Clinical Characteristics and Visual Outcome

of Severe Ocular Chemical Injuries in

Shanghai
Jiaxu Hong, MD, Ting Qiu, MD, Angi Wei, MD, Xinghuai Sun, MD, PhD, Jianjiang Xu, MD, PhD

Objective: To study the clinical characteristics of patients with severe ocular chemical injury in Shanghai and
to determine their relationship with visual outcome.
Design: Retrospective case series.
Participants: A total of 79 525 in-patients at Shanghai Eye, Ear, Nose, and Throat Hospital between 1998
and 2008.
Methods: Medical records of severe ocular chemical injuries were reviewed retrospectively. Patients’ age,
gender, occupation, location where injury occurred, the nature of chemical agent, complication, and visual acuity
at final follow-up were described. The relationship between visual impairment and clinical characteristics was
analyzed.
Main Outcome Measures: Estimated prevalence rate, demographics of patients, nature of injury, progno-
sis, and factors associated with visual impairment.
Results: The estimated prevalence rate in Shanghai of severe ocular chemical injury was 1.58 per 100 000.
One hundred ninety cases with 239 eyes were identified for analyzing the clinical characteristics. The average age
of all subjects was 35.3⫾14.8 years with a male:female ratio of 6:1. Factory and construction worker (n ⫽ 141;
74.2% of total cases) were the most common occupations. Most of the accidents occurred at workplace (n ⫽
144; 74.8%); the majority of injuries were caused by alkali agents (n ⫽ 129; 67.9%). Complications were found
in 222 eyes (92.9%). A visual acuity of ⱖ6/60 was achieved only in 5 eyes (2.1%). In multivariate logistic
regression analysis, being visually impaired was significantly associated with the patients’ complication (P ⫽
0.021).
Conclusions: The prevalence of severe ocular chemical injury in Shanghai is low. Most subjects needed
surgery to restore visual function. Successful management provides a good prognosis for most patients.
Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials
discussed in this article. Ophthalmology 2010;117:2268 –2272 © 2010 by the American Academy of Ophthalmology.

Chemical burns are the second most common cause of burns
in China.1 Chemical injuries of the eye may produce exten-
sive damage to the ocular surface and anterior segment,
resulting in permanent unilateral or bilateral visual impair-
ment. Most victims are young, and in most large series
exposure occurs in industrial accidents, at home, and in
association with criminal assaults.2 According to a previous
retrospective case series, severe chemical injury of the eyes
accounts for a small but significant percentage of corneal
blindness in China.3 With the improvement of operative
techniques, the prognosis of ocular chemical injury has
improved considerably.4 – 6 Information on the nature of the
chemicals and the clinical presentation of eye injuries has
been reported for other countries.7,8 However, to the best of
our knowledge, few studies have been performed to deter-
mine the clinical characteristics and visual outcomes in
Chinese patients.
The Shanghai Eye, Ear, Nose, and Throat Hospital of
Fudan University, which was established in 1952 and is
among the most famous eye centers in China, was autho-
rized by the Health Ministry of China to execute a large-
scale study on ocular chemical injuries in Chinese. The
institute serves a population of ⬎13 million registered
Shanghai residents, and approximately 5 million migrant
workers from rural areas into Shanghai, and is a major
center for treating ocular burns in East China. Although
minor chemical burns may be treated in general casualty
clinics, severely injured patients in Shanghai usually came
to our unit.
We retrospectively analyzed the records of patients with
severe ocular chemical injury in Shanghai from 1998 to
2008 to summarize the clinical characteristics and explore
their relationship with visual outcome.
Methods
We reviewed the medical records of patients in our unit from 1998
to 2008. The Medical Ethics Committee of Shanghai Eye, Ear,
Nose, and Throat Hospital approved the study protocol.
Severe ocular chemical injury was defined as any person sus-
taining an injury with9 total loss of the corneal epithelium, corneal
haziness obscuring iris detail or worse, and over 120° of limbal
ischemia. These findings equate to grades 3 or 4 on the Hughes–
Roper–Hall classification scale. All patients included in the study

2268 © 2010 by the American Academy of Ophthalmology ISSN 0161-6420/10/$–see front matter
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 Hong et al 䡠 Clinical Characteristics and Visual Outcome in SOCIS

