CASE SERIES

Graphite Pencils Caused Ocular Injury in Pediatric Patients:

A Case Series
Los lápices de grafito causaron daño ocular en pacientes
pediátricos: una serie de casos
Kamalul Khusus Khairil-Ridzwan1, Mohmad Zulhisham2, Tan Chew-Ean3, Hui Di Khor4, Shuaibah Abdul Ghani5,
Ismail Shatriah6
Received on: 12 November 2020; Accepted on: 18 May 2023; Published on: 13 July 2023

A b s t r ac t
Purpose: Graphite pencils rarely cause ocular injury. However, the available data is limited. We aimed to identify the demographic data, clinical
manifestations, presenting visual acuities and final visual outcomes in children with ocular injuries caused by graphite pencils.
Methods: A retrospective case series was conducted of children who had ocular trauma due to graphite pencils and were treated at Sabah
Women and Children Hospital, Malaysia, from May 2015 to April 2018. The information about age, gender, presenting visual acuity, site and
severity of injury, and treatment received were documented for each case. The final visual acuity at six-month post trauma was recorded.
Results: Eight boys were recruited. The mean age was 8.4 years, and ranged from 5 to 10 years old. All had unilateral ocular involvement. The
left eye was affected in 62.5% of the patients. The injuries occurred both at home and in schools, with equal distribution of closed and open
globe injuries. 75.0% had injuries that involved the conjunctival, corneal, and scleral tissues and the remaining 25.0% had injuries to the deeper
structures including the iris, lens and vitreous. A presenting visual acuity worse than 6/12 (20/40) was documented in 62.5% of the patients.
and 37.5% had a final visual acuity 6/12 (20/40) or worse, mainly due to corneal scars.
Conclusions: Injuries caused by graphite pencils mainly affected boys aged from five to 10 years. The majority of the boys had injuries to the
anterior segment structures, and 62.5% had final visual acuities of 6/9 (20/30) and better. These injuries are essentially preventable.
Keywords: Graphite Pencils, Ocular Injury, Pediatric Patients, Clinical Profile, Visual Outcome.

Resumen
Propósito: Los lápices de grafito rara vez causan lesiones oculares. Sin embargo, los datos disponibles son limitados. Nuestro objetivo fue
identificar los datos demográficos, las manifestaciones clínicas, la agudeza visual que presenta y los resultados visuales finales en niños con
lesiones oculares causadas por lápices de grafito.
Métodos: Se realizó una serie de casos retrospectiva de niños que tenían traumatismo ocular debido a lápices de grafito y fueron tratados
en el Hospital de Mujeres y Niños de Sabah, Malasia, de mayo de 2015 a abril de 2018. La información sobre edad, sexo, agudeza visual de
presentación, sitio y La gravedad de la lesión y el tratamiento recibido se documentaron para cada caso. Se registró la agudeza visual final a
los seis meses posteriores al trauma.
Resultados: Se reclutaron ocho niños.La edad media fue de 8.4 años y osciló entre 5 y 10 años.Todos tenían afectación ocular unilateral. El ojo
izquierdo se vio afectado en el 62.5% de los pacientes. Las lesiones ocurrieron tanto en el hogar como en las escuelas, con una distribución
equitativa de lesiones de globo cerrado y abierto. El 75.0% tenía lesiones que afectaban a los tejidos conjuntival, corneal y escleral y el 25.0%
restante tenía lesiones en las estructuras más profundas, como el iris, el cristalino y el vítreo. Se documentó una agudeza visual de presentación
peor que 6/12 (20/40) en el 62.5% de los pacientes y el 37.5% tenía una agudeza visual final de 6/12 (20/40) o peor, principalmente por cicatrices
corneales.
Conclusiones: Las lesiones causadas por los lápices de grafito afectaron principalmente a niños de cinco a 10 años. La mayoría de los niños
tenían lesiones en las estructuras del segmento anterior y el 62.5% tenía una agudeza visual final de 6/9 (20/30) y mejor. Estas lesiones son
esencialmente prevenibles.
Palabras clave: Lápices de grafito, Lesión ocular, Pacientes pediátricos, Perfil clínico, Resultado visual.
Revista Mexicana de Oftalmología (ENG) (2023): 10.5005/rmo-11013-0013

