Cuttack/Bhubaneswar/Chennai: A smiling face framed by a black dupatta looks up, startled at my visit. She walks slowly, navigating her way through the room as she welcomes me in. Rani lives with her family in Cuttack, a city in the east Indian state of Odisha. “Meet Saroj, my husband–and she is my mother,” she points at the other woman in the room.

Rani, (whose full name is Pramodini Roul, but she prefers Rani) is a 30-year-old who survived an acid attack on April 18, 2009–a day she remembers as clearly as if it happened yesterday. It happened in Kanakpur, her village, 40 km from Cuttack. When she was 16, a paramilitary soldier, visting an army camp near her school, would ‘eve-tease’, the colloquial term for sexual harassment in India. He claimed to have fallen in love with her.

“I told my family, and we explained to him in all possible ways that this is an unacceptable proposal, but he kept chasing and following me,” says Rani. That day, she was out walking with her cousin brother when the attacker came by on a bike and poured a bottle of acid on her head.

At first, she didn’t realise it was acid. She then felt her hair burn, and her skin peel off like liquid. “I fell on the road and cried for my life,” Rani tells me, as she shows me a picture of her without the head covering. For Rani, life as she knew it till then had ended. Today, she is blind in her right eye and has 18-20% vision in her left eye; it is a fight to hold on to that little window of sight.

“This is a battle that strips you and your family of everything,” says Rani.

The National Crime Records Bureau (NCRB) recorded 1,066 acid attacks in the five years from 2017 to 2021. Of these, over 60% of the attacks were on women, data from the NCRB show. Organisations, such as the Acid Survivors Trust International, say these numbers are underreported; the real number is likely to exceed 1,000 attacks a year. Around a third of the victims (31%) suffer complete or partial blindness, experts estimate.

Experts say India has a history of acid attacks being carried out as an extreme form of revenge, the intention being to humiliate and debilitate rather than to kill. In most cases, when thrown on a person’s face, acid speedily eats into the eyes, ears, nose and mouth. The pain is agonising. The healing of acid attack burns leaves thick scars and causes skin to tighten or turn leathery, which exposes victims to further deformity and makes them vulnerable to blindness. This is the story of Rani, and of other acid attack survivors like her who fight to regain their vision.

Rani sits with her husband, Saroj, at a park in Chennai. For four years, Rani, who went blind because of an acid attack, could not see her husband.

As Rani and I walked through Bhubaneswar's LV Prasad Eye Hospital, I saw water bubbles forming in one of her eyes. “Relax,” she laughs. “I see the world with eyes that release water bubbles.”

In 2009, Rani suffered 80% burns, leaving her blind and paralyzed. After five years, she overcame the paralysis. But for nine years she had no sight, and her eyes bulged out. After a cornea transplant in 2017 in her left eye, at Sankara Nethralaya in Chennai, she regained 18% of her vision.

For the last five years, she has been undergoing treatment at the Chennai hospital. With complete vision loss in the right eye, Rani can only see to a distance between three to five feet from her left eye. Every two months, she has to keep visiting Chennai, where Sankara Nethralaya offers cheap eye treatment to acid attack survivors.

On September 30, 2022, Rani’s right eye was removed because it had fully bulged out. She now waits for a new cosmetic eye.

On a cold February night, Rani [who is six-months pregnant], is preparing to travel with her husband to Chennai for cosmetic eye replacement surgery. They agree to let me join them.

As Saroj packs Rani’s luggage, I stand with her mother, Kavita, in the kitchen as she prepares dinner. Our conversation is about Rani.

“When acid was thrown on my daughter, her skin came off in the form of yellow liquid, and I collected it with these hands and filled it in a bucket,” she says, as she collects water from the kitchen tap mimicking what she had to do that day.

‘I wanted to see the world again’

For seven months, from April until November 2009, Rani was in the Intensive Care Unit (ICU). In August that year, she was in a coma for 24 hours, and when she emerged from it, she was paralysed. In the initial months, doctors battled to save her life but they could not protect her vision.

“Most of the girls who survive an acid attack live a compromised life,” Rani tells me, as she brings her phone close to her left eye to check her Instagram feed. “But I took a strong resolve. I wanted to see the world again.”

In 2016, armed with this resolve, she began her battle to regain her lost vision. In October that year, she went to Chennai for the first of many rounds of operations at Sankara Nethralaya. By then, she had completely lost her right eye. “I can never forget that time in my life,” Rani says.

“The doctor told us that we will have to wait till someone donates an eye for a transplant,” her mother adds. “He told us that we won’t know how long the wait would be–as short as two days, as long as two months, or maybe more. There was nothing to do but wait. I kept Rani in Chennai, in a hostel, where I slept on the floor.”