Table 1. Prevalence of Severe Ocular Chemical Injuries in Patient Demographics

Shanghai (n ⫽ 190)
A total of 239 eyes of 190 patients were enrolled in the study,
Agent Patients including 49 patients suffering bilateral injuries. The demograph-
ics of these subjects are shown in Table 1. Apart from 28 females,
Age (yrs) 35.3⫾14.8 the rest of the patients were all male, with a gender ratio of 6 males
Male, n (%) 162 (85.3) to 1 female. The average age was 35.3⫾14.8 years. The majority
Occupation
of the patients were factory workers (n ⫽ 80; 42.1%), followed by
Factory 80
Construction 61
construction workers (n ⫽ 61; 32.1%). The injury occurred during
Peasant 35 paid employment in 144 cases (75.8%), followed by being at home
Laboratory 8 in 38 cases (20%), and during another activity in 8 cases (4.2%).
Commercial 6 None of the patients was wearing goggles at the time of injury.
Location where injury occurred
Workplace 144
Home 38
Nature of the Injury
Playground 8 A wide range of chemicals was involved in these injuries. The
causative chemical was reported as alkaline in 129 (68%), acidic in 36
had treatment initiated within 6 hours of injury. Briefly, they all (19%), organic in 18 (9%), and unknown in 7 (3%) cases (Table 2).
received immediate irrigation at the time of injury, and they were
treated with a short course of topical steroids, cycloplegics, and Prognosis of Severe Ocular Chemical Injury
prophylactic antibiotics (approximately 7 days). For those patients
with indications, operations were performed to revascularize the Complications are summarized in Table 3. Central corneal opacity
limbus, restore the limbal cell population, or reestablish the forni- or perforation was the most frequent problem in 61.5%. The
ces, including amniotic membrane transplantation, division of best-corrected visual acuity in the affected eye at final follow-up is
symblepharon, correction of eyelid deformities, keratoplasty, and also shown in Table 3. Only 5 eyes (2.1%) recovered to a visual
limbal stem transplantation. acuity ⬎6/60. Two hundred twenty-one eyes (92.5%) were con-
Data were limited to the clinical course ⬎1 month to achieve sidered to be visually impaired. The visual acuity of 10 eyes was
relatively stable results of the visual outcome. For these patients, not obtained because patients were not cooperative.
their information was analyzed including age, gender, occupation,
location where injury occurred, the nature of the chemicals in-
volved, complications over the course of follow-up, and visual Multivariate Logistic Regression Analysis for
acuity at the final follow-up examination. An eye was considered Potential Factors Associated with Visual
to be visually impaired if best-corrected distance visual acuity was Impairment
⬍6/60.
Statistical analysis was performed using a statistical software The only variable related to being visually impaired was compli-
package (SPSS for Windows, version 13.0; SPSS, Inc., Chicago, cations (Table 4; P ⫽ 0.021). The presence of visual impairment
IL). Normal distribution data are shown as mean values ⫾ standard was not significantly associated with the patient’s age (P ⫽ 0.372),
deviations; all other data are presented as medians and interval gender (P ⫽ 0.348), location where injury occurred (P ⫽ 0.703),
quartile ranges. All variables were entered into a binary logistic or cause of injury (P ⫽ 0.267). Its association with occupation was
regression analysis, one at a time, and those variables with a marginally significant (P ⫽ 0.067).
probability of ⱕ0.2 for relationship with visual impairment were
entered into multivariate logistic regression analysis. The follow-
Table 2. Nature of Injury (n ⫽ 190)
ing variables were analyzed: age, gender, occupation, location
where injury occurred, cause of injury and complications. All P Agent Patients
values were 2-sided and were considered significant when the
values were ⬍0.05. Alkali agents 129 (67.9%)
Lime 57
Sodium hydroxide/NaOH 44
Potassium hydroxide/KOH 16
Results Ammonium hydroxide/NH4OH 8
Aluminium hydroxide/Al(OH)3 4
Shanghai Prevalence Rate of Severe Chemical Plural acid 36 (18.9%)
Corneal Injury Sulfuric acid 12
Hydrochloric acid 10
During the study period, the Shanghai Ocular Chemical Injury Battery acid 5
Study (SOCIS) used a reporting base of approximately 79 525 Nitric acid 3
medical records. From 1998 to 2008 inclusive, the SOCIS received Acetic acid 3
357 reports of patients with ocular chemical injury. Of these, 72 Formic acid 2
did not meet the inclusion criteria, and 95 injured ⬍1 month before Hydrofluoric acid 1
the end of the collection period. Therefore, there were 190 patients Organic chemicals 18 (9.5%)
who were suitable for multivariate logistic regression analysis for Acetone 5
Ethanol 4
potential factors associated with visual impairment. The current
Formaldehyde 4
population in Shanghai is estimated to be approximately 18 mil-
Benzene 3
lion. The reported prevalence rate of severe ocular chemical injury Ethyl cyanoacrylate 2
was therefore estimated to be 285 per 18 million or 1.58 per History not recorded 7 (3.7%)
100 000.

