There are numerous reports in the last few days and weeks of individuals sustaining eye injury from tear gases and rubber bullets. I’d like to summarize review papers for ophthalmologists and health care colleagues. I’d also like to offer some initial management options. Protect the eye and seek medical attention immediately.

Tear gases

Kim, Payal, and Daly wrote an excellent review article, “Effects of tear gases on the eye,” (Survey of Ophthalmology, July-August 2016, Volume 61, Issue 4, Pages 434–442). Tear gases come in numerous forms, and the ocular injuries can be caused by the chemical and explosive effects.

Photo by Koshu Kunii on Unsplash

Kim et al state, “The effects on eyes include conjunctival injection, complete
corneal epithelial defects, pseudopterygium, corneal neovascularization, persistent conjunctivalization, corneal opacities, and reduced visual acuity. Current management, based on limited human studies, emphasizes decontamination and symptomatic treatment.” (Survey, page 434)

Pepper Spray injury to the cornea (Epstein RJ and Majmudar PA, Ophthalmology Oct. 2001, p. 1712)

Schep, Slaughter, and McBride state, “The eyes and respiratory systems are the primary target organs, with onset of ocular and respiratory tract irritation occurring within 20–60 s(econds). The ocular symptoms include pain, blepharospasm, photophobia, conjunctivitis, diffuse conjunctival and scleral injection, periorbital oedema, eyelid erythema and lacrimation.”

Hyphema is blood in the anterior chamber of the eye which can lead to significant eye injury and sequelae (Photo: Bryan Thiel, Moran CORE)

Schep and colleagues also address serious eye injuries in their paper. They state, “They (tear gases) do not typically cause irreversible eye effects, but more severe ocular injuries have been reported, including hyphema, uveitis, necrotising keratitis, coagulative necrosis, symblepharon, secondary glaucoma, cataracts and traumatic optic neuropathy and loss of sight.” (Schep LJ, Slaughter RJ, McBride DI. “Riot control agents: the tear gases CN, CS and OC—a medical review.” BMJ Military Health 2015;161:94-99.)

US Navy Seabees in full mission-oriented protective posture gear training with smoke grenades and tear gas. Public domain image. Photograph credit: Photo by Chief Mass Communication Specialist Michael B. Watkins, US Navy.

Eye protection is the best initial option to hopefully avoid exposure to tear gases and rubber bullets but they do NOT give 100% protection. If exposed to tear gas, an individual should:

  1. Remove themselves from the contaminated area as quickly and safely as possible.
  2. Seek fresh air.
  3. Seek higher ground (aerosolized tear gases are heavier than air).
  4. Blink frequently (to promote tearing).
  5. Do not rub eyes (may spread crystals within ocular surfaces).
  6. Remove contact lenses.
  7. Flush the eyes with copious clean water.
  8. Seek emergency ophthalmic evaluation.
  9. Ashley Brissette MD, a NYC cornea specialist offers great advice in a tweet here.

Rubber Bullets

Figure 2
Rubber bullet adjacent to ruptured globe, having penetrated the eyebrow and traversed the frontal sinus. From Lavy, T., Asleh, S. Ocular rubber bullet injuries. Eye 17, 821–824 (2003).

For rubber bullets, the risk for globe injury, orbital fractures, and permanent vision loss is increased. As colleagues have stated, “rubber bullets” may offer a false sense of security and may lead to blindness. Lavy and Asieh conclude, “The term ‘rubber bullet’ is misleading. ‘Rubber bullets’ cause a wide variety of ocular and periocular injuries. Orbital fractures are common. The tissues of the orbit are easily penetrated. If the globe is hit, it is rarely salvageable.” (Lavy, T., Asleh, S. Ocular rubber bullet injuries. Eye 17821–824 (2003). https://doi.org/10.1038/sj.eye.6700447 )

Instagram: is.visualart 11/19/2019

There are numerous reports of the devastating effects which rubber bullets, pellet guns, and projectiles can have on the eyes. The NYTimes profiles Dr. Natarajan Sundaram and his heroic efforts to protect sight after the protests in Kashmir, India here. (“An Epidemic of ‘Dead Eyes’ in Kashmir as India Uses Pellet Guns on Protesters” 2016). More recently, see an article from Chile: “A Bullet to the Eye Is the Price of Protesting in Chile” November 19, 2019. (link). Eye injuries are becoming increasingly common worldwide.

