Hand Sanitizer–Induced Ocular Injury: A COVID-19 Hazard in Children | Cornea | JAMA Ophthalmology | JAMA Network
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January 21, 2021

Hand Sanitizer–Induced Ocular Injury: A COVID-19 Hazard in Children

Author Affiliations
  • 1Grewal Eye Institute, Chandigarh, India
  • 2Advanced Pediatrics Centre, Postgraduate Institute of Medical Education, Research (PGIMER), Chandigarh, India
JAMA Ophthalmol. 2021;139(3):362-364. doi:10.1001/jamaophthalmol.2020.6351

Hand hygiene is central to the prevention of transmission of severe acute respiratory syndrome coronavirus 2. The current literature illustrates the potential threat to skin and mucosal surfaces, especially the eyes, with use of alcohol-based hand rubs (ABHRs).1 As frequent hand sanitization is promoted worldwide because of the coronavirus disease 2019 pandemic, there have been reports of adverse health events due to ingestion of hand sanitizer by children.2 We herein report 2 cases of toxic keratopathy in children after unintentional contact between ABHR and the eye, suggesting that increased awareness of this potential danger is needed. The Grewal Eye Institute Institutional Review Board approved the study, and parental consent was obtained in both cases.

Report of Cases

Case 1

A 4-year-old girl was brought by her parents with unintentional exposure of hand sanitizer to her right eye a day prior to examination. According to her parents, the child was attempting to use a sanitizer dispenser installed on a floor stand at a shop. On presentation, the child complained of severe photophobia. Her right eyelid was edematous. There was conjunctival chemosis and ischemia in the inferior quadrant (2.5-o’clock position) with a large epithelial defect in the central cornea sparing a 2-mm rim of peripheral corneal epithelium (Figure 1A and B). Copious irrigation with balanced salt solution was performed in the operating room. Oral and topical medications were then initiated, including eye drops with moxifloxacin, 0.5%, twice hourly; eye drops with betamethasone, 0.5%, 6 times a day; carboxy methyl cellulose, 1%, hourly; homatropine, 1%, 2 times a day; timolol, 0.5%, 2 times a day; eye drops of vitamin C, 10%, 4 times a day; doxycycline, 100 mg, once daily; and vitamin C, 250 mg, once a day. The corneal defect healed completely, and conjunctival ischemia resolved in 2 weeks.

Figure 1.  Anterior Segment Findings
Anterior Segment Findings

A, Snapshot of the right eye of a 4-year-old girl before irrigation depicting large epithelial defect sparing a rim of devitalized corneal epithelium. B, Photograph of the same eye after fluorescein staining, showing total epithelial defect. C, Slitlamp photograph of the right eye of a 5-year-old boy. D, Diffuse conjunctival congestion is seen with superficial punctate keratopathy in the inferior quadrant, which is clearly visible on fluorescein staining.

Case 2

A 5-year-old boy presented with a history of eye exposure to an ABHR 1 hour prior. On examination, the right eye had conjunctival congestion with superficial punctate keratopathy with positive fluorescein staining in the inferior quadrant of cornea (Figure 1C and D). There was no limbal or conjunctival ischemia. A thorough saline wash was performed followed by topical medications, including eye drops with moxifloxacin, 0.5%, 6 times a day; eye drops with loteprednol etabonate, 0.5%, 3 times a day; and eye drops with carboxy methyl cellulose, 1%, every 2 hours, with resolution of the ocular findings by day 5.

Discussion

Small children are at risk of severe ocular injury and possibly even blindness due to inadvertent ocular exposure to ABHRs. In most public places, the hand sanitizers are installed at a waist-level height of an adult but at eye level or above for a young child, as illustrated in Figure 2.

Figure 2.  Representative Illustration of a Child Using a Hand Sanitizer Dispenser
Representative Illustration of a Child Using a Hand Sanitizer Dispenser

Representative illustration of a child attempting to sanitize his hand through a foot-operated dispenser located above his eye level. In this position, apart from the aerosols, squirt of liquid can enter the eyes of the child, causing injury.

