Halloween is a fun-filled celebration with glitter, costumes, candy, and a spooky good time. However, it can also bring about scary eye infections and ocular complications that can be the greatest cause of nightmares.
Avoid the emergency room with these tips
Halloween is considered one of the 4 days of the year when children are admitted to the emergency room with record numbers of eye infections.1 Keep your patients’ eyes safe this spooky season by using some of the following eye-related techniques.
Do patch tests with makeup to prevent contact dermatitis
Eye makeup during Halloween is very popular—from cat eye makeup to zombie face paint. These cosmetics can create a scary situation near the eye by causing irritant and allergic contact dermatitis.
Allergic contact dermatitis: This type of contact dermatitis may occur after the immune system responds to a reactant. These patients will present with eczema-like rash symptoms around the eye.
Irritant contact dermatitis: The more common form of contact dermatitis, it appears when a substance or chemical is too strong and damages the outer layer of the skin. The most common sign of irritant contact dermatitis would be skin peeling. Other signs you may see in this patient would be excessive tearing, burning, and redness.8
Educating patients with a history of contact dermatitis on the importance of patch testing Halloween makeup before applying it near the eye can help prevent these scary reactions. In addition, it can help the patient determine if they have a certain allergy to any of the ingredients in the makeup.
“A mild steroid ointment or an oral antihistamine can be used to help treat both types of allergic reactions.”
Many Halloween makeup products have key ingredients like fragrances, preservatives (parabens and benzalkonium chloride), metallic pigments, and color additives that can be irritating.2 Another important tip is to recommend that the patient removes all their makeup at the end of their Halloween night.
Be deliberate when choosing cosmetic contact lenses
Decorative contact lenses can add a scary touch to your patient's Halloween costume by altering how their eyes and pupils are perceived. These types of contacts can come in different eye colors, pupil shapes, and can even change the whites of the eyes.
As much fun as they can be, there are numerous research articles demonstrating how they can potentially cause sight-threatening infections and permanent vision loss.
Unregulated cosmetic contacts can cause corneal abrasions
Corneal abrasions from contact lenses are superficial cuts on the surface of the cornea that can be caused by the contact lens edge or surface of the contact lens. Patients with corneal abrasions may present with symptoms of pain, watering, foreign body sensation, redness, sensitivity to light, and headaches.10 Treat with an antibiotic drop or ointment.11
“It is important to educate patients on the importance of contact lens fitting. Contacts that are provided by optometrists are medically approved devices that must follow strict FDA guidelines.”
Some of the standards under these guidelines include: measuring and fitting the contact to the eye and choosing a contact that provides the FDA-approved amount of oxygen necessary for contacts to be deemed “safe” for patient use.
Also, the patient must have a valid prescription so that the contacts will be the most up-to-date prescription for their vision as well.5
A recent study done in Japan found that tints in decorative contact lenses were unevenly displaced on the surface of the contact—which could potentially lead to areas that scratch the cornea, causing corneal abrasions and severe infections. As the cornea becomes more scratched, it can lead to visual disruptions and potential blindness.3
In a separate survey of 159 optometry patients, 23% admitted to using cosmetic contact lenses, and of those patients, 50% purchased the contacts from an unlicensed party.4
It is vital to frequently remind patients of the importance of buying contacts from their eyecare professionals, and the consequences of buying contacts online.
“Many times, patients who buy unregulated contacts are not trained in appropriate insertion and removal techniques, which can potentially be another risk factor for some of the abrasions.”
Reiterating the importance of proper insertion and removal of contact lenses at annual eye exams can help prevent these injuries.
The alarming frequency of bacterial keratitis in cosmetic contact users
Prevalent in contact lens users, bacterial keratitis is an infection of the cornea most commonly caused by two types of bacteria: Pseudomonas aeruginosa and Staphylococcus aureus. Patients may complain of pain, blurry vision, foreign body sensation, redness, photophobia, tearing, and headaches.9
A 2011 study by Bourcier and Sauer found that people who wore decorative contact lenses were almost 16 times more likely to have keratitis than people who wore regular contact lenses.12
Bacterial keratitis can potentially lead to vision-threatening corneal ulcers and blindness. Treatment is usually topical antibiotics and possible cycloplegics for comfort/prevention of synechiae.11
“As with any type of contact lens, decorative contacts require proper hygiene and routine care.”
