It's 4:30 on Friday afternoon and your receptionist tells you that a hysterical patient is on the phone. When you get the patient calmed down enough for intelligent communication, she tells you that her child was playing with a key ring and accidentally sprayed himself in the face with tear gas. The child is screaming and can't open his eyes.

What do you do? Tell the mother to call 911 because this is a life or vision threatening emergency? Have her take the child to a hospital emergency room as fast as she can? Or should you tell her to perform some simple first aid measures at home and then bring the child in if symptoms persist? To answer these questions and to formulate management plans for spray exposure cases, an understanding of the composition of the various defense spray products and how they affect the body is required.

PERSONAL DEFENSE SPRAYS

Active Ingredients
Most of the currently available defense sprays contain o-chlorobenzylidene malononitrile (CS), w-chloroacetophenone (CN), oleoresin capsicum (OC), or a combination of these active ingredients.(1) These agents belong to a class of compounds variously referred to as harassing agents, riot control agents, or lacrimators. Their effects are felt almost immediately upon exposure and generally resolve rapidly upon removal of the agent.(2-4) Harassing agents were used extensively during WW I, and have been widely used throughout the world by the police and military for crowd control and special operations since the early 1960's.(5,6)

Most agents in this category are popularly referred to as "tear gas." The term is a misnomer because the agents are not gases but are actually dispersed as aerosols or fine particulate sprays. Another commonly misused term is "Mace®." Mace is the brand name for a specific product containing CN, and should not be used as a generic term for all defense sprays.

Until the last decade, most personal defense sprays contained either CN or CS. More recently, OC has replaced CN and CS as the agent of choice for personal defense use because it seems to be more effective and has less potential for causing toxic side effects or environmental contamination.

A standardized color coding system has been adopted to assist in identifying the active agent in personal defense sprays. The color code is red for CN, blue for CS, and orange for OC. This color code usually appears as a dot or band on the spray canister, which can be helpful in determining how to manage exposure to various sprays.

CN
The chemical agent CN (w-chloroacetophenone) was first discovered in 1869 and was used extensively in WW I.(3,7) At normal temperatures, CN is a white crystalline solid that is only slightly soluble in water, and it is said to have an odor resembling that of apple blossoms.(8,9) CN is classified as a lacrimator because of its ability to cause intense tearing at very low dosages.

CN has been used in personal defense products since the 1920's. Among the first such products were tear gas pens and pistols that used a ballistic device, generally a blank pistol cartridge, to propel solid CN particles at an attacker.(2,6,10) Not surprisingly, numerous mechanical and chemical injuries to the eye resulted from the use of these products.

Unfortunately, reports on the toxic ocular effects of CN from this type of exposure were usually confounded by traumatic injuries from the blast effect of the delivery device, and this makes it difficult to determine with certainty the exact extent of ocular damage resulting from CN exposure. In addition, the blast effect can drive CN into the deeper layers of the cornea or even into the globe.(9-12) Such injuries would not be expected with exposures produced by personal defense sprays.

CN was marketed as a personal defense spray in 1965 by General Ordinance and Equipment Company under the brand name Mace. This product gained wide-spread popularity in the 1960's, and the term Mace is still incorrectly used as a generic term for all aerosol defense sprays.

A possible problem associated with the use of CN for personal defense is that it has been reported to have limited effectiveness against some individuals, notably those under the influence of alcohol or drugs, or those with certain mental disturbances.(13) Additionally, it can take several seconds for CN to achieve its full effect,(2,3) and the person using the spray would be vulnerable to attack during this time.

Exposure to CN at concentrations that might be produced by a defense spray usually results in extreme irritation of the eyes, burning pain, conjunctival hyperemia, lacrimation, and possibly blepharospasm. Concentrations of CN above those usually provided by defense sprays can cause more severe ocular complications including sloughing of the conjunctiva, corneal edema, and keratitis with subsequent risk of scarring. CN has also been reported to be capable of causing neuroparalytic keratopathy.(12)

High concentrations of CN can also cause significant non-ocular effects including respiratory tract irritation, a burning sensation and erythema of exposed skin, irritation and burning of the oral and nasal mucosa, nasal congestion, and cough. Some individuals can experience nausea, vomiting, and headache following CN exposure, and primary contact dermatitis, allergic dermatitis and blepharitis have also been reported.(3,12,14-17)

