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ORIGINAL ARTICLE
Year : 2022  |  Volume : 10  |  Issue : 1  |  Page : 15-18

Chemical injury with “packet of chunna” (lime) in children: A major ocular health concern in central rural India


Department of Pediatric Ophthalmology and Strabismus, Children Eye Care Center, Sadguru Netra Chikitsalya and Postgraduate Institute of Ophthalmology, Chitrakoot, Madhya Pradesh, India

Date of Submission16-Apr-2021
Date of Decision10-Aug-2021
Date of Acceptance21-Aug-2021
Date of Web Publication3-Feb-2022

Correspondence Address:
Pradhnya Sen
Department of Pediatric Ophthalmology and Strabismus, Children Eye Care Center, Sadguru Netra Chikitsalya and Postgraduate Institute of Ophthalmology, Jankikund, Chitrakoot, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcor.jcor_54_21

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  Abstract 


Purpose: The purpose of the study is to report the hazardous effect of chunna packet (lime) on ocular surface in terms of pattern of presentation and visual outcome in children. Materials and Methods: Children of age <16 years with definitive history of chemical injury with chunna packet were analyzed. Ocular chemical injury was graded according to Modified Roper Hall grading system. Best corrected visual acuity (BCVA) and anterior segment examination evaluation were compared at time of presentation and at 3 months and categorized on the basis of WHO visual disability classification. Likelihood ratio of BCVA with time of presentation and grade of injuries were calculated using Pearson's correlation coefficient. Results: Eighty eyes of 74 children with a history of ocular burns resulting from lime were included in the study. Of these, 6 patients had bilateral burns. Mean age at the time of injury was 8.44 ± 4.29 years. Many children presented late after 3 weeks of injury (n = 24, 32.4%). The most common grade of injury was Grade 4 (n = 31, 38.8%). Clinical presentations were corneal haze (55%), limbal ischemia (65%), lime particle in fornix (36.2%), corneal scar (33.7%), and symblepharon (22.5%). Surgical intervention was advised in 54 eyes (67.5%) in the form of amniotic membrane grafting, symblepharon release, limbal stem cell transplantation, and tectonic keratoplasty. Mean BCVA at presentation was 1.65 ± 0.99 and at 3 months was 1.39 ± 1.03. Conclusion: Grade of injury and time of presentation were strongly associated with visual outcome in cases of chemical injury with chunna packet.

Keywords: Chemical injury, chunna packet, Lime injury, ocular chemical burn


How to cite this article:
Sen P, Tripathi P, Mohan A, Agarwal K, Shah C, Parmar GS, Sen A. Chemical injury with “packet of chunna” (lime) in children: A major ocular health concern in central rural India. J Clin Ophthalmol Res 2022;10:15-8

How to cite this URL:
Sen P, Tripathi P, Mohan A, Agarwal K, Shah C, Parmar GS, Sen A. Chemical injury with “packet of chunna” (lime) in children: A major ocular health concern in central rural India. J Clin Ophthalmol Res [serial online] 2022 [cited 2022 May 27];10:15-8. Available from: https://www.jcor.in/text.asp?2022/10/1/15/337196



Ocular chemical injury is a type of ocular trauma which occurs when a chemical compound that is hazardous to ocular tissue falls into the eye. It is one of the common causes of preventable ocular morbidity.[1] The reported incidence of ocular chemical injuries in China was 8.5% among all burns related trauma.[2] The incidence in Indian subcontinent according to the study conducted in West Bengal was found to be 4.3% among close globe injuries.[3]

Alkali injuries are more commonly encountered because they are extensively used in various domestic purposes such as cleansing agents.[4] In our country especially in semi-urban and rural areas, alkali in the form of limewater is used extensively as whitewash for painting walls and ceilings. Lime is also available commonly in polythene packets and tubes which are mixed with tobacco and chewed by many people in rural region.[5] These packets are within the easy reach of playing children in houses.

Chemical injuries of the eye may produce extensive damage to the ocular surface epithelium, cornea, and anterior segment resulting in permanent unilateral or bilateral visual impairment. The prognosis depends upon number of factors starting from nature of agent, extent of injury, time of presentation following the injury, and time of initiation of treatment. Although there are literatures detailing chemical injuries in many regions in all age groups including occupational and domestic injuries, there is no report from rural population where addiction of tobacco chewing with chunna (lime) is very common.

The aim of this study was to report the hazardous effect of chunna packet on the ocular surface in terms of pattern of presentation and visual outcome in children with ocular chemical injury.


  Materials and Methods Top


This was a prospective, observational study, initiated after getting approval from institutional ethics committee and in accordance with tenets of the Declaration of Helsinki. All consecutive children of age <16 years presenting to children eye care center or emergency clinic of a tertiary eye hospital with ocular chemical injury during April 2017 to March 2018 were included in the study.

Ocular chemical injury was defined by parental report of recent eye injury from a chemical agent for which care was sought. Only those patients were analyzed in which offending agent was chunna packet with definite history of chemical agents fallen in the eyes. Informed consent to participate in study was taken in local language.

