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Jessica is the clinical supervisor for the Division of Ophthalmology at The Children’s Hospital of Philadelphia. She is the current president for the Philadelphia Regional Ophthalmic Society and a program Co-Coordinator and Adjunct Professor for the Ophth

The pediatric eye exam differs greatly from the adult eye exam-children are more than just tiny adults. To further that point, the whole dynamic of the exam is different because you are really interviewing and interacting with the family and not just the patient. In the pediatric arena, the family becomes your patient.

It’s all fun and games with pediatric patients

The emergence of SARS-CoV-2 has significantly altered optometry’s clinical protocols for patient care. On March 18, 2020, US eyecare providers were urged to cease all but urgent and emergent care. Many eyecare practices promptly closed. Some practitioners stayed home to obtain online continuing education (CE) and plan for the future. Some adopted the use of virtual visits and telehealth.

I did both. I have an older population with higher incidence of glaucoma and retinal disease. I was extremely unsettled about letting these patients go unsupervised for extended lengths of time. My staff thought I was joking when I mentioned drive-by intraocular pressure (IOP) checks for patients, but this has been suggested by others parctitioners.

On April 16, 2020, the federal government allowed some facilities to prepare for elective surgeries. Most have returned to clinic with masks, breath shields, reduced patient numbers, and heightened sanitation protocols. Temperature may be taken prior to entry to the waiting rooms, where furniture is most likely placed to support social distancing of 6 feet. I converse less with patients in the examination lane and instruct patients not to speak during biomicroscopy and indirect ophthalmoscopy. I requested my patients wear masks until my county made it mandatory on July 8, 2020.

Related: Don’t forget to ask about CPAP usage

Because SARS-CoV-2 spreads primarily through droplets of saliva or discharge from the nose when an infected person talks, coughs, or sneezes, optometrists and staff are at high risk of exposure. COVID-19 is transmitted between persons who are within about 1.8 meters from each other. We are far closer than 1.8 m while performing slit lamp and indirect biomicroscopy.

Tear film exposure raises additional concerns. One study in 2003 reported the SARS coronavirus was detected in tears.

 Tear samples were obtained from 36 patients initially suspected to have SARS. Of those tested, 8 patients were considered probable SARS and confirmed by serology to have SARS, while 28 were SARS suspects based on symptoms and/or history of known exposure. Of the 8 probable SARS patients, tear samples from 3 patients (37.5 percent) yielded positive polymerase chain reaction (PCR) results. None of the SARS suspect patients had a positive PCR result.

I am not sure 37.5 percent would be compelling today. I found it hilarious that the authors noted, “Gloves were changed when collecting specimens in between patients to minimize risk of contamination”

. I remember when all I had to do was change gloves. Excuse me while I wash my hands for 20 seconds, careful to tilt them down, dry them with paper towel, which I hold in my hand while I touch the door handle, then throw it away and put on my mask. I bleach the chair, slitlamp table and headrest, the counters, the stand, the door knobs, light switches, and anything a human touched during the interaction, and then bleach the green flag outside the room door which I gleefully position to say, “Look, everyone, this room is clean”. But I digress.

Poll: What percentage of your pre-COVID patient base are you currently seeing?

A recent study of 17 COVID-19 patients found no evidence of the virus in tear samples tested using reverse‐transcription polymerase chain reaction (RT‐PCR) assay for the detection of SARS-CoV-2.

A second study investigated the tear secretions of 30 confirmed coronavirus pneumonia patients. Tear and conjunctival secretions were collected twice during a 2- to 3-day period with disposable sampling swabs for reverse transcriptase PCR (RT‐PCR). Only one patient’s tears tested positive for SARS-CoV-2. He suffered conjunctivitis when the samples were taken, leading the authors to conclude that SARS‐CoV‐2 may be detected in the tears and conjunctival secretions in COVID-19 pneumonia patients with conjunctivitis.

A third study of 43 patients with severe, confirmed cases of COVID-19 utilized RT-PCR to identify virus in the tear and conjunctiva. One patient has conjunctivitis. Three (7 percent) tear samples were positive for SARS-CoV-2, including the patient with conjunctivitis. All patients with positive tear RT-PCR results had positive nasopharyngeal RT-PCR results.