Introduction
Graphite pencils are the most common type of pencils used by
primary school children. The others include charcoal, colored and
mechanical pencils. Graphite pencils are made of a mixture of clay
and graphite. Charcoal pencils are made by putting compressed
charcoal (charcoal powder and gum). Colored pencils are oil or wax
based that contained varying portion of pigments and binders.
1,6
Department of Ophthalmology and Visual Science, School of
Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian,
Kelantan, Malaysia
2,3
Department of Ophthalmology and Visual Science, School of
Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian,
Kelantan; Department of Ophthalmology, Sabah Women and Children
Hospital, Likas, 88450 Kota Kinabalu, Sabah, Malaysia

2604-1731 / © 2023 Sociedad Mexicana de Oftalmología. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/
by-nc-nd/4.0/)
 Graphite Pencils Caused Ocular Injury in Children

Core diameter of pencils vary; these included a 2.0 mm in graphite
pencils, 4.5 mm in charcoal pencils (Staedtler) and 5.0 mm in color
pencils (Stabilo). Most pencils can be sharpened to a tip of 0.5-0.9
mm. On the other hand, mechanical pencils use a single lead, and
lead diameter varies from 0.3 mm, 0.5 mm, 0.7 mm and 1.0 mm.
Graphite pencil injury is a relatively uncommon ocular injury in
children. When graphite gets into the eyes, it is inert or may induce
a localized tissue reaction.1-3 There were few case reports describing
graphite pencil injuries that resulted in penetrating corneal laceration
wounds, stromal keratitis, retained intraocular foreign bodies,
recurrent iris cysts, traumatic cataracts, and endophthalmitis2-7.
Based on a PubMed search, there are limited reports on the
visual outcome after ocular injuries that are caused by graphite
pencils in pediatric patients. The aim of our study is to identify
the demographic data, clinical manifestations, presenting visual
acuities, and final visual outcomes in children who had ocular
injuries caused by graphite pencils and were treated in our
institution over a three-year period.
C a s e P r e s e n tat i o n
A noncomparative retrospective case series was performed to
review graphite ocular injuries on children aged less than 13 years
old who were treated at Sabah Women and Children Hospital, Likas,
Malaysia from May 2015 until April 2018. The patients were followed
up for at least six-month period after the presentation. This study
was conducted in accordance with the Declaration of Helsinki and
was approved for publication by the National Institutes of Health,
Ministry of Health, Malaysia.
Case 1
A 10-year old boy presented with injury to the left eye and
sustained a full thickness corneal laceration wound, iris and vitreous
prolapsed, hyphema and traumatic cataract. The presenting visual
acuity was hand movement in the injured eye. An urgent corneal
wound irrigation and primary suturing was performed under
general anesthesia. The patient was treated with subconjunctival
gentamicin 20mg at the end of the surgery, and was continued
with intravenous cloxacillin 250mg 6 hourly for one week,
guttae moxifloxacilin and subsequently was added with guttae
corticosteroids. Lens aspiration and intraocular lens implantation
was performed at one month after the injury. His final visual acuity
was 6/60 (20/200) due to a central corneal scar.
4
Department of Ophthalmology, Sabah Women and Children Hospital,
Likas, 88450 Kota Kinabalu, Sabah, Malaysia
5
Department of Ophthalmology, Sabah Women and Children Hospital,
Likas, 88450 Kota Kinabalu; Faculty of Medicine and Health Sciences,
Universiti Malaysia Sabah, 88400 Kota Kinabalu, Sabah, Malaysia
Corresponding Author: Ismail Shatriah, Department of
Ophthalmology and Visual Science, School of Medical Sciences,
Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia,
e-mail: shatriah@usm.my
How to cite this article: Khairil-Ridzwan KK, Zulhisham M, Chew-Ean T,
Khor H, Ghani SA, Shatriah I. Graphite pencils caused ocular
injury in pediatric patients: a case series. Rev Mex OftalMOl. (ENG)
2023;97(2):66–71.
Source of support: Nil
Conflict of interest: None
ceftazidime 2mg/0.1ml. The final visual acuity was 6/9 (20/30) with
a faint corneal scar.
Case 4
A 6-year old boy had injury to the left eye. The visual acuity was 6/9
(20/30) in the affected eye with sign of subconjunctival hemorrhage
in the temporal aspect. There were no other injuries observed. He
was treated with guttae chloramphenicol 0.5%. The final visual
acuity was 6/6 (20/20).
Case 5
An 8-year old boy presented with full thickness corneal laceration
wound. The presenting visual acuity was hand movement. An
urgent corneal suturing with intracameral moxifloxacin 0.5% was
performed. He was also treated with intravenous ciprofloxacin
200mg 12 hourly for one week, guttae moxifloxacin and
subsequently was added with guttae corticosteroids. The final
visual acuity was 6/18 (20/60) due to a dense central corneal scar
(Fig. 2). However, the patient defaulted follow-up.
Case 6
A 9-year old boy alleged injury to the right eye. The presenting
visual acuity was 6/12 (20/40). He sustained a partial thickness