Proper history was taken from patients, and eye examination was conducted by senior ophthalmologist. Best corrected visual acuity (BCVA), intraocular pressure, anterior segment examination, and fundus evaluation were done at least at time of presentation and at 3 months. Visual acuity was measured using Snellen and other age appropriate charts and converted to logMAR for the purpose of statistical analysis. BCVA was categorized according to the WHO visual disability classification.

Slit lamp biomicroscopy was done for detailed examination of the anterior segment. Conjunctiva, limbus, corneal surface, anterior chamber, and iris were examined with diffuse illumination. Fluorescence staining was used to confirm any epithelial defect, and documentation was done using appropriate drawing. Ocular chemical injury was graded according to Modified Roper Hall grading system.[6] Slit lamp photograph was also taken for patients advised for surgical management.

Statistical methods

Being a longitudinal and prospective study, sample size calculation was not performed. All consecutive cases with lime injury were recruited in our study. Descriptive statistical analysis was used. Data were analyzed using SPSS software. Results on continuous measurements were presented in mean with standard deviation, and results on categorical measurements were represented in number and percentages. Likelihood ratio of BCVA with time of presentation and grade of injuries were calculated using Pearson's correlation coefficient.


  Results Top


Eighty eyes of 74 children with a history of ocular burns resulting from lime (chunna) injury were included. Of these, 6 patients had bilateral burns. Of the 74 patients, 45 were male and 29 were female with a ratio of 1.5:1. The mean age at time of injury was 8.44 ± 4.29 years (range: 2–16 years). The time interval between injury and presentation ranged from <24 h to >3 weeks. Only 18 (24.3%) patients presented within 24 h of trauma. Fifty (67.5%) patients sought treatment in the acute stage, i.e. within 3 weeks of injury and 24 patients (32.4%) in chronic stage. It was noted that 56 (75.6%) patients did not receive immediate irrigation at the time of injury.

Out of total eyes involved, 55 eyes with acute injury were classified according to Roper Hall grading system of acute ocular chemical injury. The ocular complications of chemical injuries are summarized in [Table 1]. A large proportion of the patients (n = 43, 53.8%) had severe ocular burn (Grades 3 and 4). Surgical intervention was advised in 54 eyes (67.5%) in the form of amniotic membrane grafting, symblepharon release, limbal stem cell transplantation, and tectonic keratoplasty.
Table 1: Clinical presentation and management in 80 eyes

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BCVA at presentation was possible for 62 affected eyes out of which 24 (30%) had vision of <1/60. In spite of adequate treatment after 3-month follow-up, 18.8% patients still had very low visual acuity of <1/60 [Table 2]. Mean BCVA at presentation was 1.65 ± 0.99 logMAR which marginally improved to 1.39 ± 1.03 after 3 months of treatment. Correlation between delay in time of presentation and vision at 3 months was statistically significant (χ2 (15) =18.33, P ≤ 0.02) [Table 3]. A strong association was observed between vision at 3 months and grade of injury at presentation with χ2 (15) =55.94, P ≤ 0.001 [Table 4].
Table 2: Best corrected visual acuity according to the World Health Organization classification at presentation and after treatment

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Table 3: Relation between time of presentation and final best corrected visual acuity

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Table 4: Relation between grade of injury and final best corrected visual acuity

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  Discussion Top


We included 74 pediatric patients with lime injury in a year of study period. Lime in the form of chunna (calcium hydroxide) is popularly consumed as an additive to chewing tobacco in India. These chunna in a polythene packet can burst even when squeezed lightly, resulting in a spill of alkali in the eyes causing severe chemical injury. Similar mode of injury was reported in a study by Vajpayee et al., in which lime in the form of chunna packets alone was responsible for 65.7% of total chemical injuries.[5]

Usually children and young adults are more prone for chemical injuries while playing and at work environment, respectively. Patil et al. showed that lime was a common agent causing chemical injury and children from 1 to 10 years were the most affected group.[7] Saini et al. noted that majority of patients of ocular chemical injury were between the age group of 21–30 years.[4] Haring et al. and Hong et al. also shared the similar findings.[8],[9] Although our study exclusively included pediatric cases, large number of children affected in a short period is alarming. This could be due to the lack of awareness about the harmful effect of the chemicals to eye in the community of this area. Moreover, chunna packets are easily accessible to children who are usually not accompanied by elders while playing.

Approximately two-thirds of all patients in our study were male. Similar findings were noted in studies by Patil et al., El-Mekawey et al, D'Souza et al, and Tschopp et al.[7],[10],[11],[12] These findings are presumably related to the high physical contact and aggressive nature of play among young boys.

A total of 46% patients presented to us late 1 week after trauma. According to the Roper Hall grading system for acute chemical injury,[6] we could classify 55 eyes out of which 53.8% were of severe Grades 3 and 4 injury. Vajpayee et al. and Patil et al. also noted severe nature of injuries in their cohort.[5],[7] However, in studies by Saini and Sharma and Tschopp et al., most of the injuries were of mild nature.[4],[12] The severity in our study could be attributed to the nature of lime (alkali) and delayed treatment. In other studies, where alkali was most common agent, similar findings regarding severity were found.

