They are ubiquitous. Those Alcohol based hand sanitizers (ABHS) have infiltrated every corner of our world from public buildings to private retail. Once criticized as creating resilient bacteria, alcohol-based sanitizers have become an accepted everyday way of life when soap and water is not always an option. An unintended consequence of ABHS is the uptick in the number of cornea issues in kids.
Most dispensers are mounted on the wall, or are stand-alone units located in high traffic public areas. Think doctor office corridors or entrances to malls and movie theatres. While adults comfortably place their hands under the dispensers, children nearby, namely their eyes are victims to wayward squirts and splatters. The level of the actual dispense is eye level for most kids.
While dispensers are the biggest culprits, bottled dispensers have their own unintended consequences. Counters and reception tables are also at children’s eye level and can result in the same unintended consequences. Recent reports have revealed that dispensers placed at or above the eye levels of children have resulted in them sustaining corneal and conjunctival injuries by accidentally getting hand sanitizer squirted in their eyes.
In January 2021, Yangzes et al published two case studies of eye injuries in kids due to ABHS in JAMA Ophthalmology. They say “small children are at risk of severe ocular injury and possibly even blindness due to inadvertent ocular exposure to ABHS. 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.” They go on to say that “for ABHS, the US Food and Drug Administration recommends a concentration of 60% to 95% ethanol or isopropanol. 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.” The two patients in their cases were lucky and were treated promptly. They did not go on to have any permanent corneal or ocular damage, however they do warn that there are other published cases on alcohol-based eye injuries in which subjects were not as lucky.
Also this year, Martin et al performed a retrospective review of ABHS cases from the French Poison Control Centers, which indicated that “a 7-fold increase of alcohol-based hand sanitizer-related ocular exposures in children was found [in 2020] in comparison with 2019, and a pediatric ophthalmology center reported 13% of [those] patients requiring surgery for severe lesions.” Dr. Martin says that “the number of cases occurring in public places increased in 2020 (from 16.4% in May to 52.4% in August). Similarly, admissions to the eye hospital for ABHS exposure increased during the same period (16 children in 2020 including 10 boys; mean [SD] age, 3.5 [1.4] years vs. 1 boy aged 16 months in 2019). Eight of them presented with a corneal and/or conjunctival ulcer, involving more than 50% of the corneal surface for 6 of them. Two cases required amniotic membrane transplant.”
So, what can be done? Many in the eye care profession are urging for design change in the dispensers. Some suggest the height of dispensing change, while others recommend the type of dispense, such as foam versus gels. Foam varieties
are safer as they are less prone to spray due to the denseness of the foam. Other suggestions include an emergency eye wash station accompany each stand-alone dispenser and a caution sign warning of the potential for eye injury when small children attempt to use the dispenser.
Eye and healthcare professionals prefer kids use soap and water to wash their hands whenever possible. When ABHS is the only option, adult supervision is recommended.