Dr Shweta S Agarwal, associate consultant (cornea) at Sankara Nethralaya, has been handling Rani’s case from the beginning. “Probably if we could have seen Rani in the early stages, we could have saved her right eye,” she tells me. “By the time Rani reached Chennai, she could not perceive light in the right eye because the eye pressures were very high and the nerve behind it had become completely dead. So nothing could be done there.”

The corneal transplant: Using stem cells to restore eye-sight

On October 9, 2017, Rani had a corneal transplant. The transplant of an eye damaged in an acid attack is a complex process. “Her left eye was also quite bad,” Dr Agarwal says. “But luckily her lids were fine, we were able to do a corneal transplant, take cells from the right eye and transplant them to help her see with the left eye.”

The stem cells surrounding the cornea help maintain its health. In patients with acid injury, these stem cells get damaged. Such patients therefore need a stem cell transplant. Rani’s right eye was non-functional, but a small part of it had somehow survived, uninjured. It was from this part that the doctors were able to take the stem cells and transplant it to the left.

Rani recalls gradually going under the anaesthetic, while various machines monitored her heartbeat, lung function etc. After the operation was over, and the dressing in place, the anaesthetist disconnected the machines and gradually restored her to consciousness.

“However,” says Dr Agarwal, “her graft [transplanted cornea] is slowly getting weaker as time passes, so there is a very high possibility that she is going to require another corneal transplant.”

Since Rani has no more undamaged stem cells in the right eye that can be transplanted she– like a lot of other sufferers from acid attacks–is going to require a donor, someone who has passed away and left behind documentation permitting organ harvest. Surgeons take stem cells from such dead donors and transplant them to the acid victim – and in such cases, the patient has to be on prolonged oral immunosuppressive drugs to prevent the body from rejecting the transplanted cells.

Dr Shweta Agarwal examining Rani at Sankara Nethralaya, Chennai, Tamil Nadu. For eight years of her life, Rani has been going for regular visits to the hospital to help her regain part of her vision.

“I really love travelling on an aeroplane,” says Rani, as we board the flight to Chennai from Bhubaneswar. She barely saw anything in the first couple of months after the corneal transplant. Even though the doctor assured her that she will gradually regain some vision, she says, “I used to wait every single day. On some days, I used to imagine how the world would actually look.”

She vividly recalls September 14, 2017. “I was on a flight when I suddenly saw some colours,” she says, her voice rising in recalled excitement. “I shouted out loud to my husband, and everybody around looked at me. We told everyone that I had just regained my vision, and everyone applauded.”

Rani and Saroj on the flight from Bhubaneswar to Chennai. “I really love travelling on an aeroplane,” says Rani, who lost her vision when she was attacked with acid in 2009.

The gift of sight came with a welcome bonus. She had never seen her husband before that day. “Saroj was the first person I saw with my new eyes,” she says.

“Can I have blue eyes?”

On a Thursday afternoon, Rani has an appointment with oculoplasty specialist Dr Kirthi Koka.

As we wait to enter Dr Koka’s cabin, Rani talks to me about her life before the attack.

She shows me the only pre-attack photo of hers that she has. She was 16 at the time. It is a passport-size photo with Rani staring into the camera with a poker face. “Kabhi kabhi zindagi mein kya ho jata hai na! Sab kuch original part nikal gaya, sab kuch.” [Sometimes we don’t know what happens in life. All original parts of my body have been taken out.]

Rani’s treatment will not increase the minimal vision she now has. “All this has to be done just to keep the eyes intact and to maintain whatever vision she has,” says Dr Agarwal. “She will never see more than this.”

Dr Koka arrives and Rani walks into the consulting room, dressed in a black salwar kameez with her bald head covered by a red dupatta. Dr Koka asks Rani to be seated for a quick eye check up.

“OK,” says Dr Koka. “We removed your right eye in September last year, right?”

“Yes, this side” said Rani, indicating her red, watery right eye.

Ocularist Prabhu designs Rani’s new cosmetic eye at Sankara Nethralaya, Chennai.

The doctor works her way round Rani’s right eye, matching it with the transplanted left eye. “Your left eye is doing fine, no?” she asks.

“Yes. You are putting a new artificial eye on the right side. My left eye is slightly blue so for the other side too…Maybe, can I have blue eyes?” Rani asks.

At the prosthetic clinic where Rani is taken to get her artificial eye prepared, she meets Prabhu, the ocularist who is to make her the “blue eye” she wants. As he takes the measurements and colours the eye in a bluish shade, he asks Rani, “Does it look blue enough?”

“Can it resemble my left eye a little more?” asks Rani.

“Yes, it will take some more time but we will get it right,” says the ocularist.