Extremely heavy exposure to CN (well beyond the levels that could be produced by typical personal defense sprays) can cause severe inflammation of the respiratory tract and cerebral edema. Several deaths have resulted from exposure to extremely high concentrations of CN in confined spaces.(18) The severity of effects produced by CN are concentration and time dependent with routine symptoms remitting rapidly after removal of the agent. The more severe pulmonary and cerebral effects are delayed responses which take hours or days after exposure to develop.(2,7,19)

CS
CS was first prepared in 1928 by Corson and Stoughton, and it takes its designation from the initials of their names. It was further developed by the British as a riot control agent in the 1950's, in part due to dissatisfaction with the performance of CN.(5) CS came into widespread use in the 1960's, and, because of its greater effectiveness and lower potential for toxicity, largely replaced CN as the agent of choice for military and police crowd control missions. Also classified as a lacrimator, CS is a white crystalline substance with an odor of fine pepper. On a by weight basis, CS is approximately ten times as effective as CN.(6,8,9,20)

The effects of CS are similar to those of CN.(21) However, in part due to the lower concentrations required to achieve an equivalent response, CS is less likely to cause significant eye injuries, dermatitis, or toxic systemic effects.(3,22) Although CS exposure has been shown to be capable of causing death in laboratory animals,(5,7,19,23,24) controversy exists over reports of human fatalities directly attributable to the toxic effects of CS.

OC
Oleoresin capsicum is the newest addition to the list of active agents used in defense sprays. It is a reddish-brown liquid derived from plants of the genus capsicum, commonly referred to as hot peppers or chilies.(25) The active ingredient believed to be primarily responsible for the irritative properties of OC is capsaicin, a white crystalline compound that is virtually insoluble in water.(26,27) At least four separate, naturally occurring homologues of capsaicin have been isolated from pepper plants, the principle form (approximately 70%) being trans-8-methyl-N-vanillyl-6-nonenamide.(1,28,29) A synthetic version of capsaicin is also available which might have physiological effects somewhat different from the naturally occurring capsaicinoids.(30)

In addition to capsaicin, OC contains over 100 distinct volatile compounds which might interact to produce effects significantly different from pure capsaicin.(30) Since OC is a plant derivative, its exact chemical composition varies with the type of pepper used, its age, the parts of the plant from which the extract is obtained, and numerous other factors.(25,30) As a result, the Scoville Heat Unit (SHU) is often used to compare the relative potency of OC products. Using this system, pure capsaicin is rated at 15 million SHU's; the OC found in personal defense sprays typically has a rating of about 1.5 million SHU's.

Personal defense sprays containing OC were first developed in the 1970's as an alternative to CN and CS sprays, and have gained widespread acceptance by law enforcement agencies and the public. The manufacture and use of OC sprays increased dramatically following the 1989 publication of a favorable three year FBI study on the use of CAP-STUN, an OC based product. In the FBI study, over 800 subjects were either sprayed directly in the face with aerosols containing from 1% to 5% OC or were exposed to 1% to 10% OC disseminated from aerosol grenades in an enclosed space. No long-term adverse medical effects were noted in either situation, and no medical treatment was required by any of the subjects.(b)

Following release of this study, the use of OC sprays became so popular that a 1992 Washington Post article reported over 2000 law enforcement agencies were using pepper sprays.(31) The popularity of OC sprays has now increased so much that current industry estimates indicate at least 15 million defense spray canisters (a majority containing OC) were manufactured in the three year period from 1992 through 1994.(c)

One of the reasons for the widespread acceptance of OC sprays is the fact that they overcome some of the problems associated with CN and CS products. Specifically, the OC sprays are effective in producing immediate blepharospasm and incapacitation of almost all subjects including those who are intoxicated or mentally ill,(32) and they are also effective against animals. Beyond these advantages, there are no known long-term toxic effects produced solely by the topical application of OC, and there are no environmental contamination problems associated with its use.(32)

When applied topically, capsaicin produces an immediate inflammatory reaction in mucous membranes. In the eye, it produces blepharospasm probably caused by irritation of corneal nerves, extreme burning pain, lacrimation, conjunctival edema, and hyperemia. In animal studies, it has also been shown to produce miosis and aqueous flare.(33)

In the nasal mucosa, capsaicin produces burning pain, sneezing, and a dose dependent serous discharge.(34,35) Contact with the skin produces burning pain and erythema without vesiculation.(36) Capsaicin inhalation results in transitory bronchoconstriction, cough, and retrosternal discomfort.(37-40) In dogs, direct administration of extratracheal capsaicin aerosol has been shown to produce apnea, bradycardia, and hypotension.(41)