Related: Committed to safety: One OD’s COVID-19 response

Tear samples were taken from 27 pediatric patients who tested positive using nasopharyngeal swabs for COVID-19 upon admission. Mild viral conjunctivitis was observed in 4 patients (15 percent). Conjunctival swab RT-PCR testing was positive in 3 patients (11 percent), 1 with symptomatic conjunctivitis, and 2 asymptomatic for conjunctivitis.6 Based on these studies, the transmission of SARS-CoV-2 is low, but caution should be taken in COVID-19 patients presenting with conjunctivitis. I am confident no optometrist needed to read this to know that he should not do tonometry on a COVID-19 patient with conjunctivitis.

Options for IOP measurement include Goldmann tonometry, Tonopen, noncontact tonometry (NCT), iCare, and transpalpebral tonometry. While certainly the standard for IOP measurement, the required proximity and the reuse of the tonometer tips make us nervous with COVID-19 exposures. Suggestions to reduce transmission risk include limiting IOP measurement to required cases such as recent postoperative patients, glaucoma patients, those taking topical steroids, or new patients where a baseline IOP is lacking. Multiuse tonometry devices should be cleaned per published guidelines prior to March 2020.

Alternatively, disposable tips may be used, or it may be replaced with an alternative method.

Tonopen applanation tonometry is based upon the Mackay Marg principle. The device requires anesthetic drops but does use disposable tip covers. This is advantageous when you would rather be an arm’s length away from the patient’s eye when performing IOP measurement compared to the 8 inches with Goldmann. Inter-instrument agreement and validity have been reportedly high, and its measurements correlate well with Goldmann tonometry.

 Lower IOP values in patients with IOP greater than 20 mm Hg on Goldmann have been reported.

Related: Life with COVID-19 makes a new normal

The use of NCT has been questioned given the risk of spreading viral infection via tear dispersion. NCT uses a brief burst of pressurized air to applanate the cornea and measure IOP. Photographic analysis during performance of NCT found most eyes has some degree of tear film dehiscence and micro aerosol formation.

A recent study evaluated aerosol measurements using NCT in 60 eyes of 30 subjects wearing masks and unmasked.

Aerosol measurements were preformed using an 10000S+ air quality detector (Temtop). With repeated measurements, the aerosol particle numbers cumulatively increased. The density of the particle number was higher in unmasked subjects due to breathing compared to masked, but the difference was not significant. Investigators recommended staff wear medical goggles and mask while performing NCT. They further recommended a protective baffle should be placed between the technician and the patient.

The iCare tonometer is based on a rebound measuring principle to measure IOP. It does not require anesthetic drops and does not cause dispersion of tears. Its popularity prior to COVID-19 was patient response to the test, which was excellent. Its current popularity is more likely based on the device’s single use probes. I was surprised to note that even my local glaucoma specialist has been using iCare post-operatively since February 2020. Rebound tonometry has been found to correlate well with Goldmann IOP measurements, and also found to agree with Goldmann in eyes S/P corneal grafts.

Transpalpebral scleral tonometry is available. I am sure patients will consider this just as good as gas at the dentist. This device is based upon determining the acceleration of a freely falling rod as it rebounds against the tarsal plate of the eyelid through the sclera. While initially recommended for corneal disease such as ulcers, severe keratitis, and keratoconus, and postoperative corneal conditions,

 the Diaton (DevelopAll Inc., formerly BiCOM) tonometer’s applicability has expanded now that we would like to avoid touching the cornea while 8 inches from the patients face. Corneal biomechanics are less likely to influence measurement with this method, since there is no applanation of the cornea, which may be advantageous following keratorefractive surgery.

 No anesthetic is required, and patients look down when the test is performed.

Some comparisons of IOP measurement between examiners as well as to Goldmann have found no significant differences,

 while other studies have found poor agreement with Goldmann applanation tonometry, and voiced concern for its use in routine clinical practice.

 In the current climate where ODs want to provide care in the safest manner possible, evaluating IOP with a wider range of error while reducing infection risk may be more acceptable. There is a learning curve, but users have reported the online training is good.

I personally have increased my use of Tonopen and reduced my performance of Goldmann. I appreciate hand-held units, especially for my planned parade of in-car IOP checks should a second lockdown occur.

More by Dr. Swartz: Can azithromycin treat COVID-19?

