Eur opean Rev iew for Med ical and Pharmacol ogical Sci ences 2015; 19: 2311-2317 The “Eyeballing” technique: an emerging and alerting trend of misuse

F.S. BERSANI 1,2 , O. CORAZZA 2, G, ALBANO 3, S. BRUSCHI 4, A. MINICHINO 2, R. VICINANZA 5, G. BERSANI 3, G. MARTINOTTI 6, F. SCHIFANO 2

1Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy 2School of Life and Medical Sciences, University of Hertfordshire, UK 3Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy 4Department of Ophthalmology, Ocular Immunovirology Service, Sapienza University of Rome, Rome, Italy 5Department of Cardiovascular, Respiratory, Nephrologic and Geriatric Sciences, Sapienza University of Rome, Rome, Ital y 6Department of Neuroscience and Imaging, Gabriele D’Annunzio University, Chieti, Italy

Abstract. – OBJECTIVE: Alternative meth - prevalence, characterize the effects, and identify ods of alcohol consumption have recently adequate forms of interventions for this emerg - emerged among adolescents and young adults, ing phenomenon. including the alcohol “eyeballing”, which con - sist in the direct pouring of alcoholic sub - Key Words: stances on the ocular surface epithelium. In a Alcohol eyeballing, Alcohol misuse, Substances context of drug and behavioural addictions abuse, Addiction, , New trends. change, “eyeballing” can be seen as one of the latest and potentially highly risky new trends. We aimed to analyze the existing medical litera - ture as well as online material on this emerging Introduction trend of alcohol misuse. MATERIALS AND METHODS: Literature on al - cohol eyeballing was searched in PsychInfo and Alcohol-use disorders are among the most rel - Pubmed databases. Results were integrated with evant medical and public health problems, result - a multilingual qualitative assessment of the ing in significant morbidity, mortality, and high database provided by The Global Public Health health care expenses and leading to adverse so - Intelligence Network (GPHIN) and of a range of cial, psychological, occupational, legal, and med - websites, drug fora and other online resources ical consequences 1-3 . According to the World between March 2013 and July 2013. RESULTS: Alcohol eyeballing is common Health Organization “Status Report on Alcohol among adolescents and young adults; sub - and Health in 35 European Countries 2013”, al - stances with high alcohol content, typically vod - cohol consumption has been identified as a major ka, are used for this practice across the EU and risk factor for the burden of disease and for pre - internationally. The need for a rapid/intense ef - mature mortality globally, and as a substantial fect of alcohol, competitiveness, novelty seeking problem in the European Region 1. In the Euro - and avoidance of “alcoholic fetor” are the most pean Union, 1 in every 7 deaths in men and 1 in frequently reported motivations of “eyeballers”. Local effects of alcohol eyeballing include pain, every 13 deaths in women in the group aged 15 - burning, blurred vision, conjunctive injection, 64 years is due to alcohol consumption, and alco - corneal ulcers or scarring, permanent vision hol is considered to be causally relevant for more damage and eventually blindness. than 200 International Classification of Diseases CONCLUSIONS: Alcohol eyeballing repre - (ICD)-10 three digit codes 1. sents a phenomenon with potential permanent In the past few years alternative methods of alco - adverse consequences, deserving the attention of families and healthcare providers. Health and hol consumption emerged among adolescents and other professionals should be informed about young adults, including the alcohol “eyeballing”, this alerting trend of misuse. Larger observa - which consists in the direct pouring of alcoholic tional studies are warranted to estimate the substances on the ocular surface epithelium 4.

Corresponding Author: Francesco Saverio Bersani , MD; e-mail: [email protected] 2311 F.S. Bersani, O. Corazza, G, Albano, S. Bruschi, A. Minichino, R. Vicinanza, et al.