To date, no substantiated cases of human death resulting strictly from OC sprays are known. However, several cases of in-custody deaths following exposure to pepper sprays have been widely publicized. In these cases, positional asphyxia and/or prior drug use were generally implicated as the direct causes of death.(42)

Carriers
In addition to the active ingredients, personal defense sprays contain some form of carrier vehicle in which the active ingredient is dissolved or suspended. Common carriers include alcohol, water, organic hydrocarbons, and methylene chloride.(32,43) In addition to keeping the active ingredient in an appropriate state for aerosol dispensing, the carrier can also increase the effectiveness of the spray by improving penetration, removing skin oils, or prolonging contact time. If they reach the eyes, some carriers can also cause temporary ocular irritation or superficial keratitis.

Propellants
The third component in personal defense sprays is the propellant used to expel the active ingredient from the canister. Commonly used propellants include propane, butane, and compressed gases (e.g., carbon dioxide or nitrogen).(43) Virtually any propellant found in common household aerosol products can be used in personal defense sprays.

Legal Aspects of Personal Defense Spray Possession and Use
Federal laws prohibit the transportation of defense sprays on commercial aircraft.(44) The reason for this prohibition is obvious; given the fact that most aircraft re-circulate a considerable percentage of cabin air, a leaking or ruptured canister could incapacitate the flight crew as well as passengers.

Although no state is known to have laws requiring that use of a defense spray must be formally reported health care providers treating spray exposure cases should consider making a formal or informal report of the treatment to the police, especially if it is suspected that a "hostile" spray exposure occurred.

EFFECTS OF OC SPRAY ON THE EYES

To assess the effects of OC on acuity, corneal integrity, and conjunctival appearance, a total of 22 subjects participating in police training sessions were evaluated.

After being sprayed with a product containing 5% OC (Punch II, manufactured by AERKO International, Inc., Ft Lauderdale, FL) all officers experienced immediate and intense blepharospasm, conjunctival injection, burning pain, mild respiratory difficulties, excessive mucus secretion, and incapacitation. These effects were transient and lasted between 30 to 45 minutes.

Visual acuity was measured approximately 15 minutes after spray exposure and was unchanged from pre-exposure levels for all subjects. Some subjects experienced superficial cornea "water-spot" shaped staining, probably as a result of exposure to the alcohol carrier in the spray. Staining was not detectable 24 hours after exposure.

IMMEDIATE MANAGEMENT OF SPRAY EXPOSURES

Though frightening, the direct result of OC defense spray exposure is rarely serious or life threatening. However, anxiety, fear, and disorientation, sometimes to the point of panic, are normal reactions in untrained individuals,(3,6,32) therefore providing reassurance is a valuable part of any immediate intervention. Victims should be moved away from any continuing source of exposure, and then checked for signs or symptoms of serious systemic distress such as cardiac or respiratory problems beyond those typically associated with spray exposure. Transient and self-correcting increases in blood pressure and heart rate can be expected as a result of anxiety,(6,48,49) but it is also possible that pre-existing cardiac or respiratory conditions could be aggravated in susceptible individuals.(6,19,32)

The goal of immediate aid is to make the patient more comfortable and speed the recovery from spray exposure; however, almost all patients will recover completely in an hour or less, even if no aid is provided. Although the risk of complications is low, patients should be advised that problems could develop and should be instructed to seek further aid if unexpected signs or symptoms occur.

Patient Decontamination
The emphasis in immediate treatment is to remove the source of irritation. Simply guiding the patient to an uncontaminated area and allowing fresh air to circulate over exposed areas will assist in recovery. Increasing circulation by fanning the exposed area will also speed the process. Contaminated clothing should be removed and bagged in plastic until it can be cleaned or discarded. Then the affected skin and mucous membranes should be irrigated with copious amounts of cool water to help soothe the burning sensation and flush away spray residual. If the patient was sprayed with CS, irrigation can result in temporarily increasing the burning sensation, but it should still be attempted. With any spray exposure, patients should avoid rubbing affected areas because this tends to spread any residual agent and work it into open pores.(12,19,21,23,50,51)

Washing the face and eyelids with a mild, oil-free soap (e.g., Ivory) will help break down the oily OC resin and speed its removal from the skin. After any spray exposure, the skin should be blotted dry rather than rubbed and care should be taken to avoid recontamination from used towels.