Alcohol-related corneal injuries have been reported in the literature.3-5 Although ethanol has a therapeutic role in ophthalmology for epithelial debridement in various ophthalmologic procedures, it is known to be highly toxic to corneal limbal stem cells and exerts an immediate cytotoxic effect on corneal epithelial cells.4,5 In their experimental study on human corneal limbal epithelial cells, Oh et al5 found that ethanol markedly decreased viability of cells in a concentration-dependent manner. For ABHRs, the US Food and Drug Administration recommends a concentration of 60% to 95% ethanol or isopropanol.6 The irritant in our case report was 70% ethyl alcohol, which led to total loss of corneal epithelium along with conjunctival ischemia in one case and localized epitheliopathy in the other. Toxic keratopathy following use of alcohol-containing antiseptics in 3 cases was described by Liu et al.3 All patients needed further surgery, including cataract surgery, penetrating keratoplasty, and lamellar keratoplasty.

In both children in our case report, there were no long-term sequelae, but it is not hard to imagine a situation where care is delayed, increasing the chance of long-term corneal and ocular surface complications. We recommend that children should always be assisted by an adult while using ABHRs. Hand washing with soap and water should be promoted as a safer first-line preventive measure. As nations gear up to open public places and schools, it is necessary to consider the hazards of hand sanitizers and take appropriate preventive measures.

The following measures can be taken to prevent such unintentional injuries in children:

  1. Promoting hand washing with soap and water over ABHRs, especially at home.

  2. Teaching and training children how to use hand sanitizers.

  3. Having separate dispensers at shops and malls for children, preferably at lower height (ie, below face level).

  4. Placing caution signs next to sanitizer dispensers.

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Article Information

Corresponding Author: Sonam Yangzes, MS, Grewal Eye Institute, Sector 9-C, Chandigarh 160009, India (sonamyangz@gmail.com).

Published Online: January 21, 2021. doi:10.1001/jamaophthalmol.2020.6351

Conflict of Interest Disclosures: None disclosed.

Additional Contributions: We thank the parents of the patients for granting permission to publish this information. We thank Parminder Singh, MSc (Grewal Eye Institute, Chandigarh, India), for image formatting and Shaurya Bajwa, MSc (Clinical Research, Grewal Eye Institute), for his contribution in data collection. Neither contributor was compensated.

References
1.
Maier  A, Ovesen  JL, Allen  CL,  et al.  Safety assessment for ethanol-based topical antiseptic use by health care workers: evaluation of developmental toxicity potential.   Regul Toxicol Pharmacol. 2015;73(1):248-264. doi:10.1016/j.yrtph.2015.07.015PubMedGoogle ScholarCrossref
2.
Yip  L, Bixler  D, Brooks  DE,  et al.  Serious adverse health events, including death, associated with ingesting alcohol-based hand sanitizers containing methanol—Arizona and New Mexico, May-June 2020.   MMWR Morb Mortal Wkly Rep. 2020;69(32):1070-1073. doi:10.15585/mmwr.mm6932e1PubMedGoogle ScholarCrossref
3.
Liu  HY, Yeh  PT, Kuo  KT, Huang  JY, Lin  CP, Hou  YC.  Toxic keratopathy following the use of alcohol-containing antiseptics in nonocular surgery.   JAMA Ophthalmol. 2016;134(4):449-452. doi:10.1001/jamaophthalmol.2016.0001PubMedGoogle ScholarCrossref
4.
Chen  CC, Chang  JH, Lee  JB, Javier  J, Azar  DT.  Human corneal epithelial cell viability and morphology after dilute alcohol exposure.   Invest Ophthalmol Vis Sci. 2002;43(8):2593-2602.PubMedGoogle Scholar
5.
Oh  JY, Yu  JM, Ko  JH.  Analysis of ethanol effects on corneal epithelium.   Invest Ophthalmol Vis Sci. 2013;54(6):3852-3856. doi:10.1167/iovs.13-11717PubMedGoogle ScholarCrossref
6.
Boyce  JM, Pittet  D; Healthcare Infection Control Practices Advisory Committee; HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force; Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America.  Guideline for hand hygiene in health-care settings. recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.   MMWR Recomm Rep. 2002;51(RR-16):1-45. doi:10.1086/503164PubMedGoogle Scholar
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