This phenomenon, together with some other ing newspapers and magazines, were followed as behaviours like “choking” 5 , is typically associat - well. Additional searches were carried out in the ed with binge drinking and multiple substance database provided by The Global Public Health abuse. About 90% of the alcohol consumed by Intelligence Network (GPHIN). This is a secure youth under the age of 21 in the United States is Internet-based early warning system that gathers in the form of binge drinks and the teen binge- preliminary reports of public health significance drinking rate in Europe ranges between 28% and by monitoring global media sources near ‘real- 60% 6. It is known that binge-type drinking is a time’, 24 hours a day, 7 days a week basis. crucial step in adolescents’ progression to alco - GPHIN is operated by the Public Health Agency hol abuse and dependence 7 and that binge drink - of Canada, and monitors news sources and web - ing is usually associated with unintentional in - sites across the globe in 9 languages (e.g. English, juries (e.g., car crashes, falls, burns, drowning), French, Farsi, Portuguese, Arabic, Russian, Span - intentional injuries (e.g., firearm injuries, sexual ish, and Chinese simplified/traditional) 15 . Permis - assault, domestic violence), and many health sion for the study was granted by the School of problems including alcohol poisoning, sleep dis - Pharmacy Ethics Committee, Hatfield, UK (15 orders, altered neurodevelopment, anxiety and December, 2010; PHAEC/10-42). cognitive impairments 8-11 . Alcohol eyeballing can be seen as a new trend of misuse within the phenomenon of the rapid Results diffusion of new forms of addiction and drug abuse. This phenomenon represents not only an Only two brief communications regarding al - unprecedented challenge in the field of drug ad - cohol eyeballing were identified on PubMed and diction but also a fast growing challenge from so - PsycInfo 4,16 both published in 2013 in Spanish cial, cultural, legal and political perspectives 12-14 . language. A statement from the American Acade - Alcohol eyeballing has potential permanent my of Ophthalmology about “Vodka Eyeballing” adverse consequences and seems to be prevalent was released in 2010 17 . Several YouTube videos in the United States (US) and the United King - and articles in online newspapers were identified dom (UK). However, recent alerts have also been through the other utilized search engines 18-24 . recorded in several EU Member States, Asia and Several online reports of personal experiences Oceania. Considering the above, we aimed here were identified as well 25-30 ; examples are provid - at firstly analysing the existing medical literature ed in Table I . as well as online material on this new way of al - cohol misuse. Ways of Consumption The eyeballing technique is performed by pouring alcoholic substances directly into the Materials and Methods eyes 4,16 . Substances with high alcoholic content are generally preferred, although cases of misuse The literature on alcohol eyeballing was of other substances (e.g., cinnamon schnapps searched in PsychInfo, Pubmed, EBSCO and Sco - [15-50% alcohol by volume [ABV]]) have also pus databases. Considering the very limited peer- been reported 19,21,22,29,30 . reviewed data, results were integrated with a mul - According to anecdotal online and media re - tilingual qualitative assessment of a range of web - ports, substances with high alcoholic content are sites, drug fora and other online resources (i.e.: generally preferred because young consumers newsgroups, chatrooms, mailing lists, e-newslet - believe that the desired effects (“highs”) can be ters, and bulletin boards). Between March 2013 achieved in shorter time; although the trend may and July 2013, exploratory qualitative searches of vary according to individual preferences, vodka websites have been carried out in English using (35-50% ABV) is currently the most commonly generic and specific keywords, such as “alcohol used . Alcohol eyeballing is usual - eyeballing”, “vodka eyeballing”, “”, ly performed in combination with alcohol oral in - “substances abuse”, and “college alcohol abuse” gestion 4,16,19,25,29,30 . in the Google search engine. These websites were monitored on a regular basis, daily, weekly or Diffusion monthly depending on relevance. Links from fo - Eyeballing seems to be a diffuse trend of rums, websites and other related material, includ - abuse among college and university students in

2312 The “Eyeballing” technique: an emerging and alerting trend of alcohol misuse

Table I. Relevant personal experiences related to vodka eyeballing.