As the symptoms abate and the patient is able to open the eyes, it is helpful to irrigate the upper and lower palpebral cul-de-sac because spray residuals tend to collect in these locations and become entrapped. If the patient is wearing contact lenses, they should be removed at this time.

Environmental Decontamination
No special decontamination procedures beyond laundering and/or exposure to fresh air are required for removal of OC from clothing. Simple aeration of contaminated areas and materials for 45 minutes is reported to adequately disperse any residual OC from defense spray exposure.(32,43)

Decontamination procedures for CN or CS formulations that might be found in personal defense sprays should also include laundering and aeration.

Procedures required for decontamination of environmental areas such as houses or cars exposed to CN or CS are dependent on the degree of exposure and the agent used. The quantities of CN or CS that would normally be generated by the use of a personal defense spray should require no more than aeration to remove any perceptible residue.

Decontamination following extremely heavy exposures to CN or CS (beyond the levels that might be expected from the use of personal defense sprays) could be more of a problem. Although not considered to be a persistent agent, CN in formulations and high concentrations that might be delivered by pyrotechnic devices (e.g., gas grenades) can penetrate plaster and rubber-based products resulting in long-term contamination of vehicles or homes. Residue in furniture, carpets, and other fabrics can be neutralized by treatment with alkaline solutions and steam,(8,51) but this process could require the services of professionals.

CS is somewhat more persistent than CN and very heavy concentrations (again beyond the levels delivered by personal defense sprays) can be absorbed into most porous surfaces. Decontamination of clothing, homes, and vehicles contaminated by CS can be difficult and is best accomplished by using strong alkaline solutions or sodium hypochlorate with steam.(8,51) As with CN, professional services could be required for comprehensive decontamination.

Decontamination of Contact Lenses
It is inevitable that patients wearing contact lenses will be exposed to defense sprays. Obviously, the lenses should be removed as quickly as possible following spray exposure, but there is a question about whether lenses can be decontaminated. Reports from police training exercises indicate that although rigid lenses can be cleaned and reused with no ill effects, soft contact lenses might retain sufficient contamination to make them unwearable.

Two previous studies have addressed this issue and found that soft lenses exposed to CN and CS did not retain any residual contamination. In fact, it was suggested that the lenses might even have provided some corneal protection for the wearers.(52,53) Unfortunately, the studies do not specify how the lenses were analyzed for residual contamination, and, therefore, do not provide a definitive answer regarding the ability to decontaminate soft lenses exposed to CN or CS.

To address the question of soft lens decontamination following OC exposure, four brands of soft lenses were sprayed with Punch II spray containing 5% OC and sent to the Bausch and Lomb Contact Lens Division for analysis. Lenses were cleaned two times each according to manufacturer's instructions with contact lens cleaners recommended for the lenses and OC residues were extracted with 5 mL of tetrahydrofuran for a minimum of 24 hours. Gas chromatography was used to determine whether there was any residual capsaicin remaining in the lenses.

The majority of lenses remained slightly discolored after cleaning, and residual capsaicin was detected, but at fairly low concentrations.(d) It is possible that these concentrations would be too low to cause acute difficulties, but the risk of chronic problems cannot be ruled out. Therefore, it seems prudent to recommend discarding any soft lenses that have been exposed to OC. Although the ability to decontaminate lenses exposed to CN or CS was not specifically evaluated, soft lenses exposed to these agents should also probably be discarded.

IN-OFFICE MANAGEMENT OF SPRAY EXPOSURE PATIENTS

Some spray exposure patients will require an in-office evaluation. These patients could simply be concerned about the possibility of ocular damage or might be suffering from corneal, conjunctival, or dermatologic symptoms beyond those normally expected.

If at all possible, patients presenting for in-office examinations should be decontaminated prior to arrival; this will preclude exposure of other patients or office personnel.(23) It has been shown that residual contamination which does not affect the patient can still cause acute reactions in previously unexposed personnel.(54)

Examination of a spray exposure patient should follow a pattern similar to an examination for any chemical exposure, and should include history (with special emphasis on any potential legal issues regarding the circumstances of the exposure), acuity measurements, external evaluation of the eye and adnexa, and slit lamp evaluation of the anterior segment. Additional irrigation might be required if the patient complains of discomfort or if spray residual is detected. During the examination, practitioners and staff should wear gloves to prevent contamination and transfer of spray residual.(6,54) Even in the absence of a burning sensation on the skin, spray residue can still cause irritation of mucous membranes.(55) For this reason, patients should be cautioned that even after thorough washing, exposed fingers can still cause significant irritation if they touch mucous membranes.