Case 2
A 10-year old boy presented with injury to the right eye. The
presenting visual acuity was 6/60 pH 6/60 (20/200). He sustained a
full thickness paracentral corneal laceration wound with a prolapsed
iris. The patient underwent corneal wound suturing procedure
with intracameral injection of moxifloxacin 0.5%. He was treated
with intravenous ciprofloaxacin 200mg 12 hourly for one week and
guttae moxifloxacin. His final visual acuity was 6/12 (20/40) due to
astigmatism resulting from a corneal scar (Fig. 1).

Case 3
A 5-year old boy alleged injury to the left eye. His visual acuity
was 6/60 (20/200) in the affected eye. The patient sustained a full
thickness corneal laceration wound. He underwent corneal suturing
procedure with intravitreal injection of vancomycin 2mg/0.1ml and Fig. 1: Anterior segment photos showing paracentral corneal scars

Revista Mexicana de Oftalmología (ENG), Volume 97 Issue 2 (March–April 2023) 67

 Graphite Pencils Caused Ocular injury In Children
Fig. 2: Anterior segment photos showing paracentral corneal scars
Fig. 3: Anterior segment photos showing paracentral corneal scars
corneal laceration wound at paracentral location. The patient was
treated with guttae moxifloxacin, and subsequently started on
guttae corticosteroid. The final visual acuity was 6/6 (20/20) with a
paracentral corneal scar (Fig. 3).
Case 7
A 9-year old boy presented with a self-sealed partial thickness
corneal laceration wound. The presenting visual acuity was
6/12 (20/40). The patient was treated with guttae moxifloxacin.
Subsequently, guttae corticosteroid was added later. The final visual
acuity was 6/9 (20/30).
Case 8
A 10-year old boy sustained a partial thickness corneal laceration
wound with intracorneal foreign body. The presenting visual acuity
was 6/6 (20/20). He underwent corneal suturing procedure, removal
of foreign body and intracameral injection of moxifloxacin 0.5%
(Fig. 4). He was treated with combination of topical antibiotic and
corticosteroid during the post-operative period. The final visual
acuity was 6/6 (20/20) with a faint paracentral corneal scar.
68 Revista Mexicana de Oftalmología (ENG), Volume 97 Issue 2 (March–April 2023)
Fig. 4: Anterior segment photo showing a dense central scar at six
months after the injury
The above injuries were classified according to the Birmingham
Eye Trauma Terminology system8. The details for demographic data,
clinical manifestations, and visual outcomes at six months after the
injury are summarized in Table 1. Table 2 summarizes demographic
and clinical characteristics. Table  3 displays the visual acuity at
presentation and 6-months after trauma.
Discussion
Ocular injuries due to writing instruments have been described in
numerous published reports.1-7,9-11 However, these reports have
incorporated all types of writing instruments including graphite
pencils, mechanical pencils, colored pencils, and pen.9-11 Colored
pencil (44.4%) was reported as the leading cause, followed by pencil
injury (30.6%), pen (19.4%) and mechanical pencil (5.6%).9 Thus, we
conducted a hospital-based observation regarding ocular injuries
occurring in pediatric patients and focused on graphite pencils only.
We provide a more detailed data in over a three-year period, and
also highlight the final visual outcomes in our patients.
Our study found that boys are affected more than girls. Children
aged five years and older are most likely to incur graphite pencils