Desired effects of vodka eyeballing “I just took some vodka in my eyeball and i feel funny. I did not have my eye open when i did it i just sort of blinked it in, and my eye feels funny like painfull. I have been drinking all day as well and that shot did more to me than any other i have had tonight” 26 . “It makes more sense than filling your stomach up with vodka, and getting drunk and sober at a less controllable rate” 29 . “It induces feelings of drunkenness at break-neck speeds, providing an instant high” 30 . Unpleasant immediate effects of vodka eyeballing “The other night me and a few friends decided to engage in the wonderful method of "eyeballing" shots of vodka. It hurt like nothing else and reaction to said method was to roll around on floor holding eye swearing and shouting. Apparently it gets you drunk faster, but none of us were brave enough to take a whole shot, so this is still to be confirmed” 25 . “Me and my girlfriend were at a party and one of her friends who was really drunk poured a shot of vodka in her eye. She says she is in a lot of pain and cannot see out of it” 27 . “I did that once before! The high volume of alcohol going into your eye will make your eye very bloodshot, sting and it give you a headache, or dizzy! The alcohol will affect you pretty much straight away!” 26 . “I've tried it, only once ,is very harmful for the eyes, it goes to your bloodstream faster for THE AMOUNT you use, how - ever you can drink more much faster so really, you can get drunker faster by drinking it normally” 28 . Unpleasant delayed/permanent effects of vodka eyeballing “My vision is okay but my eye is irritated and burning” 26 . “I'm in constant pain because of what I did, my constantly watering left eye has been left permanently scarred by my an - tics. It got more and more sore and bloodshot. It was as if I had conjunctivitis all the time. It was sore and weepy, very sen - sitive. I was really frightened” 30 . “At the moment, my vision is blurred in that eye, but that's because it's watering all the time. It's really sore and weepy. I've got used to the pain now. I just have to bear it. I don't think people can tell looking at me, but it is more bloodshot than the other one. It's never a clear white colour. It's hard to wear eye make-up because if anything goes in it, it's really painful and starts watering” 30 . Use of other types of alcohol “One of my friends did it at a party, repeatedly throughout the night about 4 years ago. He was using some sort of tequila, think it was called Samba. […] He never had any long lasting ill effects from it though, just at the time of doing it” 30 . “I've tried snorting and eyeballing a shot of single malt. That was pretty horrendous” 30 . the UK and the US , although recent alerts have Unwanted Effects also emerged in , Italy, France, Eastern Eu - Local effects of alcohol eyeballing include ropean Countries, Canada, Japan and Aus - pain, burning, blurred vision, conjunctival injec - tralia 16,18,20,23,31 . Its popularity is witnessed by tion, corneal ulcers or scarring, permanent vi - about 22,600 results on the Google Search en - sion damage and eventually blind - gine for the term “vodka eyeballing” 32 and by ness 19,22,25,30,34,35 . Systemic unwanted effects are about 1,500 clips on YouTube website 24 . A those of ethanol intoxication, including incoor - Google Trend search on “vodka eyeballing” re - dination, slurred speech, attention impairment, sulted in 2 main picks of search, in May 2010 anterograde amnesia, aggressiveness and poten - (greater pick, corresponding to the period of the tially coma and death 1. However, while the local first reports) and in January 2011, mainly local - effects represent a frequent and actual concern, ized in the US 33 . the ethanol intoxication is a rare possibility giv - en the small amounts that can be introduced by Desired Effects the eye. Pouring alcohol directly into the eyeball is considered by misusers an effective way to achieve a more rapid and intense effect of alco - Discussion hol (a “quick high”) by absorbing it through the “mucous membrane and veins at the back of the To the best of our knowledge, this work con - eye” 4,16,30,34 while avoiding the “alcoholic fetor” stitutes the first report on alcohol eyeballing . associated with its oral ingestion 4. Other relevant During the last decade, new drug trends have reported psychological motivations are competi - emerged among adolescents and young adults fa - tion among peers and novelty seeking 4,16,19,30 . vored by the ability of the Internet to disseminate

