08 June 2023: Articles
Unexpected Ocular Manifestations Due to Exposure to Highly Concentrated Peracetic Acid: A Case Report
Unusual clinical course, Challenging differential diagnosis, Diagnostic / therapeutic accidents, Management of emergency care, Rare disease, Clinical situation which can not be reproduced for ethical reasonsLuiz William L.S. Cavalcanti 1EF, Antonio Brunno V. Nepomuceno 2BCG, Juliana de Lucena Martins Ferreira 3AD*
Am J Case Rep 2023; 24:e940114
BACKGROUND: Peracetic acid is among the disinfectants that irritate the upper respiratory tract, skin, and conjunctiva. It can cause symptoms of eye irritation, secondary to an inflammatory process that can lead to various manifestations. Irritation happens due to the high reduction potential of the acid, which causes the consequent release of reactive oxygen species. This fact serves to reinforce the importance of personal protective equipment when handling peracetic acid.
CASE REPORT: During an accident at work, a 21-year-old patient received a strong jet of disinfectant solution directly into both eyes. The composition of the disinfectant solution was 15% peracetic acid, 15-16% hydrogen peroxide, 22-23% acetic acid, and 16-17% horticultural sanitizers. Twenty-four hours after the incident, eye damage (punctate keratitis and low visual acuity) had occurred, and was treated by washing the eye with ice water and frequently applying lubricating eye drops. The next day, the patient returned with an improvement of irritative symptoms, but with a major complaint of low visual acuity in left eye, secondary to optic neuritis, detected by fundoscopy and confirmed by optical coherence tomography. In the following week, fluorescent angiography indicated the persistence of neuritis in the left eye. This was treated with prednisone, 40 mg/day, which brought about gradual improvement. Two months later, the patient returned with test results showing normal magnetic resonance imaging and negative serologies (for syphilis, HIV, and herpes virus), visual acuity 20/20 in both eyes, and normalization of angiography and optical coherence tomography parameters.
CONCLUSIONS: Until now, there have been no published studies demonstrating neuritis caused by direct contact of peracetic acid into the eyes. Therefore, this is the first report in the world literature of this manifestation of ocular exposure to peracetic acid. This is a chemical formulation that is widely useful and prevents the growth of various pathogens. Further investigation and studies on the subject should be encouraged to improve its management and use.
Keywords: Keratitis, optic neuritis, papilledema, Peracetic Acid, personal protective equipment
In the formula of peracetic acid, there is an extra oxygen atom inserted into the COOH bond of its parent chemical acetic acid, resulting in a formula of CH3CO3H, which leads to a higher reduction potential than either chlorine dioxide or sodium hypochlorite, and enhanced reaction with various cellular components, resulting in cell death. Due to its great potential as an oxidizing agent, it was initially used only as a disinfectant, with wide commercial use in medical facilities. Since peracetic acid is a low-temperature sterilant that does not react with plastics and metals, it can be applied to heat-sensitive objects, and will not damage delicate devices such as endoscopes [1,2]. In addition, this acid is very effective, in solution with hydrogen peroxide, in reducing microorganisms such as
However, the use of this acid requires care because direct exposure can cause severe burns, allergies, and damage to the ocular mucosa, skin, and respiratory tract, with exposure at 4.67 mg/m3 for 12 minutes causing minor burns and 6.23 mg/m3 for 60 minutes causing severe mucosal damage. Exposure to concentrations greater than 0.35% peracetic acid is related to irreversible damage to the eye, but at concentrations less than 0.35%, the damage may be reversible, depending on the time of exposure [2,4]. Therefore, the present study aimed to report the case of a patient who had ocular contact with peracetic acid that manifested as visual complaints followed by evolution to ophthalmologic damage. We also correlate the results with data reported in the world literature.
A 21-year-old man was working, but was not wearing safety goggles, when he received a strong jet of peracetic acid-containing solution (the composition of which was 15% peracetic acid, 15–16% hydrogen peroxide, 22–23% acetic acid, and 16–17% horticultural sanitizers) directly into both eyes, but more intensely in the left eye. He proceeded to wash both eyes abundantly with running water for approximately 30 minutes. Due to eye burns, he sought an ophthalmology service following the accident on January 22, 2019, approximately 24 hours after the incident. Ophthalmological examination showed conjunctival hyperemia on assessment, 1+/4+ in the right eye and 2+/4+ in the left eye, in addition to significant ciliary injection in the left eye and mild ciliary injection in the right eye. When fluorescein was dripped, diffuse punctate keratitis was observed in the left eye, without ulcers, and the patient was advised to wash the eye with ice water and to frequently apply lubricating eye drops (carmellose sodium 5 mg/ml). When asked, the patient denied having any previous diseases (ocular or systemic).
The next day, the patient returned with an improvement in irritative symptoms. The right eye had normal vision (20/20), but the patient reported very low visual acuity in the left eye; a finger-counting test revealed that he was only able to visualize the physician’s fingers at a distance of 50 cm, despite normal biomicroscopy of the ocular surface. Fundoscopy showed mild papillary edema in the right eye and quite accentuated papillary edema in the left eye, in which the thickness of the optic disc edema was measured by optical coherence tomography (OCT). The OCT was 580 μm in the right eye and 940 μm in the left eye. Fluorescent angiography was requested for better evaluation of the papillary edema.
The fluorescent angiography was done on February 1, 2019. It revealed no papillary edema in the right eye, but a progressive increase in disc blurring was observed along the image sequence of the left eye, with wide diffusion of contrast and pronounced blurring of the disc margins (Figure 1). On this day, prednisone 40 mg/day for 5 days was prescribed, and magnetic resonance imaging (MRI) of the brain was ordered, along with serology for syphilis, HIV, and herpes.