injury. Our observation is parallel to the previously published
reports.3,5,7,9,11 This can be explained by the fact that graphite pencils
are the most common type of pencils used by children attending
kindergartens and primary schools. However, Zhang et al. reported
an outcome that is contradictory to our finding.10 They reported
that four children who sustained graphite pencil injuries were aged
two to six years of age and that the majority were female (three
patients, 75%).10
Among our patients, the left eye (62.5%, 5 eyes) was affected
more frequently than the right eye. However, right eye injuries were
more common in other published data.3,7,9,10 The majority of our
patients had no eyewitness during the incident, and their injuries
occurred equally at home and in schools. We also documented one
case of self-inflicted injury and an assault case. Thus, it is important
to emphasize in children, parents and teachers regarding ocular
injuries can be caused by graphite pencils and to encourage
preventive measures both at home and in schools.
Seven patients (87.5%) in our study sustained injuries to
the anterior segment structures, including the conjunctival,
corneal, anterior chamber and iris structures. This is consistent
 Table 1:  Clinical profiles
Age Ocular
(Years)/ Presenting findings Treatment
Case Gender Visual acuity Site of Injury IOFB Imaging
Right Anterior Posterior
Eye Left Lye segments segments Surgical Medical Final findings Final visual acuity
1 10 / 6/9 Hand Left eye Full thickness corneal No fundus view Nil Skull Surgical repair Subconjunctival gentamicin Central 6/60
Male Movement laceration wound from B-scan X-ray of corneal (20 mg) once, IV cloxacillin cornea scar
9 to 3 o’clock, iris and ultrasonography laceration 250 mg 6 hourly for one week,
vitreous prolapsed, showed a flat wound guttae moxifloxacin 0.5% and
presence of hyphema retina gutt pred forte 1%
and traumatic cataract

2 10 / 6/60 6/6 Right eye Vertical line full thickness No fundus view Nil Skull Surgical repair Intracameral moxifloxacin Corneal scar 6/12
Male corneal laceration wound B-scan X-ray of corneal 0.5% once, IV ciprofloxacin
at 7 o’clock at paracentral ultrasonography laceration 200 mg 12 hourly for one
area, iris prolapse and showed a flat wound week, guttae moxifloxacin
corneal edema retina 0.5% and gutt pred forte 1%
3 5/ 6/9 6/60 Left eye Full thickness central Normal Nil Skull Surgical repair Intravitreal vancomycin Faint central 6/9
Male corneal laceration funduscopy X-ray of corneal 2mg/0.1mL and ceftazidime cornea scar
wound examination laceration 2mg/0.1mL once, IV covering
wound ciprofloxacin 200 mg visual axis
12 hourly, guttae moxifloxacin
0.5% and gutt pred forte 1%
4 6/ 6/6 6/9 Left eye Subconjunctival Normal Nil Not Not available guttae chloramphenicol 0.5% Clear cornea 6/6
Male hemorrhage on funduscopy done
temporal aspect examination
5 8/ 6/7.5 Hand move- Left eye Vertical full thickness Normal Nil Skull Surgical repair Intracameral moxifloxacin Paracentral 6/18
Male ment corneal laceration funduscopy X-ray of corneal 0.5% once, IV ciprofloxacin cornea scar Defaulted
wound examination laceration 200 mg 12 hourly for one follow up
wound week, guttae moxifloxacin
0.5% and gutt pred forte 1%
6 9/ 6/12 6/6 Right eye Partial thickness cornea Normal Nil Not Not available guttae moxifloxacin 0.5% and Paracentral 6/6
Graphite Pencils Caused Ocular Injury in Children