2313 F.S. Bersani, O. Corazza, G, Albano, S. Bruschi, A. Minichino, R. Vicinanza, et al. information and products quickly and efficient - petition among peers and novelty seek - ly 12,36,37 . The present work represents an overview ing 4,16,19,26,30 ; to this respect this bizarre way to of distribution, motivational bases, and physical misuse alcohol may be considered at the same effects of a new way of alcohol consumption level of other dangerous and trendy games of the consisting in pouring alcoholic substances direct - moment, such as “balconing”, “choking”, ly into the eyes. “planking”, “batmanning”, and “owling” 5. Some Since 2010, when the first reports appeared on reports indicate alcohol eyeballing as an initia - the Web, alcohol eyeballing has been encounter - tion ritual performed to enter a new group 44 . In ing growing popularity among students 4,16,19,30 . relation to this issue, a user anecdotally reported Although the exact origin remains unknown, that “ It was really painful. But bearing the pain American colleges or university campuses in UK is part of the competitiveness ”45 . The pain in - seem to be the places where this phenomenon duced by the eyeballing is actually severe and first arose 4,16,25 . Other anecdotal reports claim that sharp, as the cornea receives one of the densest alcohol eyeballing would have started as a night - sensory innervations of all the body, which is ex - club trick performed by bar attenders willing to clusively composed from small-fiber nociceptive increase they tips in the US, especially in Las Ve - (pain-sensing) neurons 39 . gas 16 . Recent experimental studies demonstrated that The main objective of “eyeballers” is to ob - the exposure of human corneal epithelial cells to tain a more rapid and intense effect of alcohol, a incremental concentration (20% to 100%) of “quick high”, short-circuiting the hepatic pas - ethanol for 30 seconds determines cell lysis, sage and the degradation by the enzyme system apoptosis, and reduced proliferation in a concen - (as other misusers do with other substances like tration-dependent manner 46 . In addition, signifi - N,N-Dimethyltryptamine 12,25,38 ). This expecta - cant damage to the corneal epithelial tight junc - tion is only partially realistic. The systemic ab - tions 47 and increased expression of proinflamma - sorption of topical solutions in the eye occurs tory cytokines and chemokines 46 have been ob - through two pathways, the conjunctival mucosa served after exposure of the cornea to 20% alco - and the nasopharyngeal mucosa which commu - hol. About this point, data suggest that brief ex - nicates with the eye surface through the naso - posure of corneal cells to ethanol may lead per - lacrimal duct 39 . However, the volume of alcohol sistent inflammation of the ocular surface. Ocular absorbed by the eye is very limited and unable surface inflammation is a main pathogenic factor to cause the “quick high” effect. In fact, the av - for ocular surface disorders including dry eye erage normal tear volume is 6.2 microliters 40 , syndrome 46,48 . while drop volume varies between drug manu - The epithelium is the layer of cells that cover facturers, ranging from 33.8 microliters to 63.4 the surface of the cornea. It is only about 5-6 microliters 41 . This means that when instilling cell layers thick and quickly regenerates when eye drops, one single drop has the maximum the cornea is injured. If the injury penetrates volume that the eye can hold. Any exceeding more deeply into the cornea, it may leave a volume can still reach the nasopharyngeal mu - scar. Scars leave opaque areas, causing the cosa passing the nasolacrimal duct, but, the corneal to lose its clarity and luster, resulting in punctal openings in the eyelid are 0.3 mm in di - decreased visual acuity. Also, it is possible that ameter and the volume drained with each blink exposure of the corneal limbal area to ethanol is approximately 2 microliters 42 . Thus, if a shot, may deplete epithelial progenitor cells (stem a glass or a bottle of vodka is poured on an eye, cells) and cause permanent failure of corneal the major part of the liquid simply spill out of epithelial regeneration 46 . In addition, if the al - the ocular surface. Moreover, pain and irritation cohol-induced destructive process reaches due to ethanol toxicity produce a strong defen - deeper anatomical structures, other ophthalmo - sive reflex causing hypersecretion and, thus, logic disorders could potentially occur. tearing 43 . This contributes to alcohol dilution Interestingly, for its ability to damage corneal and elimination. Therefore, eyeballing do not epithelial cells and facilitate corneal epithelial really make the abusers “drunk”, but rather rep - debridement, diluted ethanol is used in ophthal - resents a psychological way to enhance the psy - mology for treating some pathological condi - chedelic effects of orally ingested alcohol. tions, such as infectious keratitis and recurrent Other driving forces encouraging young stu - corneal erosion or for removing corneal epithe - dents to engage in this harmful practice are com - lium during excimer laser refractive surgery 49-51 .