After the examination, office equipment that has come in contact with the patient should be thoroughly cleaned before reuse.

Complications Associated with Exposure to OC
Complications resulting from OC exposure appear to be quite rare. Despite its widespread usage, the lack of case reports in the medical literature involving OC sprays substantiates this. In fact, studies involving application of pure capsaicin directly to the human cornea have shown that it does not cause damage.(56) However, as previously noted, OC contains over 100 volatile compounds in addition to capsaicin, and some of these could conceivably affect the cornea.

Corneal trauma not related to the OC itself can result from eye rubbing following exposure, vigorous irrigation, or from the effects of other spray components. Corneal exposure to an alcohol carrier could result in significant corneal epithelial erosion that might require treatment.

Management of any mechanical trauma accompanying the spray exposure should be based on presentation and could require the use of topical anesthetics, antibiotics, cycloplegics, topical corticosteroids, and/or pressure patching as appropriate. Topical antibiotic prophylaxis should also be considered in any case of corneal epithelial damage in which non-sterile irrigating solutions were used for first aid.

Although unlikely, OC spray exposure could result in dermatologic reactions on the face and eyelids. Repeated, prolonged exposure to capsicum extracts (e.g., in persons whose work requires them to handle peppers daily) is known to cause contact dermatitis, and numerous substances, including topical steroids, have been suggested to alleviate the symptoms or promote healing.(55,57-59) Only a single case of allergic dermatitis has been reported following exposure to a defense spray containing OC.(60)

Complications Associated with Exposure To CN
In cases of limited exposure to CN, such as would be produced by defense sprays, there is only a slight risk of complications. However, animal studies and human case reports have suggested that excessive or improper use of CN aerosols might cause ocular damage. For example, heavy or prolonged exposure, or application of sprays from close distances (e.g., at less than 2 meters) can result in loss of corneal epithelium, stromal edema, and iritis.(5,10,45,61-63) Beswick notes that a short-term rise in intraocular pressure can occur as an infrequent consequence of exposure to riot control agents,(6) and Berger, et al, reported a single case of persistent elevated IOP in a police officer who experienced long-term systemic exposure to CN from a leaking canister of Mace.(64) These IOP increases are probably exceptions and no significant relationship between IOP and spray exposure is know to exist.

Evaluation of spray victims should also include examination of the skin around the eyes. CN has been shown to be a potent sensitizer, and contact or allergic dermatitis resulting from repeated exposure to it are well documented. Penneys reported that after initial sensitization, subsequent contact with CN exceeding one minute in duration could result in dermatitis.(15)

Treatment of allergic blepharitis or dermatitis involving the ocular adnexa might require the use of topical corticosteroids and/or oral antihistamines depending on severity.(3,50)

Complications Associated with Exposure to CS
As with OC and CN, complications associated with single exposures to CS from defense sprays are rare. Several studies have found no long-term ocular problems following application of this agent.(65-71) The ocular pain associated with exposure usually subsides within minutes after removal of the agent, but the conjunctivitis can persist for up to 30 minutes.(2,3)

Although not as potent a sensitizer as CN, CS can cause allergic blepharitis and contact dermatitis.(22) Severe exposure might even result in blistering of the skin.(3,24) Irrigating the skin with solutions in the pH range of 9-10 can help neutralize CS contamination,(21,24,50) but caution should be exercised if any of these neutralizing solutions are used near the eyes because they can cause corneal damage.(24)

FIRST AID PROCEDURES FOR SPRAY EXPOSURE

1. Calm the patient.
2. Move the patient to fresh air and/or provide adequate ventilation.
3. Check for acute pulmonary or cardiac complications arising from aggravation of pre-existing conditions, or from trauma. If present, call for emergency medical personnel.
4. Flush affected areas with copious amounts of cool water. Irrigate the eyes with sterile saline if available. Skin should be washed with non-oil based soap if available.
5. Remove contaminated clothing and contact lenses.
6. Monitor. Significant improvement should be noted within 15-30 minutes after exposure. If symptoms persist or are severe, the victim should be evaluated by appropriate medical personnel.
7. Provide comprehensive ocular evaluation and treatment as for any suspected chemical injury.
8. Remember that the patient will likely recover even if no first aid is provided, so avoid "heroic" measures that could cause iatrogenic injury.

