Pepper spray is a legal and non-lethal form of self-protection commonly used by police, security guards, and civilians against assailants. The active ingredient in pepper spray is capsaicin, which is an oily extract from chili pepper plants. The spray’s recommended target is the eyes because of its immediate onset of action inducing pain, tearing, blurred vision, and blepharospasm. A single exposure to pepper spray is intended to cause a minor and transient ocular surface injury that is relatively harmless to the cornea and conjunctiva.

However, serious and long-lasting ocular damage can result with delayed management (i.e., prompt irrigation and medical care). Hua and Hughes (2013) presented a case report of a 27-year-old male who suffered a large central corneal abrasion secondary to a pepper spray exposure.

A Burning Problem

Our patient is a 36-year-old male who at age 22 was on the wrong end of a pepper spray incident that caused significant corneal and conjunctival damage to his left eye. Entering visual acuities without correction were right eye 20/20 and left eye 20/400. Slit lamp examination of the left eye showed superior corneal/conjunctival scarring and pterygia formation secondary to the suspected stem cell compromise from the initial injury (Figure 1). It is impossible to know how much of the ocular surface damage was caused by the initial exposure to the pepper spray mixture, the violent rubbing, and/or the delays in irrigation and medical treatment.

Figure 1. Slit lamp appearance of the patient’s left eye post-pepper spray injury.

The inferior two-thirds of the pupillary axis was relatively clear; therefore, an improved visual acuity was expected with the contact lens refraction. The posterior segment examination of the left eye was within normal limits. Corneal topography was attempted on the left eye, but failed due to the corneal scarring.

An Underlying Condition

The patient was diagnostically fitted with a scleral lens (Figure 2), and the best-corrected visual acuity (BCVA) was 20/60. This was somewhat less than anticipated based on the slit lamp exam. Anterior segment optical coherence tomography (AS-OCT) showed a subepithelial scar with a thickness of about 60 microns at the level of Bowman’s layer (Figure 3). We suspect that the less-than-anticipated BCVA may be related to the subepithelial scar.

Figure 2. Diagnostic scleral lens on the patient’s left eye.

Figure 3. AS-OCT images of the patient’s left eye vertical (180º) meridian.

The patient was referred to a cornea specialist/ophthalmic surgeon for a possible superficial keratectomy or excimer laser phototherapeutic keratectomy (PTK) to remove the subepithelial scar.

This case illustrates the value of AS-OCT in helping to identify a central corneal scar that we missed during our initial slit lamp examination. CLS

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