Male laceration wound at funduscopy done gutt pred forte 1% cornea scar
paracentral area with examination
stromal infiltration,
anterior chamber cells 2+
7 9/ 6/7.5 6/12 Left eye Self-sealed partial Normal Nil Not Not available guttae moxifloxacin 0.5% and Paracentral 6/9
Male thickness corneal funduscopy done gutt pred forte 1% cornea scar
laceration wound examination
8 10 / Male 6/6 6/6 Right eye Partial thickness corneal Normal Corneal Skull Surgical repair Intracameral moxifloxacin Paracentral 6/6
laceration wound with foreign X-ray of corneal 0.5% once, IV ciprofloxacin cornea scar
corneal foreign body body laceration 200 mg 12 hourly, guttae
in situ wound and moxifloxacin 0.5% and gutt
foreign body pred forte 1%
removal

Revista Mexicana de Oftalmología (ENG), Volume 97 Issue 2 (March–April 2023)

IOFB = intraocular foreign body, IV = Intravenous

69
 Graphite Pencils Caused Ocular injury In Children

Table 2:  Demographic and clinical characteristics Table 3:  Visual acuities of affected eye at presentation and six months
Frequency post trauma
Variables n (%) Visual acuities Visual acuities at six
Total number of patients 8 (100.0) on presentation month post-trauma
Variable n (%) n (%)
Total number of eyes 8 (100.0)
6/6 to 6/9 3 (37.5) 5 (62.5)
Gender
6/12 to 6/60 3 (37.5) 3 (37.5)
Male 8 (100.0)
Worse than 6/60
Female 0 (0.0)
Age of injury (years) Counting fingers 2 (25.0) 0 (0.0)
Hand Movement 0 (0.0) 0 (0.0)
0-5 1 (12.5) Perception of light 0 (0.0) 0 (0.0)
6-10 7 (87.5) No perception of 0 (0.0) 0 (0.0)
Witness light
Yes 3 (37.5)
No 5 (62.5) penetrating injuries. Magnetic resonance imaging (MRI) is an
Intention option for non-metallic foreign bodies.12 However, Tabatabaei et al.
Unintentional 6 (75.0) suggested that MRIs be reserved for selected cases only, especially
Intentional those where CT-scan is negative but intraocular foreign bodies are
strongly suspected.9
Self-inflicted 1 (12.5) More than half of our patients had final visual acuities of 6/9
Assault 1 (12.5)
(20/30) and better. Three patients (37.5%) had final visual acuities
Laterality of 6/12 (20/40) and worse because of central dense corneal scarring
Right eye 3 (37.5) that would likely have benefitted from penetrating keratoplasty
Left eye 5 (62.5) procedures. Good final visual outcomes were reported in previously
Place of occurrence published data.1-3,5,9,10 Nevertheless, Zhang et al. documented that
Home 4 (50.0)
the final visual acuity was poor in one of their patients who had a
Schools 4 (50.0) pencil injury along with endophthalmitis and rhegmatogenous
retinal detachment.10 Hamanaka et al. also reported a case in which
Type of injury
Closed globe a poor final visual outcome was due to endophthalmitis.7
In conclusion, boys aged five years and older are the group that
Contusion 1 (12.5)
is most affected by injuries caused by graphite pencils. The incidents
Lamellar laceration 3 (37.5)
occurred both at home and in schools. The majority of cases in our
Open globe
study had injuries to the anterior segment structures, and their
Laceration 4 (50.0) final visual acuities are promising. It is important to emphasize to
Rupture 0 (0.0) children, parents, and teachers the need for preventive measures,
Tissue involvement in ocular injury to avoid incidents in which graphite pencils cause ocular injury.
