Increased Hand Sanitizer Use Poses Risks to Children's Eyes

New research¹ published in JAMA Ophthalmology highlights the unintended consequence of increased hand sanitizer use among children during the coronavirus disease 2019 (COVID-19) pandemic: a greater potential for ocular injuries.

“Regular hand disinfection with alcohol-based hand sanitizer (ABHS) is one of the main barrier gestures to limit the spread of COVID-19,” researchers wrote. But widespread use of ABHS has been associated with an anecdotal increase in unintentional exposures in children since the pandemic’s onset.

“Chemical injuries vary in severity from mild and self-limited to severe and vision-threatening or even globe-threatening,” Kathryn Colby, MD, PhD, wrote in an accompanying commentary.² “The specter of amblyopia looms over even mild injuries in very young children. Recent work suggests that posterior segment inflammation can accompany ocular surface chemical injuries, further compounding the threat to visual acuity.”

For those exposed to chemical irritants, early diagnosis and treatment are paramount because they can reduce the long-term sequelae of chemical eye injuries.

In an effort to quantify the trend of pediatric eye exposures to ABHS during the pandemic and uncover the severity of the ocular lesions, the researchers conducted a national retrospective review of French Poison Control Centers (PCCs) between April 1, 2020, and August 24, 2020. They compared cases of ocular exposure to chemical agents in children younger than 18 documented in the French National Database of Poisonings during the 5-month timeframe in 2020 and 2019.

In a subsequent case series analysis, they evaluated electronic medical records of children younger than 18 who consulted the emergency department of a referral center in pediatric ophthalmology for exposure to a chemical agent within the 2 windows.

“Using 2 complementary data sets, we showed a 7-fold increase in the number of ABHS eye exposures in children with several cases of serious corneal lesions,” the authors wrote.

An analysis of national epidemiologic data revealed:

• The proportion of calls to PCCs associated with chemical eye splatter in children was significantly lower compared with the same period in 2019: 2336 cases (2.2% of pediatric calls) in 2020 vs 2553 cases (4.2% of pediatric calls) in 2019 (difference, 2.0 percentage points 95% CI, 1.9-2.2; P < .001)
• The proportion of ABHS eye exposures significantly increased, from 1.3% in 2019 (33 cases; mean [SD] age, 3.4 [3.8] years) to 9.9% in 2020 (232 cases; mean age, 4.5 [3.5] years) (difference, 8.6 percentage points; 95% CI, 7.4-9.9; P < .001)
• The proportion of ABHS eye splatters significantly increased during the study period, from 5% in April 2020 to 9%, 10%, 11%, and 15% in May, June, July, and August 2020, respectively
• In 2020, 63 cases of ABHS exposure occurred in a public place, while none were reported in 2019
• Cases of ABHS exposures in public places continuously increased, from 5 in May (1.0% of eye exposure; 12.2% of ABHS), to 9 in June (1.8% and 16.4%, respectively), to 16 in July, to 33 in August (up to August 24; 8.0% and 52.4%)

Although the case series found no difference between the 2 periods regarding the proportion of chemical eye exposures among pediatric populations, in 2019, 1 boy was admitted for an exposure to ABHS compared with 16 cases of ABHS eye splatter admitted in 2020.

Of these 16 cases:

• 8 had a corneal and/or conjunctival ulcer, involving more than 50% of the corneal surface for 6
• 2 (12%) of these children required amniotic membrane transplant (AMT) with general anesthesia after a median time of 3 days of medical treatment, because of delayed re-epithelialization.
• 1 case required AMT twice because of an incomplete re-epithelialization 10 days after the first AMT

Overall, the study “illustrates collateral damages of the widespread use of ABHS during the COVID-19 pandemic and led to a National Public Heath alert” in France. The researchers hypothesized the pediatric specificity of the outbreak is likely due to the placement of sanitizer dispensers within the proximity of children’s eyes. Pressure-operated dispensers are usually around 1 meter high.

Any delay in washing eyes after exposure is detrimental to the ocular surface. Two additional case reports published in JAMA Ophthalmology³ document toxic keratopathy in children after unintentional contact between alcohol-based hand rubs (ABHR) and the eye. Although ocular findings resolved within 2 weeks in both cases, authors cautioned, “Small children are at risk of severe ocular injury and possibly even blindness due to inadvertent ocular exposure to ABHR.”

Currently, the FDA recommends a concentration of 60% to 95% ethanol or isopropanol for ABHRs, but composition is highly variable. Eyes exposed to undiluted ethanol for longer than 30 seconds can experience immediate cytotoxic effects on corneal epithelia cells while the substance reduces proliferation and induces apoptosis. Irritant additives like hydrogen peroxide, polyethylene glycol, or perfumes can also increase ocular toxicity.

To limit risks of ABHS-induced ocular injuries, experts recommend parents promote hand washing with soap and water over ABHRs among children, especially when at home. Teaching children how to use sanitizers, having separate dispensers at lower heights in public places, and placing caution signs next to dispensers could all help mitigate risks.

References

1. Martin GC, Le Roux G, Guindolet D, et al. Pediatric eye injuries by hydroalcoholic gel in the context of the coronavirus disease 2019 pandemic. JAMA Ophthalmol. Published online January 21, 2021. doi:10.1001/jamaophthalmol.2020.6346
2. Colby K. Unintended consequences of hand sanitizer use in the coronavirus disease 2019 pandemic. JAMA Ophthalmol. Published online January 21, 2021. doi:10.1001/jamaophthalmol.2020.6327
3. Yangzes S, Grewal S, Gailson T, Grewal SPS. Hand sanitizer-induces ocular injury: a COVID-19 hazard in children. JAMA Ophthalmol. Published online January 21, 2021. doi:10.1001/jamaophthalmol.2020.6351