Temporary eyeshield made from styrofoam cup. Anton Helman MD. https://emergencymedicinecases.com/ocular-trauma/

As with potential tear gas exposure, eye protection is the best initial option to hopefully avoid injury from rubber bullets & projectiles but they do NOT give 100% protection. If exposed to a rubber bullet or projectile injury, an individual should protect the eye immediately. The eye may have an “open injury” (ruptured globe) and the intraocular contents are fragile and must be preserved. This is a medical emergency.

The Mass Eye & Ear, Harvard Medical School “Benchmark Protocols for Managing Eye Trauma” states, “The annual incidence of open-globe injuries worldwide is estimated to be 203,000 cases. Overall, males comprise approximately 80 percent of open-globe injuries. Males age 10 to 30 are at greatest risk. The chance of blunt globe rupture also increases after some types of ocular surgical procedures, including: large incision cataract removal, cornea transplant, glaucoma filtering, or refractive surgery.” (Eye Insights Issue 01: Ocular Trauma)

If injury occurs, remember the military phrase SHIELD AND SHIP. In transit to the emergency room:

  1. Do not touch the eye.
  2. Do not rub the eye.
  3. Stay upright.
  4. SHIELD: Place a hard shield around eye. Even a temporary eyeshield, such as paper cup or styrofoam cup, may work in an emergency.
  5. SHIP: Seek emergency room and ophthalmology consultation immediately.

Tear gases and rubber bullets can cause permanent eye damage, eye injury, discomfort, pain, loss of vision, and blindness. In cases of chemical injury and eye trauma, protect the eyes and seek medical attention immediately.

Amee Azad, MD, MSEpi student Stanford Med @ameeazad
& Ryan Brewster MD student Stanford Med @_ryanbrewster_

Additional resources since this blog posted:

  1. Interviewed by Reporter Evan Koslof (WUSA 9 in Washington DC) on the risks of ophthalmic injury with contact lens use and tear gas exposure (June 3, 2020)
  2. Nation’s Ophthalmologists Condemn Use of Tear Gas and Rubber Bullets. American Academy of Ophthalmology (June 3, 2020)
  3. Statement on Rubber Bullets for Crowd Dispersion. American Academy of Ophthalmology (June 4, 2020)
  4. “Rubber bullets are touted as a ‘safe alternative.’ My patient’s wound tells a different story” (Opinions). Dr. Lilun Li, Washington Post (June 4, 2020)
  5. “A guide to the less-lethal weapons that law enforcement uses against protesters.” By Alyssa Fowers ,Aaron Steckelberg andBonnie Berkowitz, Washington Post June 5
  6. Steve Gieser, MD, MPH, a Chicago ophthalmologist and glaucoma specialist, has posted poignant clinical vignettes of individuals affected by tear gas, rubber bullets, and other projectiles. Instagram
  7. The Department of Ophthalmology at the University of California San Francisco, in conjunction with the American Academy of Ophthalmology, is collecting information regarding ocular injuries surrounding civil protests. To add a case to this registry, please use the Google Form here.
#NoRubberBullets vignettes by Steve Gieser, MD, MPH on Instagram

(Media: Journalists covering eye health news who are in need of information, expert and/or patient interviews should contact the American Academy of Ophthalmology’s public relations department at media@aao.org or call the media line at 415.561.8534.)

#NoRubberBullets #NotOneMoreEye #SaveTheEye