1. McDermott G. Ophthalmologist Shares Experience Implementing Drive-Through IOP Checks Into Practice. 

https://eyewire.news/articles/ophthalmologist-shares-experience-implementing-drive-through-iop-checks-into-practice/

2. Loon SC, Teoh SC, Oon LL, Se-Thoe SY, Ling AE, Leo YS, Leong HN. The severe acute respiratory syndrome coronavirus in tears. 

3. Seah IYJ, Anderson DE, Kang AEZ, Wang L, Rao P, Young BE, Lye DC, Agrawal R. Assessing Viral Shedding and Infectivity of Tears in Coronavirus Disease 2019 (COVID-19) Patients. 

4. Xia J, Tong J, Liu M, Shen Y, Guo D. Evaluation of coronavirus in tears and conjunctival secretions of patients with SARS-CoV-2 infection. 

5. Karimi S, Arabi A, Shahraki T, Safi S. Detection of severe acute respiratory syndrome Coronavirus-2 in the tears of patients with Coronavirus disease 2019. 

6. Valente P IG, Federici M, Petroni S, Palma P, Cotugno N, De Ioris MA, Campana A, Buzzonetti L Ocular manifestations and viral shedding in tears of pediatric patients with coronavirus disease 2019: a preliminary report. 

. Available at: https://www.aaojournal.org/article/S0161-6420(20)30314-6/pdf. Accessed 7/3/2020.

8. Ng V, Tang G, Lai T, Tang E, Li K. Intraocular pressure measurement during COVID pandemic. 

9. Schweier C, Hanson JV, Funk J, Töteberg-Harms M. Repeatability of intraocular pressure measurements with Icare PRO rebound, Tono-Pen AVIA, and Goldmann tonometers in sitting and reclining positions. 

10. Lester M, Mermoud A, Achache F, Roy S. New Tonopen XL: comparison with the Goldmann tonometer. 

11. Britt JM, Clifton BC, Barnebey HS, Mills RP. Microaerosol Formation in Noncontact 'Air-Puff' Tonometry.

12. Chunchun L YT, Zhangyan C, Aisun W, Xiaoqiong H, Yanyan C, Jia Q. Aerosol formation during non-contact “air-puff” tonometry and its significance for prevention of COVID 19.

13. Salvetat ML, Zeppieri M, Miani F, Tosoni C, Parisi L, Brusini P. Comparison of iCare tonometer and Goldmann applanation tonometry in normal corneas and in eyes with automated lamellar and penetrating keratoplasty. 

14. Chakraborty AK, Majumder M, Sen S. Comparison of transpalpebral tonometer with Goldmann applanation tonometer. 

15. Margarita Rozhdestvenskaya M, Dr. Alexey Dashevsky, Munchen, Prof. Dr.Ing. Dr. Habil. Konstantin Kotliar, FH Aachen and Campus Julich. Advantages of the extra corneal diatom tonometry in patients before and after photo refractive intervention Joint Event on 3rd Edition of International Conference on Eye and Vision & 2nd International Conference and Expo on Advanced Eye Care and Cataract. June 14-15, 2018 Rome, Italy.

16. Rozhdestvenskaya M DAaKK. Repeatability and inter-examiner reliability of non-corneal tonometry using Diaton. 

17. Doherty MD, Carrim ZI, O'Neill DP. Diaton tonometry: an assessment of validity and preference against Goldmann tonometry. 

18. Gunvant P, Miller B, Dalton K. Evaluation And Comparison Iop Estimates Obtained With Diaton Tonometer With Other Clinical Tonometers. 

Is noncontact tonometry still safe to use?

The challenge of measuring IOP in COVID era

CRANBURY, N.J., Aug. 4, 2021 /PRNewswire/ -- 

®, the leading resource of news and information for optometry professionals, is thrilled to announce its Strategic Alliance Partnership (SAP) with the Optometric Cornea, Cataract and Refractive Society (OCCRS).

"As an organization that provides unparalleled support and resources to the niche refractive eyecare community, OCCRS has become a cornerstone of the ophthalmic specialty," said Mike Hennessy Jr., president and CEO of MJH Life Sciences™, parent company of 

®. "We look forward to the guidance that we will gain through this alliance with OCCRS as we continue to provide our readers with cutting-edge insights that impact patient care."

The SAP program partners leading medical associations with each other for national reach and visibility.

