Paeds · ophthalmology
Ocular trauma and chemical injury
Also known as Chemical eye injury · Ocular chemical burn · Open globe injury · Globe rupture · Traumatic hyphema · Birmingham Eye Trauma Terminology · Ocular Trauma Score · Dua classification of ocular surface burns
Fellowship topic on paediatric ocular trauma and chemical injury: the two time-critical first-contact emergencies — chemical injury, irrigated first before examination, and suspected open globe, shielded and not pressed; the Birmingham Eye Trauma Terminology (BETT) separating closed globe (contusion, lamellar laceration, superficial foreign body) from open globe (rupture from blunt force, or laceration — penetrating versus perforating — with retained intraocular foreign body); the Ocular Trauma Score and its raw-score components; the alkali-versus-acid pathophysiology of liquefactive versus coagulative necrosis with hydrofluoric acid as the exception; the Dua classification graded by clock hours of limbal ischaemia and the Roper-Hall grades; the immediate irrigation protocol continued until pH 7.0 to 7.2; the recognise-shield-refer pathway for open globe; traumatic hyphaema and the place of aminocaproic acid; retained intraocular foreign body and sympathetic ophthalmia; and ANZ, UK and North American guidance.
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Target exams
Red flags
- A chemical splash to the eye is irrigated immediately and copiously with saline or Ringer lactate for at least 30 minutes — before any examination or pH check; do not let assessment delay irrigation, the single intervention that decides outcome
- A teardrop or peaked pupil, a shallow or flat anterior chamber, hyphema, prolapsed dark uveal tissue or vitreous, a 360-degree subconjunctival hemorrhage, or a soft eye with hypotony after trauma means a suspected open globe — protect with a rigid shield, do not press, give intravenous antibiotics and tetanus, and refer urgently for surgery
- Never press a suspected open globe, never apply a pressure patch or drops, and never measure intraocular pressure — each can extrude intraocular contents
- A hyphema that rebleeds on day two to five, a rise in intraocular pressure, corneal blood staining, or sickle cell disease in an at-risk child — each threatens the optic nerve and needs urgent ophthalmology
- An inconsistent history, a pre-mobile infant, or retinal hemorrhages without a plausible mechanism — consider non-accidental injury and the abusive-head-trauma pathway
Life stages
Care settings
Clinical exam formats
Board mappings
- General Paediatrics and Ophthalmology: chemical eye injury — irrigate first; open globe — shield, do not press, refer; corneal abrasion; hyphema
- Emergency care and injury prevention: eye protection, household chemical safety, and first aid for eye injuries in children
- Renewed curriculum — Emergency care and Ophthalmology: the BETT and Ocular Trauma Score classifications, the Dua chemical-burn grade, and the recognise-shield-refer pathway for open globe
- Ophthalmology: traumatic hyphema, retained intraocular foreign body, sympathetic ophthalmia and amblyopia surveillance
- General Paediatrics: first-contact management of the injured eye — immediate irrigation for chemical injury, a rigid shield for suspected open globe, and timely referral
- Emergency care: prioritising irrigation over assessment, recognising open-globe signs, and avoiding pressure on the globe
- Long Case / Structured discussion: a child with a severe chemical or open-globe injury — classification, resuscitation, definitive management, complications and prognosis
- Communication station: explaining the urgency of irrigation and the open-globe shield to a family, and the safety-net after discharge
- Level 2 / 3 — Ophthalmology and emergency care: recognition and immediate management of chemical eye injury and open globe, and child safety and injury prevention
- Safeguarding: considering non-accidental injury when the history of an ocular injury is inconsistent
- Foundation of Practice (FOP): the BETT classification, the open-globe signs, and the irrigation-first principle for chemical injury
- Applied Knowledge in Practice (AKP): the Dua and Roper-Hall classifications, the Ocular Trauma Score, and hyphema management including sickle cell
- History-taking and management: a child with an eye injury — mechanism, first aid, recognition of the open globe and the irrigation-first decision
- Communication: explaining the urgency of treatment and the safety-net to a family