This includes washing and drying hands prior to inserting contacts, using a fresh contact solution and lens case, emptying and refilling the contact lens solution, not sharing contacts, and lastly, not using any water around the contacts.
It is important as eyecare professionals to stress the significance of getting contacts fitted by a professional with a valid contact prescription, and also being trained in contact lens hygiene. Patients can be reminded during contact lens fitting appointments or new contact lens patient appointments.
Common reactions to decorative contacts: Hypersensitivity and toxicity
Patients may present with conjunctival injection and irritation after wearing cosmetic contact lenses. Other symptoms may include: superficial punctate keratitis (SPK), palpebral conjunctival follicles, and corneal infiltrates.11
Often specialty contacts bought online or from Halloween supply stores are not regulated, and are considered to be illegal by the FDA. They may contain materials and ingredients that are not approved for the cornea.
A study in Japan found that the material in some cosmetic contact lenses contained high levels of chlorine and iron.4 These chemicals can be highly toxic to the human body, especially if they are released into the eyes.
Treatment is usually to discontinue the use of these contacts, possibly along with a topical steroid to reduce inflammation.11
Keep an eye on your ocular accessories
Halloween is known as one of the few times most people use extravagant accessories like feathers, false lashes, and all that is glitter. Many times when patients put these accessories near the eye it can cause problems, such as corneal foreign bodies, corneal abrasions, and allergic reactions.
All that glitters is not gold: Accessories and corneal foreign bodies
A corneal foreign body is an object that is superficially embedded into the cornea. These patients may present with symptoms of tearing, a history of foreign body sensation, and trauma.
Signs may include: SPK, rust ring, conjunctival injection, and eyelid edema. It is recommended to avoid using glitter around the eyelid margin as it can easily migrate into the eye and eventually cause vision-threatening scratches on the cornea.11
In addition, if glitter must be used for the costume, the first tip would be to avoid any glitter near the eyes, but also to look into the type of glitter that is being used. Craft glitter that is commonly found at the dollar store contains certain chemicals, including metal and glass, that can irritate the eye.2
The treatment for corneal foreign bodies involves initially irrigating with an eye wash to remove any remnants of the foreign body. If the corneal foreign body is still present, use an anesthetic and remove the foreign body, along with removing the rust ring with an alger brush if present. If there is a corneal abrasion present, treat as needed.
Have an aesthetician apply your false lashes
False lashes are also commonly used during Halloween to re-create different looks. Sometimes, decorative false lashes that are found at Halloween stores can cause allergic reactions due to the glue used on the eyelids.
A study has shown there was use of formaldehyde in glue and removing agents in false lashes.13
Before applying the false lashes to the eyelid with glue, a good idea would be to patch test the eyelash glue 24 hours prior to applying it to the eye.
To avoid the fear of having puffy eyelids this Halloween, it is important to get an experienced aesthetician who uses proper hygiene to apply them to the eyelash margin.6 In general, using these types of false lashes should ultimately be avoided as they are a high risk factor for many allergies and eye injuries.
Elevate your Halloween costume with safe props
Wands, fake glasses, and capes are essential Halloween props for the “Harry Potter” look. Props like these can be a dangerous eye hazard in busy streets crowded with trick-or-treaters, where they can cause vision problems to patients, such as corneal abrasions and corneal/conjunctival lacerations.
When the claws come out, beware corneal abrasions
Many patients might come to your clinic presenting with sharp pain, watering, foreign body sensations, and a history of hitting their eye with things like fake nails on Halloween. Epithelial staining can help diagnose this ocular condition.
“Abrasions may also have an anterior chamber reaction associated with it.”
Antibiotic treatment with possible NSAID is usually recommended with these patients. If an anterior chamber reaction is associated, a cycloplegic agent can be used.11
Foam is your friend for corneal/conjunctival lacerations
A corneal or conjunctival laceration is similar to a corneal abrasion, however, it is considered to be much deeper and potentially, partially or fully, cut through the cornea or conjunctiva. These types of injuries are usually caused by something forcefully striking the cornea or flying into the eye, such as props during Halloween.