Organized in 2002 and chartered in 2004, the former Optometric Council on Refractive Technology, now OCCRS, allows doctors of optometry and vision care researchers to meet in an optometric educational venue to share information and ideas. The group encourages research on cornea, cataract, and refractive technology, hosts forums at which such research may be presented, develops and delivers educational programs on cornea, cataract, and refractive technology to the optometric profession. Throughout the year, OCCRS partners with a variety of eye-care organizations to offer virtual continuing education (CE) and plans to return to in person meetings in 2022.

OCCRS is a member-based, non-profit organization made up of primarily optometrists and ophthalmologists, but also welcomes residents, fellows, and students studying optometry, medicine, or osteopathy. Members often act as a resource for colleagues that may not be directly involved in surgical care, but whose patients seek such care. OCCRS supports collaborative care with surgeons for the benefit of patient care.

The SAP program partners leading medical associations, health plans, advocacy groups and medical institutions with each other for national reach and visibility. By utilizing the MJH Life Sciences™ communication platform, these groups can showcase cutting-edge initiatives, content, research and thought leadership. The SAP Program also fosters collaboration and an open exchange of information among trusted peers for the benefit of patients and their families.

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Optometry Times® Welcomes Optometric Cornea, Cataract and Refractive Society (OCCRS) to Strategic Alliance Partnership (SAP) Program

Years ago, I treated a police officer who presented for a dry eye evaluation. While other doctors before me had treated him with tears and punctal plugs, I used steroids and cyclosporine (Restasis, Allergan) to control his ocular inflammation. Following any use of pepper spray, he would see the departmental doctor who would insert plugs to improve his extremely dry eye.

This would inevitably backfire, and within 2 weeks he would return to the office begging me to remove his plugs. Each time I would remove them, treat with a topical steroid taper, and maintain topical cyclosporine. Despite my written instructions on how to better treat his ocular surface following exposure, this cycle went on for years.

As healthcare providers, ODs may be called on to assist those who have been affected by tear gas, pepper spray, and other agents used during periods of unrest. It is not their job to judge but rather to assist these patients by resolving pain and promoting healing. While exposure to these irritants may be common to military medical personnel, civilian practitioners may not be as familiar. This article is not meant to incite political discussion regarding the intended or actual use of these agents. It is to educate readers on the history of and management of exposure to them.

To begin, a historical perspective on chemical warfare may be of value. Chinese armies used “stink pots” in 2300 BCE during warfare. They burned red peppers in hot oil to produce offensive smoke to burden their opposition prior to attack. Japanese fighters ground peppers to a fine dust and wrapped the dust in rice paper to throw into the faces of opponents.

Wood saturated with pitch and sulfur was burned to create offensive smoke in the Peloponnesian wars (431 BCE). “Greek fire,” a liquid containing sulfur, lyme, pitch, resin, and petroleum, was pumped into the water in front of ships and burned. Greek fire and hot oil were catapulted over walls in the Middle Ages.

Related: Handling ocular chemical burns in children and adolescents

Chemical agents in grenades of clay and glass jars were first used in the 13th century. Separate containers would contain two different chemicals, resulting in a chemical reaction when mixed.

Bacteriolgical warfare was first used in 1422 in Italy when cartloads of horse manure were launched over city walls to the detriment of those inside the city of Tarantine.

The Civil War saw the first chemical warfare in America. Wood covered with pitch and sulfur was burned around cities. Greek fire was used on coastal cities.

A German chemist developed chloroacetophenone, a chemical lacrimator, in 1869. In 1912, the French used chemical agents in glass containers. A lacrimator called ethyl bromacetate causing severe tearing, blepharospasm, and painful foreign body sensation was used by the French in World War I. In retaliation, Germans used chlorine gas pumped into enemy trenches. British soldiers created gas masks using two surgical masks with sodium carbonate powder between them.

During World War I, omega-chloracetophenone (CN) was used to train soldiers using masks. In 1913, Germans used diphenylaminechlorarsine (DM) to make enemies sick, requiring removal of gas masks to strengthen exposure.

 This was later used by British police during civil disorders, resulting in several deaths.

 It was declared a war gas by the United Nations and banned for export from the U.S. in 1958.

In 1928, scientists developed orthochlorbenzalmalononitrile (CS), which irritated the skin and respiratory system as well as the eyes. Lacrimators and irritants were widely used during World War II. English scientists developed dibenzoxaprine (CR) in 1962, but leaking containers caused third-degree burns on military police so it was discontinued.