- General Pediatrics Content Outline — ocular trauma and chemical injury: recognition, first aid, referral and complications
- Emergency Medicine and injury prevention: immediate irrigation, the open-globe shield, hyphema and retained foreign body
- Ophthalmology: BETT, Ocular Trauma Score, Dua classification and amblyopia surveillance
- Patient Care: recognition and immediate stepwise management of chemical eye injury and open globe across severity, with timely referral
- Systems-Based Practice: coordinated care with ophthalmology, anaesthesia and retrieval, and injury-prevention counselling
- Medical Knowledge: BETT and Ocular Trauma Score classification, alkali-versus-acid pathophysiology, the Dua grade and hyphema management
- Medical Expert: ocular trauma and chemical injury diagnosis, classification, immediate and definitive management, and complications
- Collaborator: multidisciplinary management with ophthalmology, anaesthesia and paediatric intensive care
- Health Advocate: injury prevention, eye protection and household chemical safety
The two first-contact pillars — irrigate or shield
Chemical injury — irrigate FIRST
Suspected open globe — SHIELD, do not press
Overview & Definition
Picture a seven-year-old who runs in from the kitchen clutching his eye after a dishwasher tablet burst, and a ten-year-old hit in the eye by a dart. Both are screaming, both eyes are firmly shut, and in both cases the temptation is to prise the lids apart and examine. That instinct is right for one and dangerous for the other — and telling them apart is the whole skill of paediatric ocular trauma. For the chemical splash, the first thing you do is irrigate, because every minute of retained alkali destroys limbal stem cells. For the dart, the first thing you do is shield, because pressing a full-thickness wound extrudes the contents of the eye. Everything else — the classification, score, surgery — follows from getting those two first moves right. [5] [8]
Ocular trauma means any mechanical, chemical or physical injury to the eye and its adnexa. In children it is common, it is frequently preventable, and it remains a leading cause of non-congenital unilateral blindness because the developing visual system is unforgiving: a scarred cornea, a deprived retina or a neglected injury all seed amblyopia as well as structural damage. [8] [10] The clinical task is layered. The first layer is first aid — irrigate the chemical injury, shield the open globe. The second layer is recognition — naming the injury in the standardised BETT language so that it is communicated the same way to the ophthalmologist. The third layer is prognosis and definitive care — the Ocular Trauma Score, the chemical-burn grade, and the surgical and follow-up pathway. [1] [3]
References12ShowHide
- [1]Kuhn F; Morris R; Witherspoon CD; Heimann K; Jeffers JB; Treister G A standardized classification of ocular trauma. Graefes Arch Clin Exp Ophthalmol, 1996.PMID 8738707
- [2]Pieramici DJ; Sternberg P Jr; Aaberg TM Sr; Bridges WZ Jr; Capone A Jr; Cardillo JA A system for classifying mechanical injuries of the eye (globe). The Ocular Trauma Classification Group. Am J Ophthalmol, 1997.PMID 9535627
- [3]Kuhn F; Maisiak R; Mann L; Mester V; Morris R; Witherspoon CD The Ocular Trauma Score (OTS). Ophthalmol Clin North Am, 2002.PMID 12229231
- [4]Dua HS; King AJ; Joseph A A new classification of ocular surface burns. Br J Ophthalmol, 2001.PMID 11673310
- [5]Wagoner MD Chemical injuries of the eye: current concepts in pathophysiology and therapy. Surv Ophthalmol, 1997.PMID 9104767
- [6]Gharaibeh A; Savage HI; Scherer RW; Goldberg MF; Lindsley K Medical interventions for traumatic hyphema. Cochrane Database Syst Rev, 2019.PMID 30640411
- [7]Bansal S; Gunasekeran DV; Ang B; Lee J; Khandelwal R; Sullivan P Controversies in the pathophysiology and management of hyphema. Surv Ophthalmol, 2016.PMID 26632664
- [8]Salvin JH Systematic approach to pediatric ocular trauma. Curr Opin Ophthalmol, 2007.PMID 17700228
- [9]Hoskin AK; Fliotsos MJ; Rousselot A; Ng SMS; Justin GA; Blanch R Globe and Adnexal Trauma Terminology Survey. JAMA Ophthalmol, 2022.PMID 35862061
- [10]Ashourizadeh H; Grinspan N; Lu ES; Armstrong GW A nationwide retrospective study of toy-related ocular injuries in children presenting to emergency departments in the United States. J AAPOS, 2026.PMID 42431578
- [11]Patek GC; Bates A; Gurnani B Ocular Burns. StatPearls, 2026.PMID 29083604
- [12]Rajarajan M; Bhambhani Chavda V; Murugesan V; Agarwal S Chemical Injuries Classification and Management - Current Perspectives. Semin Ophthalmol, 2026.PMID 40709370