2314 The “Eyeballing” technique: an emerging and alerting trend of alcohol misuse

–––––––––––––––– –-– –– It is, thus, conceivable that the direct contact of Conflict of Interest corneal epithelial cells with substances with All the authors of this paper have no relevant affiliations or high ethanol content may have long-term per - financial involvement with any organization or entity with manent effects. For this reason the American a financial interest in, or financial conflict with the subject Academy of Ophthalmology officially advised matter or materials discussed in the manuscript. This in - the public to not engage in this alcohol eye - cludes employment, consultancies, honoraria, stock owner - balling practice 17 . ship or options, expert testimony, grants or patents re - ceived or pending, or royalties. All authors acknowledge From a clinical perspective, being aware of the that the conflict of interest disclosures are complete for existence of alcohol eyeballing and knowing its both themselves and their co-authors, to the best of their presentation may help physicians in emergency knowledge. departments, ophthalmologists, and other health - care professionals to recognize it promptly and to select adequate interventions. From a psychiatric References point of view, it is known that binge-type drink - ing such as alcohol eyeballing is a crucial step in 1) STATUS REPORT ON IN 35 E URO - adolescents’ progression to several other psychi - PEAN COUNTRIES 2013 . WHO Regional Office for atric problems such as alcohol abuse and depen - Europe, 2013. dence, addictions, sleep, mood and anxiety disor - 2) SAHA TD, C HOU SP, G RANT BF. Toward an alcohol ders 7-11,52 . For this reason, this maladaptive form use disorder continuum using item response the - ory: results from the National Epidemiologic Sur - of recreational alcohol use among adolescents vey on Alcohol and Related Conditions. Psychol should not be underestimated. Med 2006; 36: 931-941. One could wonder about the limitations of 3) RAPINESI C, K OTZALIDIS GD, S ERATA D, D EL CASALE A, carrying out a risk of misuse assessment of a BERSANI FS, S OLFANELLI A, S CATENA P, R ACCAH RN, drug whilst taking into account the online com - BRUGNOLI R, D IGIACOMANTONIO V, C ARBONETTI P, F EN - ments; in fact, it may be inappropriate to trust SORE C, T ATARELLI R, A NGELETTI G, F ERRACUTI S, G IRARDI P. Efficacy of add-on deep transcranial magnetic information obtained from the Internet without stimulation in comorbid and independent verification. However, in presence dysthymic disorder: three case reports. The Pri - of very limited relevant peer-reviewed data, this mary Care Companion for CNS Disorders 2013; seems to be the only method to obtain prelimi - 15(1). pii: PCC.12m01438. nary information about new and emergent phe - 4) BURILLO -P UTZE G, H ERNÁNDEZ SÁNCHEZ MJ, C LIMENT nomena 53-57 . GARCÍA B, P INILLOS ECHEVERRÍA MA . [New ways of consuming alcohol]. Anales de Pediatria 2013; 77: 419-420. Conclusions 5) MCCLAVE JL, R USSELL PJ, L YREN A, O'R IORDAN MA, BASS NE . The choking game: physician perspec - tives. Pediatrics 2010; 125: 82-87. Alcohol eyeballing represents a new alerting 6) DEPARTMENT OF JUSTICE , O FFICE OF JUSTICE PROGRAMS , trend among adolescents and young adults with OFFICE OF JUVENILE JUSTICE AND DELINQUENCY PREVEN - potential permanent adverse effects, deserving TION . Drinking in America: Myths, Realities, and the attention of families and healthcare profes - Prevention Policy Washington, DC: US, 2005. sionals. Larger observational studies are warrant - 7) GILPIN NW, K ARANIKAS CA, R ICHARDSON HN. Adoles - ed to estimate the prevalence, characterize the ef - cent binge drinking leads to changes in alcohol drinking, anxiety, and amygdalar corticotropin re - fects, and identify adequate forms of interven - leasing factor cells in adulthood in male rats. tions for this phenomenon. PLoS One 2012; 7: e31466. 8) COURTNEY KE, P OLICH J. Binge drinking in young adults: Data, definitions, and determinants. Psy - ––––––––––––––––– –– chol Bull 2009; 135: 142-156. Acknowledgements 9) COLEMAN LG J R, H E J, L EE J, S TYNER M, C REWS FT . This publication arises from collaborative activities and Adolescent binge drinking alters adult brain neu - staff exchanges among the collaborating institutions fund - rotransmitter gene expression, behavior, brain re - ed by the European Commission (Erasmus Project). Au - gional volumes, and neurochemistry in mice. Al - thors would also like to acknowledge the contribution of cohol Clin Exp Res 2011; 35: 671-688. the Canadian Centre on Substance Abuse (CCSA), The 10) BERSANI FS, I ANNITELLI A, P ACITTI F, B ERSANI G. Sleep Public Health Agency of Canada and the World Health and biorythm disturbances in schizophrenia, Organization (WHO) for granting access to the GPHIN mood and anxiety disorders: a review. Riv Psichi - database. atr 2012; 47: 365-375.

