aleksandra Radosavljevic et al13 (2013) also
every case depending upon the severity of injury. reported that in between 21-40years ocular
All the cases were followed up for a maximum chemical injury constituted of 48.5%.
period of 6 months. In our study, 72 cases (70.59%) of chemical injury
The incidence of chemical injury in relation to the were caused by alkalis and 19 cases (18.6%) by
total number of ocular traumas during the study acids and rest 11 cases (10.8%) were caused by
period was 13.04%.The incidence of chemical other agents. Aleksandra Radosavljevic et al13
injury; reported by Verson SA et al7 (1983) was (2013) found in his study that 73% were affected
7% to the total number of ocular trauma. Study by by alkali chemical injury and only 18.2% affected
Jones N.P et al8 (1986), reported the incidence of by acids, which is simillar.
9.9% of all ocular trauma. But Karaman et al9 Out of 102 cases, unilateral involvement of either
(2004) and Ho.C.K.Yen et al10 (2007) reported the right or left eye was found in 61 cases (59.8%)
incidence of 13.6% and 19.6% of all ocular whereas bilateral involvement was in 41 cases
trauma respectively. Chemical injury cases (40.2%). Aleksandra Radosavljevic et al13 (2013)
increase due to vast use of chemicals in many reported in his study that unilateral cases are more
fields, industries and day to day works. In the that of 63.5% than the bilateral of 36.5%.
present study, the incidence of chemical injury Out of 143 eyes of 102 cases, 26 cases (18.1%)
was 11.2% of all ocular trauma, which seems to were of grade-1 and 51 cases (35.6%) were in
be higher in comparison to the 1983 and 1986 grade -2 injury. Grade -3 injury was found in 48
studies, similar to 2004 but less than 2007 study. cases (33.5%) and grade – 4 injury in 18 cases
Higher incidence of chemical injury was found in (12.60%). Aleksandra Radosavljevic et al13 (2013)
male (73.5%) than female (26.5%).Marijamatovic found in his study and concluded that Grade-1
et al 11 (2014) found that males were more often chemical injury constituted of only 4, Grade-2 of
reported with injures than females (66.37% vs. 31.1%, Grade-3 of 42.6% and Grade-4 of 18.3%
33.63%). Subrat das et al 12 (2015) found that male (in 4% no data available). It is concluded that
to female ratio was 1.7:1. Preponderance of male Grade-2 and Grade-3 ocular chemical injuries
to chemical injury is more because of their more constituted most cases. (Table 4)
exposure to industrial works, agricultural fields Nimmymerin Mathew et al14 (2017) in a study
and other outdoor activities found among the 34eyes with chemical injury on

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JMSCR Vol||07||Issue||06||Page 807-812||June 2019
review after 2 months, 30 eyes had best corrected 5. Hughes, W., Alkali burns of the eye. I.
visual acuity improved to 6/6 - 6/18 (88.2%). Still, Review of the literature and summary of
3 eyes (8.8%) had their visual acuity in the range present knowledge. Archives of
of 6/24 - 3/60 and one eye had visual acuity<3/60. ophthalmology, 1946. 35: p. 423.
During the course of treatment and follow up 6. Roper-Hall, M.J., Thermal and chemical
period, several cases were found to have some burns. Transactions of the
complication (Table 6). In 54 eyes (37.76%) there ophthalmological societies of the United
was corneal scarring. Dry eyes were found in 46 Kingdom, 1965. 85: p. 631-53.
eyes (32.16%), most of which were due to either 7. Verson SA; Analysis of all new cases seen
severe scarring of cornea or due to lid deformity. in a busy regional center ophthalmic
The lid deformity of various types was found in casualty department during a 24 week
23 eyes (16%). Symblepharon was seen in 9 eyes period. J.R .Soc. Med, 1983; 76:273-282.
(6.29%). Glaucoma developed in 42 (29.3%) eyes. 8. Jones NP, Hayward JM, Khaw PT, Claoue
Cataract as a complication of chemical injury was CNP, Elkington AR; Function of an
found in 16 eyes (11.1%). In those eyes having ophthalmic accident and emergency
severe corneal scar, the detection of cataract was department; result of a six month survey;
not possible. In 3 eyes (2.09%) there was Br. Med. J. 1986; 292:188-190
perforation followed by infection which was 9. Karaman K, Gvoreovic .AntinicaA,
finally subjected to evisceration. Rogosia V, Lokos-KazetjV, RozgaA, S:
Epidemiology of adult eye injuries in
Conclusion Split-Dalmatia country,Croatia Med J
Chemical injuries of the eye, though constitutes a 2004;304-309.
small fraction of ocular trauma, but it needs early 10. Ho.C.K.Yen, Y.K.Chang, H.C.Shen,
attention to minimize complications.It can be Y.Y.Chang, P.Y: Epidemiologic study on
concluded that the majority of cases of chemical work related eye injury in Kaohsiung,
injury of eye are likely to be minor and in those, Taiwan, Kaohsiung J Med 2007
where significant injury has occurred, early and Sci23:463-469.
intensive management may secure a good 11. Marija Matovic, Katarina Janicijevic,
prognosis and minimize long term sequelae. Mirjana A. Janicijevic Petrovic PONS
Med Č 2015 / PONS Med J 2015;
References 12(2):64-67 [10].
1. Clare, G., et al., Amniotic membrane 12. Subrata Das, Md. Firoz Kabir, Joyabrata
transplantation for acute ocular burns. Das, Ahmed Abdul Hannan, Md. Wazed
Cochrane database of systematic reviews, Chowdhury, Saiem Mohd Nurul Anwar,
2012. 9: p. CD009379. Rajiv Mothey Chattagram Maa-O-Shishu
2. Burns FR, Paterson CA. Prompt irrigation Hospital Medical College Journal Volume
of chemical injuries may avert severe 13, Issue 1, January 2014
damage. Occup Hlth 1985; 58: 33-36 13. Aleksandra Radosavljevic, Tanja Kalezic,
3. Pfister RR. Chemical Injuries to the eye. Slobodon Golubovic, SrpArhCelok
Ophthalmology 1983; 90:1246- 1253 Lek,2013 Sept-Oct; 141:592-596.
4. Singh P, Tyagi M, Kumar Y, Gupta KK, 14. Nimmy Merin Mathew, Mallika. O.U.
Sharma PD. Ocular chemical injuries and JMSCRVol|| 05|| Issue|| 03|| Page 19379-
their management. Oman J Ophthalmol. 19383|| March 2017.
2013;6(2):83–86. doi:10.4103/0974-
620X.116624

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