In our study, surgical intervention was advised in 54 eyes (67.5%) among which 50% patients were operated immediately to remove embedded lime particles along with amniotic membrane transplantation. Two patients presented with anterior staphyloma due to damage and thinning of cornea underwent tectonic keratoplasty. Similarly, in a study conducted by Agarwal et al. on ocular injury resulting from chunna packets, 68% of the patient underwent 1 or more surgeries in the form of symblepharon release, amniotic membrane grafting, allograft or autograft stem cell transplantation, and large diameter lamellar keratoplasty.[13]

After treatment, only marginal improvement in visual acuity was observed. This may be related to the severity of injury, which was further affected by delayed initial presentation. In a study by Saini and Sharma, 70.34% patients recovered to a visual acuity of 6/60 or more and ten eyes (6.90%) ended up as phthisis bulbi.[4] Similarly, in a study by Vajpayee et al., visual acuity at the final presentation was worse than 3/60 for 64.2% of patients.[5] On contrary, Blackburn et al. noted that most injuries were not sight threatening, as most cases presented with better than 0.30 logMAR vision.[14] These findings suggest that alkali burns had more devastating effect on ocular tissue resulted in poor visual outcomes.

The main limitation of our study is short duration of follow-up as it is possible that some patients might have experienced a subsequent improvement in their vision after surgical interventions.


  Conclusion Top


Our study highlights the perils of ocular chemical injury caused by lime in the form of chunna packets. Visual outcomes remained poor during the course of follow-up. Severe grade of chemical injury and delayed presentation to clinic were significantly associated with poor visual outcomes. The findings of present study highlight the need for primary prevention, education of community, and control measures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Singh P, Tyagi M, Kumar Y, Gupta KK, Sharma PD. Ocular chemical injuries and their management. Oman J Ophthalmol 2013;6:83-6.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Xie Y, Tan Y, Tang S. Epidemiology of 377 patients with chemical burns in Guangdong province. Burns 2004;30:569-72.  Back to cited text no. 2
    
3.
Sengupta P, Majumdar M, Gyatsho J. Epidemiology of ocular trauma cases presenting to a tertiary care hospital in a rural area in West Bengal, India over a period of 2 years. IOSR J Dent Med Sci 2016;15:92-7.  Back to cited text no. 3
    
4.
Saini JS, Sharma A. Ocular chemical burns – Clinical and demographic profile. Burns 1993;19:67-9.  Back to cited text no. 4
    
5.
Vajpayee RB, Shekhar H, Sharma N, Jhanji V. Demographic and clinical profile of ocular chemical injuries in the pediatric age group. Ophthalmology 2014;121:377-80.  Back to cited text no. 5
    
6.
Hall AH. Epidemiology of ocular chemical burn injuries. In: Schrage N, Burgher F, Blomet J, Bodson L, Gerard M, Hall A, et al., editors. Chemical Ocular Burns. Berlin, Germany: Springer-Verlag; 2011. p. 9-15.  Back to cited text no. 6
    
7.
Patil M, Ambarkar L. Epidemiological study of chemical and thermal ocular injuries at a rural hospital in eastern Maharashtra. Int J Biomed Res 2015;6:709.  Back to cited text no. 7
    
8.
Haring RS, Sheffield ID, Channa R, Canner JK, Schneider EB. Epidemiologic trends of chemical ocular burns in the United States. JAMA Ophthalmol 2016;134:1119-24.  Back to cited text no. 8
    
9.
Hong J, Qiu T, Wei A, Sun X, Xu J. Clinical characteristics and visual outcome of severe ocular chemical injuries in Shanghai. Ophthalmology 2010;117:2268-72.  Back to cited text no. 9
    
10.
El-Mekawey HE, Abu El Einen KG, Abdelmaboud M, Khafagy A, Eltahawy EM. Epidemiology of ocular emergencies in the Egyptian population: A five-year retrospective study. Clin Ophthalmol 2011;5:955-60.  Back to cited text no. 10
    
11.
D'Souza AL, Nelson NG, McKenzie LB. Pediatric burn injuries treated in US emergency departments between 1990 and 2006. Pediatrics 2009;124:1424-30.  Back to cited text no. 11
    
12.
Tschopp M, Krähenbühl P, Tappeiner C, Kupferschmidt H, Quarroz S, Goldblum D, et al. Incidence and causative agents of chemical eye injuries in Switzerland. Clin Toxicol (Phila) 2015;53:957-61.  Back to cited text no. 12
    
13.
Agarwal T, Vajpayee RB, Sharma N, Tandon R. Severe ocular injuries resulting from chunna packets. Ophthalmology 2006;113:960-1.  Back to cited text no. 13
    
14.
Blackburn J, Levitan EB, MacLennan PA, Owsley C, McGwin G Jr. The epidemiology of chemical eye injuries. Curr Eye Res 2012;37:787-93.  Back to cited text no. 14
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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