2315 F.S. Bersani, O. Corazza, G, Albano, S. Bruschi, A. Minichino, R. Vicinanza, et al.

11) POPOVICI I, F RENCH MT . Binge drinking and sleep 25) “Y AHOO ANSWERS ” web forum – 1, http://answers.ya - problems among young adults. Drug Alcohol De - hoo.com/question/index;_ylt=AocUUeSOSJtGX6rL4 pend 2013; 132: 207-215. RYgNZ8jzKIX;_ylv=3?qid=20070808033850AA - 12) CORAZZA O, A SSI S, S IMONATO P, C ORKERY J, B ERSANI iamMM FS, D EMETROVICS Z, S TAIR J, F ERGUS S, P EZZOLESI C, 26) “YAHOO ANSWERS ” web forum – 2, PASINETTI M, D ELUCA P, D RUMMOND C, D AVEY Z, http://answers.yahoo.com/question/index;_ylt=Ao BLASZKO U, M OSKALEWICZ J, M ERVO B, F URIA LD, F ARRE RpoVirz2wdW_YuEx1GKREjzKIX;_ylv=3?qid=20 M, F LESLAND L, P ISARSKA A, S HAPIRO H, S IEMANN H, 120804205310AAMqBff SKUTLE A, S FERRAZZA E, T ORRENS M, S AMBOLA F, V AN 27) “YAHOO ANSWERS ” web forum – 3, http://answers.ya - DER KREEFT P, S CHERBAUM N, S CHIFANO F. Promoting hoo.com/question/index;_ylt=AtxEf - innovation and excellence to face the rapid diffu - SORqmxwV4QrICuNV60jzKIX;_ylv=3?qid=20130 sion of Novel Psychoactive Substances in the EU: 622153312AAvJRRk the outcomes of the ReDNet project. Hum Psy - chopharmacol 2013; 28: 317-323. 28) “YAHOO ANSWERS ” web forum – 4, http://answers.ya - hoo.com/question/index?qid=20130805130549A 13) SCHIFANO F, R ICCIARDI A, C ORAZZA O, D ELUCA P, D AVEY A617hQ. Z, R AFANELLI C. New drugs of abuse on the Web: the role of the Psychonaut Web Mapping Project. 29) “WILMOTT ” web forum, Riv Psichiatr 2010; 45: 88-93. http://www.wilmott.com/messageview.cfm?catid= 15&threadid=81984&STARTPAGE=1 14) SIMONATO P, C ORAZZA O, S ANTONASTASO P, C ORKERY J, DELUCA P, D AVEY Z, B LASZKO U, S CHIFANO F. Novel 30) “DRUGS -F ORUM ” web forum, http://www.drugs-fo - psychoactive substances as a novel challenge for rum.com/forum/showthread.php?t=129109&high - health professionals: results from an Italian sur - light=vodka+eyeballing#ixzz2b8KBaUdM vey. Hum Psychopharmacol 2013; 28: 324-331. 31) “Il Mattino”, 28 July 2013, 15) KELLER M, B LENCH M, T OLENTINO H, F REIFELD CC, http://www.ilmattino.it/napoli/cronaca/eyw - MANDL KD, M AWUDEKU A, E YSENBACH G, B ROWNSTEIN balling_vodka_occhi_napoli_allarme/no - JS . Use of unstructured event-based reports for tizie/309359.shtml global infectious disease surveillance. Emerg In - 32) “G OOGLE SEARCH ” engine, fect Dis 2009; 15: 689-695. https://www.google.it/#q=%22vodka+eye - 16) ASCASO FJ. Vodka eyeballing: Give me another balling%22 