Oleoresin capsicum (OC) was introduced in 1982. This inflammatory agent is produced from cayenne or chili peppers. It causes lacrimation, blepharospasm, and capillary dilation. The mucous membranes are directly affected, causing swelling in the nose throat. Skin inflammation may result. It is the most commonly used agent in policing, riot and crowd control, and self-defense, including defense against attacking animals.

Related: Lactoferrin levels can diagnose dry eye disease

General primary effects include lacrimation, conjunctivitis, sneezing, coughing, reduced vision due to tearing, nasal irritation, mild burning and itching of skin. Blepharospasm, salivation, nasal and throat congestion, dyspnea, nausea and emotional reactions are secondary. Productive cough, contact dermatitis, retching, epistaxis, diarrhea, pulmonary edema, distorted sense of taste may also occur.

High concentrations of CN may cause corneal damage, opacity, and permanent visual impairment. Papulovesicular dermatitis and superficial burns may affect periocular skin. Ingestion of food or water contaminated with CN may result in ulcers, nausea, vomiting and lower GI upset. Exposure to CS may result in abortion or premature labor and delivery in pregnant women. Hydrolysis of CN is slow in aqueous solution, difficult to decompose or decontaminate while CS can be easily inactivated using water with soap.

OC may cause more intense burning to eyes, nose, and respiratory tract than other products, with difficulty breathing due to throat closure, loss of motor skills, and inability to speak.

 OC is also associated with keratitis, conjunctivitis, corneal burns, and damage to nerve fibers.

Related: Homeostasis is the Holy Grail in dry eye disease

A peptide neurotransmitter called substance P is generated by nerve endings within the central nervous system (CNS) to transmit pain signals. Upon contact with skin, capsicum causes depletion of substance P, telling the brain the body is suffering life-threatening pain and results in disorientation. When Substance P is applied to small areas, transmission of pain from the area may be reduced, and this treatment may be used to address chronic pain. In the eye, however, this effect may be catastrophic.

Subtance P is also considered a polypeptide neurotoxin because aerosol inhalation causes rapid loss of blood pressure and may result in loss of conscieousness within seconds. Direct skin contact results in a similar but delayed reaction (10 to 15 seconds). Note than those with darker skin will have a significantly delayed reaction of up to 5 minutes. Prior exposure to pepper products will increase response time.

The Scoville Heat Scale was used in the 1920s to assess the “hotness” of certain foods; the foods were mixed with a sugar solution and sampled by five trained testers. This process was abandoned due to subjectivity and replaced by science such as high-pressure liquid chromatography. The unit of measure is the Scoville Heat Unit (SCH). Examples of levels of potency using this measure are noted in Table 2.

Unfortunately, it is common to boost the “hotness” level of OC products without information on boosting released to the public. In addition, different products may be blended to enhance effect. OC/CS combinations are referred to as “Fortified Mace” or “Freeze+P.”

The molecular target of capsaicin TRPV1 is a transient receptor potential (TRP) ion channel expressed in nociceptors.

 These receptors are part of the pain-sensing sensory nerves of the trigeminal, vagal, and dorsal root ganglia (DRG). Nociceptors are located in the skin, cornea, and conjunctiva, as well as in mucous membranes of the respiratory system. TRPV1 promotes neuronal depolarization when activated, acting as a warning sensor for imminent tissue damage.

 TRPV1 is sensitized through signaling from a range of G protein–coupled receptors including bradykinin, prostaglandin, nerve growth factor, cytokine and chemokine receptors.

The tear gas agents CS, CN, and CR have been linked to a single target, TRPA1, despite being structurally dissimilar. TRPA1 is also a TRP ion channel expressed in nociceptors. Pain neurobiological research has demonstrated that TRPA1 is also the target of mustard oil, wasabi, and horseradish. This will not come as a surprise to anyone eating these foods by mistake.

Ocular and nasal pain are sensed almost immediately after exposure to CN, CR, and CS as well as OC due to activation of TRPV1 and TRPA1 receptors in trigeminal nerve endings in the cornea and nasal passages. Chronic TRPA1 activity creates nerve calcium overload and excitotoxicity. This results in chronic pain signaling and peripheral neurodegeneration, a loss of sensation, or altered sensations.

 When ligands of TRPV1 and TRPA1 are applied topically, extensive desensitization and remodeling of cutaneous nerve endings may occur.

