Rubber Bullets, Tear Gas: What Doesn't Kill Can Still Blind

This transcript has been edited for clarity.

Hello. I'm Dr Ann Murchison, director of the Wills Eye Hospital Emergency Department in Philadelphia. This is a collaboration with Medscape Ophthalmology.

In recent weeks, we have seen an increase in the use of rubber bullets and tear gas in the United States in attempts to disperse or control crowds. Unfortunately, this has led to significant injuries, including eye injuries. It is important to distinguish the broad types of eye injuries sustained from rubber bullets and tear gas because each is treated differently. As a rule, rubber bullets result in a blunt-force injury to the eye, eyelids, or orbit, whereas tear gas, also known as a lachrymator, mainly causes a chemical injury to the eye.

Rubber bullets are considered nonlethal, but as the American Academy of Ophthalmology noted, they are not nonblinding. These bullets are made of rubber or plastic materials and some have metal cores. While protective eyewear may help protect the eyes, it is no guarantee. The extent of the injuries from these bullets varies and commonly includes eyelid lacerations and hyphemas. However, more serious injuries, including ruptured globes and orbital fractures, have occurred.

For those with an eye injured by a rubber bullet, they should shield the eye and seek care immediately. The eye should not be touched or rubbed. The removal of any foreign material on or in the eye should not be attempted. Avoid irrigation of the eye.

It is important to place a protective shield, not a patch, over the eye. A typical patch or gauze puts pressure on the eye, which may exacerbate the injury, with extrusion of intraocular contents if the globe is lacerated. A shield is applied to the bony orbital rim and vaults over the injured eye, protecting it without any pressure. Eye shields may not be readily available in the field or in many community-based emergency rooms. In these cases, a simple disposable cup will suffice; cut down the cup and apply it to the orbital rim with a piece of adhesive tape.

Tear gas is a term that encompasses different irritating gasses that mostly impact the eyes and respiratory system. The ocular effect depends on the directness of the exposure to the eye (ie, a diluted fog vs a direct spray) and the length of the exposure.

Mechanical injury to the eye can occur from the metal tear gas canister, similar to that from a rubber bullet. The most common injury to the eye from tear gas is chemical. Generally, corneal and conjunctival irritation and pain occur from the tear gas, but the damage can lead to chronic issues, including ongoing eye discomfort and corneal scarring, which can lead to decreased vision. Eye protection, such as goggles, may help minimize an exposure.

For those exposed to tear gas, they should exit the contaminated area, preferably to higher ground and fresher air. Blinking frequently and flushing the eyes with an eyewash, artificial tears, or clean water — but not milk — should be done as soon as possible. The eye should not be rubbed.

Contact lenses should be removed immediately, as they may act as a persistent reservoir for the chemicals in the tear gas.

Any contaminated clothing near the face should also be removed. If wearing a face mask, it should be replaced. If no replacement face mask is available, then the mask should be removed in an uncrowded area to minimize the risk for COVID-19 transmission.

Immediate care will help minimize the damage to the eyes from tear gas.

It is simply impossible to overemphasize the importance and effectiveness of protective eyewear in circumstances where the use of rubber bullets or other projectiles and tear gas may occur.

Those of us at the Wills Eye Hospital Emergency Department and the ophthalmologists at Wills Eye Hospital are here to help every hour of every day. Thank you.

Follow Medscape on Facebook, Twitter, Instagram, and YouTube