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 Ophthalmology Volume 117, Number 12, December 2010

Table 3. Clinical Outcomes of Severe Ocular Chemical Injuries in Shanghai (n ⫽ 239 eyes)

Eyes Alkali Agents Plural Acid Organic Chemicals Others Total

Complication*
Elevated intraocular pressure 16 7 5 / 28
Corneal opacity or perforation 105 23 14 5 147
Pannus or symblepharon 32 6 5 1 44
Ectropion or entropion 54 3 2 / 59
Cataract 13 7 1 / 21
Retinal detachment 2 2 / / 4
Total 222 48 27 6 /
Visual acuity†
ⱖ6/12 3 0 1 1 5
6/15 to 6/36 8 3 0 2 13
6/60 to CF 49 15 4 1 69
HM 70 14 8 1 93
LP 25 8 7 1 41
NLP 4 4 0 0 8
Unknown 4 0 3 3 10
Total 163 44 23 9 239

CF ⫽ counting fingers at 1 meter; HM ⫽ hand movement at 1 meter; LP ⫽ light perception; NLP ⫽ no light
perception.
*Some patients had ⱖ2 complications.

Discussion parameters may sometimes change, they were at least rela-

Eye injury is a major cause of blindness in China.10 The
annual incidence of eye injury in Hong Kong is estimated to
be approximately 125 cases per 100 000 people.11 Although
ocular chemical injuries are considered to account for a
significant percentage of eye injury, little information is
available concerning the risk factors. Thus, determination of
these risk factors has important public health implications.
However, information about the epidemiology, clinical
characteristics, management for these chemicals, and prog-
nosis is not well enough established to address this issue.
Well-designed analytic studies might specify how much a
modifiable factor would contribute to injury reduction if
changed.
The present study clearly indicated that among the
79 525 patients seen in our unit between 1998 and 2008,
there was a prevalence of 285 severe ocular injuries. This
finding suggests that the Shanghai prevalence rate of severe
ocular chemical injury is at least 1.58 per 100 000, which is
low. One possible reason is that patients were enrolled only
when their clinical courses were ⬎1 month. This is because
not only the visual outcome but also the situation of ocular
surface in these patients was more likely to fluctuate if the
patients’ clinical history was ⬍1 month. Although these
Table 4. Multivariate Logistic Regression Analysis for Potential
Factors Associated with Visual Impairment
Parameter
Age
Gender
Occupation
Location
Cause of injury
Complications
tively stable after 1 month. Because this was a single-center
study, a degree of under-ascertainment is hard to avoid, and
selection bias of the patients may have occurred. However,
the SOCIS is generally well-supported by the government;
it was effective in recruiting almost all the severe injury
patients in Shanghai from 1998 to 2008.
The present study also describes the clinical characteris-
tics of 190 ocular chemical injuries in Shanghai where the
age distribution of the victims was 35.3⫾14.8 years. Most
victims were young men engaged in industrial or construc-
tion work, which is in agreement with previous reports12
Alkali agents are reported to be the most frequent causes of
ocular chemical injuries.13–15 This finding may be ascribed
to the rapidly increasing industrialization in Shanghai and
its surrounding cities. Previous studies about the epidemi-
ology of ocular chemical injury have usually focused on
corrosive substances, especially corrosive plural acid and
alkali agents. Epidemiologic data from the United Kingdom
have shown that severe chemical corneal injury is more
common in men (75% of cases), mainly of working age
(66.7%), with the injury most often occurring at work (50%)
or after an assault (33.3%); an alkaline substance is most
commonly implicated.9 In our study, organic chemicals
were also added to the list of agents associated with ocular
chemical injuries, which accounted for 9.5% of all subjects.
Most of these substances are neutral, which have little or no
reactivity with the ocular tissue.
Most patients in our study lacked education on the
P Value awareness of the dangerous properties of plural acid and
0.372 alkali agents and the correct methods of handling chemicals,
0.348 especially first aid measures. We found that none of these
0.067 patients was wearing any eye protection at the time of
0.703 injury, even though they believed that such protection was
0.267
required. Therefore, formal education, reinforcement, com-
0.021
pulsory use, and formal legislation should be enforced to