Corneal TRPV1 and TRPA1 activation provides immune responses to noxious environmental stresses such as temperature fluctuations, rises in ambient osmolarity, mechanical stretch, decline in pH, tissue injury, and exposure to irritant ligands.

 Expression of TRPV1 is demonstrated in the corneal epithelial cell membrane in addition to corneal nerve fibers.

 This is particular disconcerting for patients with diabetes and pre-existing neurotrophic corneal disease.

As previously stated, the most common effects of these agents include lacrimation, blepharospasm, conjunctivitis, keratitis, periorbital erythema, and edema.

Photophobia may occur. Because CR/CN/CS are solids, dust may be captured beneath the eyelid or embedded in the cornea or conjunctival tissue and require removal.

 OC solvents may cause corneal abrasions.

Periocular skin erythema and pain may be significant, particularly when the skin is raw or in high temperatures, humidity, or agent concentration. Erythema may occur hours after CS exposure, followed by vesication. This appears similar to a severe sunburn.

 Oral steroids may be required for severe dermatitis.

A study of 81 emergency department patients presenting for treatment following exposure to OC found ocular pain and redness were the most common presenting signs. Corneal abrasions and respiratory symptoms occurred with essentially identical frequency (7 and 6 patients, respectively).

Another study of ocular effects including contact lens wear was conducted with 22 police officers. Snellen acuity and anterior segment appearance were evaluated. Four brands of contact lenses were sprayed, cleaned twice using alcohol-based cleaner, and evaluated using gas chromatography. Acute ocular effects lasted 5 to 10 minutes with complete recovery in 60 minutes. All suffered conjunctivitis. Keratoepithelial defects (KEDs) were reported upon instillation of fluorescein stain. KEDs healed within 24 hours without treatment. Residue was noted on contact lenses despite cleaning. Recommendations included palliative treatment with water and immediate removal and disposal of contact lenses if exposed to OC.

Some evidence indicates that OC temporarily inhibits the blink reflex and limits responsiveness to mechanical and chemical stimuli to the eye.

Recurrent corneal erosions have also been reported.

More severe injuries to gas exposures have been reported including corneal stromal edema, conjunctival tearing, deep cornea deep vascularization vitreous hemorrhage, traumatic optic neuropathy, symblepharon, pseudopterygium, infective keratitis, trophic keratopathy, glaucoma, and cataracts.

Following are recommendations to decontaminate eyes and skin.

Thoroughly flush with water, saline, or similar substance. Note that water increases the effect of OC, so copious volumes should be used. Ensure no particles remain in ocular tissue. A study comparing the use of water versus baby shampoo with water found the use of baby shampoo was unhelpful following exposure to CS and OC.

Flush with copious amounts of water, soap and water, or a mildly alkaline solution (sodium bicarbonate or sodium carbonate). Decontamination is not needed if the wind is brisk and particles may be shaken off clothing and hair.

The pain from OC will increase with water, especially warm water. It is best to decontaminate with baby shampoo, milk (which contains casein), alcohol, or vegetable oil. Without decontamination, pain will subside over time.

Educate patients regarding delayed symptoms and signs of increased ocular surface disease. Patients should be instructed to contact the OD should symptoms progress rather than resolve. Autoinflammatory treatments such as hypochlorous acid, topical steroids, and NSAIDs may be beneficial. For those with repeated exposure, periodic evaluations to assess corneal health may be advised.

More by Dr. Schroeder Swartz: How to create an ocular surface disease treatment protocol

U.S. Army Medical Research Institute of Chemical Defense (2015-03-21) FE. RIOT-Control Agents. In: 

Medical Management of Chemical Casualties Handbook

. Fort Sam Houston, Texas: Office of The Surgeon General, Borden Institute; 2014:103-114.

Patton J. Gas in the Great War. University of Kansas Medical Center. Available at: http://www.kumc.edu/wwi/medicine/gas-in-the-great-war.html. Accessed 6/30/20.

National Institute of Corrections Community Corrections Division Chemical Agent Instructor’s Manual

. Washington, DC: Department of Justice National Institute of Corrections; 1990. Available at: https://www.ncjrs.gov/pdffiles1/Digitization/146592NCJRS.pdf. Accessed 6/17/20.

Water increases the effect of some pepper chemicals

Jessica Barr, COMT, ROUB

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