drink … in the eye, please! Arch Soc Esp Oftal - 33) “GOOGLE TREND ” engine, mol 2013; 88: 411-412. http://www.google.com/trends/explore?q=vod - 17) Statement from the American Academy of Oph - ka+eyeballing#q=vodka%20eyeballing thalmology regarding “Vodka Eyeballing”, 2010, 34) “NEWSER ”, 19 May 2010, http://www.aao.org/newsroom/release/20100601a http://www.newser.com/story/89268/dumbest- .cfm new-drinking-game-vodka-eyeballing.html 18) “LA REPUBBLICA ”, 28 June 2011, 35) “T HE WEEK ”, 18 May 2010, http://theweek.com/arti - http://d.repubblica.it/argomenti/2011/06/28/news/ cle/index/203092/what-is-vodka-eyeballing eyeballing-397581/ 36) DAVEY Z, S CHIFANO F, C ORAZZA O, D ELUCA P. e-Psy - 19) “DAILY MAIL ”, 15 May 2010, chonauts: conducting research in online drug fo - http://www.dailymail.co.uk/news/article- rum communities. J Ment Health 2013; 21: 386- 1278583/Young-people-drinking-neat-vodka-EYE- 394. quick-buzz.htm l 37) BERSANI FS, C ORAZZA O, S IMONATO P, M YLOKOSTA A, 20) “Facebook”, 2 July 2013, LEVARI E, L OVASTE R, S CHIFANO F. Drops of mad - https://www.facebook.com/eyeporter/posts/39850 ness? Recreational misuse of tropicamide collyri - 2933603612. um; early warning alerts from Russia and Italy. 21) “FOX NEWS ”, 26 May 2010, Gen Hosp Psychiatry 2013; 35: 571-573. http://www.foxnews.com/health/ 2010/05/26/eye - 38) “SHROOMERY ” WEB FORUM , balling-fad-teens-pouring-vodka-eyes/ http://www.shroomery.org/forums/showflat.php/Nu 22) “NY D AILY NEWS ”, 26 May 2010, http://www.nydai - mber/10666312 lynews.com/life-style/health/kids-darndest-vodka- 39) PAALMAN MH . "Anatomy in the eye." (2000). The eyeballing-fad-toxic-effect-eye-health-article- Anatomical Record, 261, 221. 1.447766 40) MISHIMA S, G ASSET A, K LYCE SD JR, B AUM JL . Determi - 23) “T HE AUSTRALIAN ”, 27 May 2010, http://www.theaus - tralian.com.au/news/breaking-news/vodka- nation of tear volume and tear flow. Invest Oph - eyeballing-a-growing-fad-among-teens/story- thalmol 1966; 5: 264-276. fn3dxity-1225871851606 41) GERMAN EJ, H URST MA, W OOD D. Reliability of drop size from multi-dose eye drop bottles: is it cause 24) “YOUTUBE ” search engine, http://www.youtube.com/re - sults?search_query=vodka+eyeballing&oq=vodka+e for concern? Eye (Lond) 1999; 13: 93-100. yeballing&gs_l=youtube.12..0.1306.6291.0.7056.2.2. 42) SAHLIN S, C HEN E. Gravity, blink rate, and lacrimal 0.0.0.0.131.131.0j1.1.0...0.0...1ac.1.11.youtube.A27L drainage capacity. Am J Ophthalmol 1997; 124: qU2Q6GQ 758-764.