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 Hong et al 䡠 Clinical Characteristics and Visual Outcome in SOCIS
improve compliance in using protective devices. Mean-
while, safer working practices, hazard warnings and safety
advice on chemical product packaging are also crucial for
reducing the incidence of ocular chemical injury.
To date, there is little information available about the
prognosis of severe ocular chemical injury. In this study,
central corneal opacity or perforation was the most com-
monly seen complication, followed by ectropion or entro-
pion, pannus or symblepharon, and elevated intraocular
pressure. Operative procedures were still needed for most
patients to restore visual function, which included amniotic
membrane graft, limbal stem cell graft, oral mucosa graft,
and fornix reconstruction. Cataract and retinal attachment
were found in some patients, which have been rarely re-
ported by previous studies, indicating that a fundus exami-
nation is important in these patients. Furthermore, visual
outcome was a crucial component of prognosis. In our
study, only 5 eyes (2.1%) recovered to a visual acuity
⬎6/60 and 92.8% of injured eyes were considered to be
visually impaired. In contrast, a previous study from India
showed that only 30 eyes in 102 patients (145 eyes in total)
had a visual acuity of ⬍6/60 and 10% of these eyes became
blind.12 Variations in the reported visual impairment rate
may be due to their inclusion of patients with mild to
moderate injuries. It is known that the degree of severity of
injuries determined the ultimate visual prognosis.16
Finally, the relationship between presence of visual im-
pairment and clinical characteristics of 190 patients was
explored in the current study. Interestingly, the presence of
visual impairment only had a significant association with
complications caused by the chemical burn. This result
confirms previous studies that visual prognosis is better in
eyes with mild chemical burns.12,17 We also found that the
association between the patients’ occupation and visual
impairment was statistically marginal. This may be because
these patients were working in circumstances with high risk
and there was easy access to corrosive substances.
Several limitations of the present study should be noted.
Nonparticipation can be a major concern. Of these 190
subjects, we failed to obtain visual acuity in 10 subjects
(5.3%) of the participants. However, this may not have
influenced the conclusions of this study because this pro-
portion was very small. Another limitation is that the exact
cause of visual impairment was difficult to confirm. The
coexistence of several diseases causing blindness, such as
corneal opacity, cataracts, and retinal detachment in patients
with severe chemical burns is a common finding. Therefore,
it is difficult to discriminate the exact major cause of visual
impairment. In addition, the main parameter in this study
was not the cause of visual impairment but the risk factors.
A further limitation is that socioeconomic parameters such
as level of education were not assessed. The reason for this
limitation is that this information was not present in the
medical record. Finally, because we drew statistics from a
tertiary-level center’s data, selection bias was possible.
In summary, severe ocular chemical injury in the Shang-
hai area showed the following characteristics. Patients were
mainly young men engaged in industry or construction and
injury usually occurred at the workplace. The majority of
injuries were caused by alkali agents. Most of the injured
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eyes were visually impaired. The presence of visual impair-
ment was significantly associated with the patients’ occu-
pation and complications, but not with age, gender, location
of injury, or cause of injury in multivariate analysis. These
findings may be important because they suggest that the
government should establish a comprehensive education
program to prevent occupation-related ocular chemical
burns. Effective therapy managing complications could be
of paramount importance in improving the prognosis of the
injuries, thereby reducing ocular morbidity.
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 Ophthalmology Volume 117, Number 12, December 2010

Footnotes and Financial Disclosures

Originally received: November 3, 2009. Supported by grants from the Key Clinic Medicine Research Program, the
Final revision: March 18, 2010. Ministry of Health, China (2007–2009); Shanghai Excellent Leading
Accepted: March 23, 2010. Scholars Program, Science and Technology Commission of Shanghai
Available online: June 29, 2010. Manuscript no. 2009-1525. Municipality, Shanghai (10XD1401100); Outstanding Doctoral Research
Program Fudan University (2009 –2011). The sponsor or funding organi-
Department of Ophthalmology, Eye, Ear, Nose, and Throat Hospital, zation had no role in the design or conduct of this research.
School of Shanghai Medicine, Fudan University, 83 Fenyang Road, Shang-
Correspondence:
hai 200031, China.
Jianjiang Xu, Department of Ophthalmology, Eye, Ear, Nose and Throat
Financial Disclosure(s): Hospital, School of Shanghai Medicine, Fudan University, 83 Fenyang
The authors have no proprietary or commercial interest in any of the Road, Shanghai 200031, China. E-mail: jianjiangxu@126.com.
materials discussed in this article.

Errata

In a recent editorial (Ophthalmology 2010;117:1665-6), it was stated that:

“Healey et al10 report on the diagnostic accuracy of HRT II to detect OAG in the 10-year
follow-up examination of the Blue Mountains (Australia) Eye Study. Sensitivity and specificity
based on an abnormal Moorfields Regression Analysis (MRA) was reported to be 46% and 91%,
respectively.” The actual numbers in the paper are 64.1% for sensitivity and 85.7% for specificity.

With apologies from the authors, in the article entitled, “Absence of the Trochlear Nerve in Patients with
Superior Oblique Hypoplasia” (Ophthalmology 2010;117:2208 –13) the following sentences on page
2211 should have appeared as follows:
Our study used a 3-Tesla MRI system with much higher resolution than that in previous studies; the
section thickness was smaller than the diameter of the trochlear nerve, and success finally was achieved
in visualizing the trochlear nerve in 100% of the controls, including children, in whom the visualization
of the trochlear nerve is the most difficult to detect.
In conclusion, the trochlear nerve was not visualized, and therefore congenital superior oblique palsy
should be classified as a CCDD based on the MRI documentation of congenital aplasia of the trochlear
nerve.

2272

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