By Dr. Cheryl G. Murphy, OD
Alcohol based hand sanitizers (ABHS) have been adopted by many as a convenient way to sanitize hands when hand washing is not an option. Pump dispensers and stand-alone dispensers have been placed in many public places including doctors’ offices, shops, movie theaters and schools. However, the height of these dispensers may prove to be a problem for the eyes of shorter patrons.
For young users, stand-alone dispensers can prove precarious particularly if the dispenser is at their eye level and is not working correctly, for example, if it is squirting at an angle instead of straight down. Even shared bottle dispensers that are placed with good intentions on a shelf, table or on top of the reception desk at a doctor’s office could be a cause for concern if at the wrong height for kids who may also be tempted to use them. 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.”
Many in eye care are stepping up to raise awareness of this potential hazard to the eyes of small children and some are even calling for redesigning of dispensers, particularly the stand-alone dispensers that dispense sanitizer when pressure is placed on a foot pedal. Suggestions for redesigns include ones that are at different heights for young people or that are automatic and gently dispense a more foam-like sanitizer as opposed to the gel which may be more prone to splatter. 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 care professionals and other healthcare professionals alike prefer that children wash their hands with soap and water whenever possible, however, when sanitizer has to be used on small children, perhaps it should be only applied under the supervision and guidance of an adult and when near public ABHS dispensers, adults should be careful to have children stand far out of harm’s way.