Single tissue
Conjunctiva 1 (12.5) Orcid
Cornea 5 (62.5)
Ismail Shatriah https://orcid.org/0000-0002-4753-4814
Mixed tissue 0 (0.0)
Conjunctiva and cornea
Cornea and sclera 0 (0.0) References
Cornea, anterior chamber and iris 1 (12.5) 1. Honda Y, Asayama K. Intraocular graphite pencil lead without
Cornea, anterior chamber, iris, lens and vitreous 1 (12.5) reaction. Am J Ophthalmol. 1985;99(4):494–5.
2. Philip SS, John D, John SS. Asymptomatic intracorneal graphite
with previously published reports. 3-6 We found no incidence of deposits following graphite pencil injury. Case Rep Ophthalmol Med.
2012;2012:720201.
intraocular graphite particles except for one case that presented
3. Amritanand A, John SS, Philip SS, John D, David S. Unusual case
with the particle embedded in the intrastromal layer of the cornea. of a graphite foreign body in the anterior chamber. Clin Pract.
In contrast to our findings, Zhang et  al. documented graphite 2011;1(3):e73.
particles were embedded in the ciliary body, vitreous and retina 4. Arıcı C, Arslan OŞ, Görgülü B, Yıldırım R, Onur U. Eye injuries from
of four of their patients.10 They decided to remove the foreign pencil lead: three cases. Turk J Ophthalmol. 2017;47(1):52–5.
bodies; even though graphite is inert, other components could 5. Han ER, Wee WR, Lee JH, Hyon JY. A case of retained graphite anterior
cause progressive damage to the ocular structures over a long chamber foreign body masquerading as stromal keratitis. Korean J
term period.10 Ophthalmol. 2011;25(2):128-31.
6. Bhattacharjee H, Das D. Recurrent iris cyst following pencil tip injury.
Five of our patients (62.5%) had undergone skull x-rays during
Indian J Med Res. 2013;137(6):1211.
their hospital admissions. We found that the skull x-ray was not 7. Hamanaka N, Ikeda T, Inokuchi N, Shirai S, Uchihori Y. A case of an
very helpful because they are difficult to interpret and lack of intraocular foreign body due to graphite pencil lead complicated by
precise details. Computed tomography (CT) scan was not the first endophthalmitis. Ophthalmic Surg Lasers. 1999;30(3):229–31.
option for imaging in our patients, because most of them (seven 8. Kuhn F, Morris F, Witherspoon CD, Mester V. The Birmingham Eye Trauma
patients, 87.5%) were found during presentation to have sustained Terminology system (BETT). J Fr Ophthalmol. 2004;27(2):206–10.

70 Revista Mexicana de Oftalmología (ENG), Volume 97 Issue 2 (March–April 2023)

 Graphite Pencils Caused Ocular Injury in Children

9. Tabatabaei SA, Soleimani M, Naderan M, Ahmadraji A, Rajabi MB,
Jafari H, et al. A survey of incidental ocular trauma by pencil and pen.
Int J Ophthalmol. 2018;11(10):1668-73.
10. Zhang T, Zhuang H, Wang K, Xu G. Clinical features and surgical
outcomes of posterior segment intraocular foreign bodies in children
in East China. J Ophthalmol. 2018;2018:5861043.
11. Kelly SP, Reeves GM. Penetrating eye injuries from writing
instruments. Clin Ophthalmol. 2012;6:41–4.
12. Moisseiev E, Last D, Goez D, Barak A, Mardor Y. Magnetic resonance
imaging and computed tomography for the detection and
characterization of nonmetallic intraocular foreign bodies. Retina
2015;35(1):82–94.

Revista Mexicana de Oftalmología (ENG), Volume 97 Issue 2 (March–April 2023) 71