SUMMARY

At least 15,000,000 Americans now carry personal defense sprays, the majority of which contain OC. The ubiquity of these sprays makes it almost certain that optometrists will be called upon to render first aid and/or office treatment for spray victims.

When providing first aid, it is important to keep several things in mind. First, potential helpers should avoid being contaminated by the active agent in the spray; it is difficult to help a spray victim if the rescuer is experiencing blepharospasm or ocular distress. Next, remember that moving the victim to an uncontaminated area and irrigating the affected areas with sterile saline or cool water will help speed recovery from the spray effects. Whether first aid is available or not, however, the vast majority of spray victims will recovery in an hour or less with no complications.

When complications do arise, they are usually caused by excessive or prolonged exposure, mechanical trauma, or pre-existing health problems. In these cases, emergency medical care or an office examination to check for ocular damage is appropriate. Such problems would be unlikely in simple cases of exposure to an OC spray, and only slightly more likely to occur with exposures to CN or CS sprays.

Office personnel should be taught to evaluate, reassure, and triage spray victims by telephone. Patients experiencing significant systemic problems (e.g., cardiac or respiratory) should be assisted in contacting emergency medical personnel. Others should be instructed to irrigate the affected areas with sterile saline or cool water while taking care not to re-contaminate themselves with spray residue from the irritant. They should also be instructed to remove any contact lenses as soon as they are able to do so in a manner that will not re-contaminate the eyes. Spray exposure patients should be contacted every 15 minutes for at least an hour to assure that decontamination and recovery are progressing normally.

During triage, it should also be determined whether the spray contained OC, CN, or CS because the possibility of complications is slightly higher with CN or CS. Finally, if after one hour recovery is not essentially complete, or if concerns regarding possible complications warrant it, the patient should be seen in the office for any required follow-up care.

In general, exposure to personal defense sprays is a painful, traumatic, and extremely unpleasant experience, but it is neither life or vision threatening. This fact should be kept in mind when rendering aid to spray victims.

ACKNOWLEDGMENTS

We thank Mr. Kevin Dallett, Vice President of AERKO International Inc., Ft. Lauderdale, FL for providing samples of PUNCH II defense sprays and for preparing sprays without methyl salicylate or OC; Dr. Frank Tasber, Bausch and Lomb, Rochester, NY for determining whether OC residual could be removed from soft contact lenses; Mr. Paul H. Wilson of PW Distributing, Inc., Salem OR for inviting us to police training sessions on the use of defense sprays and for providing some of the photographs used in this paper; and Dr. Richard Whitely, Jr. for assistance in an early phase of the contact lens decontamination portion of the study. We also thank Bausch and Lomb, Ciba, and Wesley Jessen for donating contact lenses and solutions. Most of all we thank the police officers from many departments in Oregon who allowed us to examine their eyes before and after exposure to OC. These acknowledgments do not necessarily imply acceptance of or agreement with any of the statements made in this paper. During the time this project was conducted, Michael Janin was a consultant for AERKO International, Inc.; the other authors had no proprietary interest in any of the products discussed in this paper. The design, data analysis, and presentation of this study were not influenced by any of the organizations that provided material or technical support. Dr. Lee was an officer in the United States Army Medical Service Corps. and a Masters student at Pacific University College of Optometry during the time this project was conducted. The views expressed are those of the authors and do not necessarily reflect the views of the Department of the Army or the Department of Defense. The Government is authorized to reprint copies of this paper, notwithstanding any copyright notice hereon.

FOOTNOTES

a. An earlier version of this article appeared as Lee, RJ, Yolton, RL, Yolton, DP, Schnider, C, Janin, ML. Personal Defense Sprays: Effects and Management of Exposure. 1996. J Amer Optom Assoc. 67(9):548-60, copyrighted by the American Optometric Association. This modification of the original paper is by permission of the American Optometric Association.

b. Sections of undated Department of Justice FBI reports entitled "Chemical Agent Research: Oleoresin Capsicum," and "Oleoresin Capsicum Training and Use."

c. Personal communication from Mr. Kevin Dallett, Vice President, AERKO International, Inc., Fort Lauderdale, FL, December 1994.

d. Personal communication from Dr. Frank Tasber, Bausch and Lomb, Inc., Rochester, NY, December 1994.

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