Understanding acid injuries to the human eye

Rani was attacked with concentrated sulphuric acid. In the “Encyclopedia of Toxicology”, sulphuric acid has been called a “dangerous dehydrating agent” that removes water from tissues. In the chapter titled ‘Ocular Toxicology’ it explains, “when concentrated sulphuric acid reacts with water in the tear film of the cornea, heat is released, causing both thermal and chemical burns to the eye. Very severe burns may cause complete opacification of the cornea or perforation of the globe with loss of significant ocular fluid. Complications include glaucoma and cataract formation.”

Simply put, and as the 2009 Law Commission Report submitted to the Supreme Court, said direct acid contact or acid vapours can damage eyes, causing blindness. “Thrown on a person's face, acid rapidly eats into eyes, ears, nose and mouth. Eyelids and lips may burn off completely. The nose may melt, closing the nostrils, and ears shrivel up.”

According to Dr Samir Mohapatra, consultant ophthalmologist at Bhubaneswar’s LV Prasad Eye Institute, acid can affect the eye from front to back. To begin with, he says, the patient might lose the eyelids. If the eye doesn't close because of exposure, the cornea starts melting. The skin of the cornea is lost, and the loss of this protective cover creates the possibility of infection. The entire eye can be lost in cases of acute injury.

In most cases, if it's an acid attack, it is usually a bilateral injury. “Very rarely do we find that one eye has got saved–probably, the position of the person at the time of the attack was such that, you know, one eye got lucky – but usually it's bilateral,” says Dr Mohapatra.

“If an immediate intervention is not done, there is a big possibility that the eye will develop a whole lot of perforation, and then we lose the eye if it is not managed at the appropriate time.”

According to him, even after a corneal transplant surgery, There are three possibilities that will lead to a failed transplant: suture-related infections, rejection and infection. The new cornea will get rejected and the eye pressures will spike. If the new cornea is accepted, the sutures in the eyes have to be removed, with regular follow ups, but there is a chance of infection.

Medical response to an acid attacked eye

Rani after her right eye was removed to replace it with a cosmetic eye at Sankara Nethralaya, Chennai. Rani now has a blue-coloured stone eye, and one eye with a transplanted cornea that can barely see a face five feet away.

“We didn’t know at first that it was acid,” Rani’s mother recalls. “So I picked Rani up in my hands as I saw her crying in severe pain. My skin also burned – see?” She points to scars on her right hand, and her waist. “We took her to the hospital, where she lay on a stretcher for the whole day. She kept crying.”

In most cases of acid attacks, delayed medical response becomes a significant reason for loss of vision. This is because, as Dr Mohapatra explains, “Our priority is always to first save the patient’s life. The rest comes much later.”

While saving the life of the patient is of prime importance, if she is admitted to a multi-speciality hospital, they can at least call an ophthalmologist and have the eye examined at the same time.

The problem is that, in many cases, if there is a lack of blood supply, then the key surgeries cannot be immediately performed. The bare minimum that can be done, Dr Agarwal explains, is to make sure that the eyes are closed. In that way, there is at least a certain extent of natural healing.

“We can save some part of the eye from getting completely damaged, but if the injury is so severe that they have lost the eyelid and the eye is not able to close, then they definitely will need some kind of an intervention,” she adds.

Psychosocial support

Rani and her husband, Saroj, wait for Dr Shweta Agarwal at Sankara Nethralaya, Chennai. It is no easy task for acid attack survivors to spend a large part of their lives waiting in hospital corridors or undergoing surgeries.

“As far as medical science is concerned, I don't think there is anything lacking in India, whether it is stem cell work, Keratoprosthesis [corneal transplant], or surgery,” says Dr Agarwal. “What we really need is funding and support from the government and NGOs, to take care of patients like Rani.”

Psychiatric counselling is also required, not just to psychologically motivate such patients but also to help them come to terms with the physical and cosmetic changes that have resulted from the attack.

This is key–while Rani managed to go through the arduous process of frequent trips to the hospital and multiple medical interventions thanks to her resolve, in most cases the survivors lose hope. It is no easy task, spending a large part of your life waiting in hospital corridors or undergoing surgeries. “If I calculate the total time I have spent waiting in hospital corridors, it would be too much to take,” Rani says of her seven-plus years to regain a semblance of normalcy.

On February 22, 2023, Rani’s damaged right eye was replaced with a cosmetic one. She now has two eyes – one, a blue-coloured stone eye, and the other with a transplanted cornea that can barely see a face five feet away.

As I reach my home in Delhi after the Chennai trip with Rani and her husband, I receive a text: “I have got a new blue eye. I have posted a picture. See how it looks.”

Rani saw a smartphone for the first time in 2016. She is now a known Instagram account, with a blue tick.

I log into my Instagram account and find this:

The photo on Instagram on the left, and the photo, showing the blue of Rani’s eye, on the right, that Rani shared with the writer.

“They are blue and you look beautiful,” I text back.

(This article was supported by Health Systems Transformation Platform as a part of the HSTP–Health Journalism Fellowship 2022.)

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