Due to social and economic factors, the patient only returned on March 15, 2019. The test results showed normal MRI and negative serologies. The visual acuity demonstrated improvement, returning to 20/20 in both eyes, and no other visual complaints were reported. Angiography parameters and OCT were both normalized (Figure 2).
According to a 2017 study by Casey et al, which evaluated ocular exposure to disinfectants with peracetic acid in their composition, eye irritation was the most described symptom in 401 exposed patients, with other symptoms including tearing, burning, and ocular discomfort . Other studies have shown that peracetic acid can cause damage to the mucosa of the upper respiratory tract, the conjunctiva, and the skin [2,4]. These data corroborate the present report, as the patient reported burning in the eyes, in addition to conjunctival hyperemia, which pointed to a local inflammation process, also demonstrated by ciliary injection and punctate keratitis, which indicated the involvement of the corneal epithelium. These findings justified the recommendation of the use of lubricating eye drops and ocular lavage [6,7].
Peracetic acid is a strong oxidizing agent, with a high reduction potential close to that of hydrogen peroxide and higher than those of chlorine and chlorine dioxide. Its concentration in disinfectant solutions should be kept between 5–15% ; in the present case, a maximum concentration of 15% was used. Given its reactive nature, this acid, once in the body, breaks down rapidly through hydrolysis or reaction with reducing agents, without the need for enzymatic participation, although degradation also occurs through enzymes such as catalases and peroxidases . This acid degradation process will produce a large amount (depending on the degree of exposure) of reactive oxygen species (ROS), producing local oxidative stress, which can cause damage to the corneal epithelium and ocular mucosa [2,9]. In addition, when the body is exposed to ROS, it will generate specific protective mechanisms, which can be enzymatic (dismutases/catalases) or nonenzymatic (vitamins A, C, and E) . Furthermore, this chemical formulation has the possibility of acting directly on the cytoplasm and nucleic acid of cells (dissolving them) and may have a mutagenic potential, which is still under discussion in the literature [2,10].
Regarding the patient, it is pertinent to consider the fact that OCT and retinography be performed 48 hours after the accident, and fluorescent angiography was done 1 week after the event. He presented with optic neuritis and visual loss, but without periocular pain or dyschromatopsia symptoms, and demonstrated a change in fluorescein angiography, which was done following the investigation protocol for retina vascularization and papillary edema . The fluorescent angiography clearly showed edema in the left eye, where it was accentuated from the beginning, but it did not detect edema in the right eye. The right eye edema had already resolved 24 hours after the event and may have remained resolved throughout the week. In a 2015 study by Pechacek et al, the possibility of peracetic acid-related nerve damage was suggested . They correlated exposure to moderate to high amounts of peracetic acid in the airway, for a prolonged period, with a large locoregional production of free radicals, stimulating the trigeminal nerve via the hematogenous route. Moreover, this acid produced a burning sensation on the facial skin, in the location of nerve innervation, even without the presence of active injury and with cessation of exposure . Furthermore, a study by Domaç et al, in 2007, showed that ROS diffuse into the perivascular space and induce lipid peroxidation of the axonal membrane and myelin in the optic nerve interstitium . Therefore, the optic nerve damage in the presently reported patient could be correlated with this increased oxidative stress, since the product to which the patient was subjected had in its composition, in addition to peracetic acid, significant amounts of hydrogen peroxide and acetic acid. The optic neuritis may have been caused by damage and inflammation resulting from the peracetic acid, which may have increased the uptake of these other substances, increasing local oxidative stress and the consequent damage to the optic nerve.
Ocular contamination with peracetic acid can promote an important local inflammatory reaction due to its intense potential for reduction and consequent release of ROS, the level of which will depend on the time, amount, and concentration of the substance . In addition, other organs, such as the skin and lungs, may also suffer from acid exposure due to increased oxidative stress, which can cause asthmatic symptoms due to the reactivity of the respiratory muscles to increased ROS [2,13]. Therefore, the present case demonstrated that abundant eye washing was not sufficient to prevent eye damage, despite eye irrigation being suggested as a helpful emergency treatment, with the common acceptance of tap water washing for at least 15 minutes. Further, brief water washing is not enough to extract chemicals already absorbed into tissues. It is therefore essential to use personal protective equipment (apron, gloves, eye or face protection, and others) during handling and exposure of peracetic acid solution, in addition to handling this substance in a well-ventilated area . Peracetic acid is a chemical formulation that is widely useful and promotes the disinfection of several pathogens. New investigations and studies on the subject should be encouraged to improve its management and use.
We know that the conjunctiva has a high absorptive capacity , and the patient had direct eye contact with the peracetic acid. However, until the present, there were no published studies demonstrating neuritis resulting from contact of this agent straight into the eyes, although there have been studies of locoregional propagation of neuritis after inhalation by the agent.
The present case brought up some points of importance that must be mentioned. It is a rare case of direct contact, into the eyes, of peracetic acid, in a liquid state, and in high concentration. We believe that this triggered an intense chemical inflammation, with locoregional propagation to the optic nerve, since we ruled out several other possible causes of neuritis.
FiguresFigure 1.. On retinography, papillary edema was only evident in the left eye (LE). Fluorescent angiography revealed hyperfluorescence with defocusing of the papilla in the LE, but in the right eye (RE) there was no change. Optical coherence tomography of the optic nerve quantitatively detected bilateral papillary edema (mild in the RE and severe in the LE). Figure 2.. Resolution of the left eye (LE) papillary edema can be seen on retinography and optic nerve optical coherence tomography when the patient returned after taking prednisone 40 mg/day for 5 days.
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