Fluorescein staining can help diagnose these lacerations; along with subconjunctival or conjunctival hemorrhages. Antibiotic ointment treatment can usually heal most of these, however larger and/or deeper lacerations may require surgical repair and prompt referral.11
Enlightening patients on the value of using a foam-like material for their props, rather than plastic or steel, which can be very pointy or sharp, will help in preventing these eye injuries during Halloween.
In addition, recommend against using any masks that have a rubber band, as these can potentially snap back and cause damage to the eye.2
Avoid spooky accidents caused by obstructed vision
As darkness falls, so does our vision during these dimly lit times. Halloween masks, hats, eye patches, and hoodies often obstruct vision—especially peripheral vision.2
Using bright reflective costumes can help drivers see partygoers and trick-or-treaters when going out at night.7 Educating patients and parents on best practices during the Halloween season is key!
Explore common eye emergencies that may show up in your clinic and how to handle them to get optimal results. Get the cheat sheet >>
In conclusion
Halloween is a wonderful event filled with creativity, community fun, and a lot of candy. Nonetheless, it is important to make sure eyecare professionals are discussing the implications of ocular complications that might arise due to Halloween makeup, decorative contact lenses, props, accessories, and obstructed vision.
Educating patients prior to Halloween using resources such as handouts in clinics or information on social media/websites, can help bring awareness to prevent your practice from seeing these creepy complications come November.
References
- Isted A. Fright Night. BMJ. 2013. doi:10.1136/sbmj.f6337
- Casey CN. Halloween and Eye Safety: What you need to know. Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/wellness-and-prevention/Halloween-and-eye-safety-what-you-need-to-know. Published October 11, 2021. Accessed September 2, 2022.
- Dang S. Over-the-counter costume contacts may contain chemicals harmful to eyes. American Academy of Ophthalmology. https://www.aao.org/eye-health/news/costume-contacts-may-contain-chemicals. Published March 29, 2017. Accessed September 2, 2022.
- Bouweraerts KP. Costumes contact lenses: All trick, no treat. Ophthalmology Advisor. https://www.ophthalmologyadvisor.com/topics/general-ophthalmology/over-the-counter-Halloween-costume-contact-lens-risks-and-treatments/. Published August 23, 2022. Accessed September 2, 2022.
- Beware: Spooky eyes for Halloween. All About Eyes. https://aaeyes.net/beware-spooky-eyes-for-Halloween/. Accessed September 2, 2022.
- Wittel R. Protect your eyes from spooky infections this Halloween. CU Anschutz Newsroom. https://news.cuanschutz.edu/medicine/protect-your-eyes-this-Halloween. Published January 12, 2022. Accessed September 5, 2022.
- Halloween safety tips: Costumes, candy, and colored contact lenses. U.S. Food and Drug Administration. https://www.fda.gov/consumers/consumer-updates/Halloween-safety-tips-costumes-candy-and-colored-contact-lenses. Accessed September 5, 2022.
- Miller K. Here's why your same old eye makeup is suddenly causing irritation. SELF. https://www.self.com/story/eye-makeup-irritation-allergies. Published October 5, 2018. Accessed September 10, 2022.
- Basics of bacterial keratitis. Centers for Disease Control and Prevention. https://www.cdc.gov/contactlenses/bacterial-keratitis.html#:~:text=Bacterial%20keratitis%20is%20an%20infection,Pseudomonas%20aeruginosa. Published February 14, 2022. Accessed September 10, 2022.
- Corneal Abrasion (scratch): First aid. Mayo Clinic. https://www.mayoclinic.org/first-aid/first-aid-corneal-abrasion/basics/art-20056659#:~:text=A%20corneal%20abrasion%20is%20a,of%20a%20piece%20of%20paper. Published August 12, 2022. Accessed September 10, 2022.
- Wajda B. The Wills Eye Manual. Lippincott Williams & Wilkins; 2016.
- T. Bourcier, A. Sauer, the French Study Group of Contact Lenses-related Microbial Keratitis; Cosmetic Contact Lenses Related Microbial Keratitis as a Foreseeable Disaster: A Prospective Study. Invest. Ophthalmol. Vis. Sci. 2010;51(13):2884.
- Amano Y, Sugimoto Y, Sugita M. Ocular disorders due to eyelash extensions. Cornea. 2012;31(2):121-125. doi:10.1097/ico.0b013e31821eea10
