Rett is chief of optometry for the Greater Boston VA Healthcare system, where he teaches students and residents of optometry.
Disclosures: Rett reports no relevant financial disclosures.
I was recently reading an article about hand sanitizer getting in children’s eyes.
It showed a drawing of a little boy reaching his hand up to a hand sanitizer dispenser, and you could easily imagine the liquid splashing off his hand, into his eyes. The article showed cases of two children’s damaged corneas; one case took weeks to heal.
We all know the proper thing to do in this situation is to irrigate immediately. But what if the presentation is more severe than we thought? What do we look for to elevate our index of suspicion? Let’s dig into hand sanitizer exposure to the eye in this era of COVID-19.
I decided to check out the ingredients list for all the hand sanitizers I could find. The brand used at my hospital has 70% ethyl alcohol in the gel and foam types. I asked around for coworkers’ personal bottles and found six different brands; all of the brands had either 63%, 70% or 80% ethyl alcohol concentrations. For comparison: During PRK, ethyl alcohol is placed on the cornea for about 15 to 25 seconds. The affected corneal epithelial cells are then devitalized and easily debrided from the corneal surface. The concentration of ethyl alcohol used in PRK? Twenty percent. The amount of alcohol in the typical hand sanitizer we use is roughly three to four times more concentrated than what is used to intentionally debride epithelium. It’s about double that of vodka (and smells stronger than vodka if you take a big sniff of either bottle). It’s not hard to imagine splashed hand sanitizer remaining on the ocular surface for 15 seconds.
When we as eye doctors are presented a case like this, it comes urgently, and we need to know what to look for upon examination. We know that bases (like ethyl alcohol) do more damage to the ocular surface than do acids. This is because acid triggers tissue coagulation, and the coagulation acts as a barrier to deeper penetrance. Bases are lipophilic and can move deeper into tissue. When the patient presents to our office, we know that we should start irrigation immediately, even before checking vision or any other tests.
We should ask what type of sanitizer it was, because the gel sanitizer will linger much longer on the surface and will take longer to irrigate (especially in the fornices). We should remove any contact lenses, because they can absorb any chemical and act as a pledget to slowly release the chemical on the ocular surface. After a long irrigation, we should check the pH of the surface several times and keep irrigating until we consistently get a pH of around 7.
Most patients will have epithelial irregularities, and many will have a large epithelial defect. But the most concerning finding is limbal ischemia. When documenting the findings of a chemical exposure to the eye, it’s vital to document whether you see limbal ischemia. Remember that the limbus is where the epithelial stem cells start their differentiation. If the base damages the limbus, then not only will the patient have a hard time re-epithelializing the defect, he’ll have a hard time re-epithelializing ever again. The presence of limbal ischemia (it essentially looks like white conjunctiva that you’d expect to be injected) should be documented in clock-hours; the more area that is ischemic signifies a more dire prognosis.
Ethyl alcohol to the eye is serious for anyone, but I’m struck by the risk to kids. The wall-mounted dispensers are eye-level for them. They might not complain right away for fear of being punished. Their complaints might be underestimated. As doctors we know what to look for and how serious to take an incident of hand sanitizer to the eye. But we can also do better in getting the word out to our patients and friends that this can be a very serious injury. When in doubt, give your eye doctor a shout.