2316 The “Eyeballing” technique: an emerging and alerting trend of alcohol misuse

43) IVESON -I VESON J. Anatomy and physiology: the eye. alcohol-assisted epithelial debridement. Cornea Nurs Mirror 1979; 148: 31-33. 2012; 31: 442-446. 44) “WALES ONLINE ”, 23 May 2010, http://www.waleson - 52) MINICHINO A, B ERSANI FS, C ALÒ WK, S PAGNOLI F, line.co.uk/news/wales-news/students-taking-vodka- FRANCESCONI M, V ICINANZA R, D ELLE CHIAIE R, B IONDI M. shots-through-1919564 Smoking behaviour and mental health disorders-- mutual influences and implications for therapy. Int J 45) “W ACKTRAP ”, 9 March 2012, http://www.wacktrap.com/nightlife/after-hours/eye - Environ Res Public Health 2013; 10: 4790-4811. balling-eyeball-shots-vodka-cause-permanent- 53) SCHIFANO F, C ORAZZA O, M ARCHI A, D I MELCHIORRE G, damage-blindness SFERRAZZA E, E NEA A, D AVEY Z, B LASZKO U, D ELUCA P. Analysis of online reports on the potential misuse 46) OH JY, Y U JM, K O JH . Analysis of ethanol effects of benzidamine. Riv Psichiatr 2013; 48: 182-186. on corneal epithelium. Invest Ophthalmol 2013; 54: 3852-3856. 54) BERSANI FS, C ORAZZA O, A LBANO G, V ALERIANI G, S AN - TACROCE R, B OLZAN MARIOTTI POSOCCO F, C INOSI E, S I- 47) ZHANG P, L IU M, L IAO R. Toxic effect of using MONATO P, M ARTINOTTI G, B ERSANI G, S CHIFANO F. twenty percent alcohol on corneal epithelial 25C-NBOMe: preliminary data on pharmacology, tight junctions during LASEK. Mol Med Rep psychoactive effects, and toxicity of a new potent 2013; 6: 33-38. and dangerous hallucinogenic drug. Biomed Res 48) STEVENSON W, C HAUHAN SK, D ANA R. Dry eye dis - Int 2014; 2014: 734749. ease: an immune-mediated ocular surface disor - 55) UNITED NATIONS OFFICE ON DRUGS AND CRIME GLOBAL der. Arch Oftalmol 2012; 130: 90-100. SMART Update 2012: Volume 7. 49) CARONES F, F IORE T, B RANCATO R. Mechanical vs. 56) CORAZZA O, V ALERIANI G, B ERSANI FS, C ORKERY J, M AR - alcohol epithelial removal during photorefrac - TINOTTI G, B ERSANI G, S CHIFANO F. “Spice”, “kryp - tive keratectomy. J Refract Surg 1999; 15: 556- tonite”, “black mamba”: an overview of brand 562. names and marketing strategies of novel psy - 50) DUA HS¸ L AGNADO R, R AJ D, S INGH R, M ANTRY S, G RAY choactive substances on the web. J Psychoactive T, L OWE J. Alcohol delamination of the corneal ep - Drugs 2014; 46: 287-294. ithelium: an alternative in the management of re - 57) CORAZZA O, B ERSANI FS, B RUNORO R, V ALERIANI G, M AR - current corneal erosions. Ophthalmology 2006; TINOTTI G, S CHIFANO F. The diffusion of performance 113: 404-411. and image-enhancing drugs (PIEDs) on the inter - 51) LI ML, S HIH MH, H UANG FC, T SENG SH, C HEN CC . net: the abuse of the cognitive enhancer piracetam. Treatment of early Acanthamoeba keratitis with Subst Use Misuse 2014; 49: 1849-1856.

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