Author:
MeganBevis Core
YasuharuOkuda
Description
- Corneal epithelial damage caused by direct exposure to ultraviolet (UV) light
- Also known as photokeratitis, UV conjunctivitis, snow blindness, and welder's flash
Etiology
- Work-related exposure seen in welders, electricians, and mechanics
- Recreational exposure, including water sports, snow sports, and tanning booths
- Occurs with corneal absorption at 290 nm, the cutoff between UV-B and UV-C light
- UV light penetrates to epithelial nociceptor axons, destroying them and triggering pain from subendothelial nerve stimulation
- Related to intensity and duration of exposure
- Long-term UV damage to eye may result in pterygium and some forms of corneal degeneration, though association with UV keratitis episodes has not been demonstrated
Signs and Symptoms
- Patients will present with bilateral eye pain, photophobia, redness, and tearing
- No purulent discharge will be present
- Associated facial edema, lid edema, erythema, and blepharospasm may be present
History
- Elicit history of exposure to UV light 6-12 hr prior to complaint of pain
- Obtain other relevant history, including contact lens use, past ocular history (i.e., trauma, surgery, glaucoma), current medications, and allergies to medications
- Inquire specifically about risk of foreign body
- In addition to pain, complaints may include:
- Photophobia
- Tearing
- Foreign-body sensation
Physical Exam
- Visual acuity may be mildly diminished
- Eye exam reveals chemosis, injection, tearing
- Diffuse corneal haze may be seen in severe cases
- Normal intraocular pressure
- Slit-lamp exam with topical ophthalmic anesthetics and fluorescein:
- Multiple superficial punctate corneal lesions or diffuse uptake of fluorescein
- May notice a well-demarcated line at the upper or lower border from protection of the lid
Essential Workup
- Accurate history including:
- Type, timing, and duration of exposure
- Visual acuity
- Complete ocular exam including:
- Extraocular movements
- Exam of conjunctiva/sclera/cornea with fluorescein
- Anterior chamber, checking for cell and flare
- Eversion of lids to check for foreign bodies
- Intraocular pressure
Diagnostic Tests & Interpretation
Lab
Blood testing is usually unnecessary unless widespread severe sunburn is present or there is concern for secondary infection
Imaging
A careful history should obviate need for orbital US/CT/MRI for foreign body
Differential Diagnosis
- Infection:
- Bacterial or viral conjunctivitis
- Corneal ulcers
- Allergic conjunctivitis
- Corneal abrasion
- Traumatic iritis
- Foreign bodies
- Acid, alkali, or thermal burns
- Acute angle closure glaucoma
Prehospital
When diagnosis is unambiguously established, pressure patching or applying mild pressure to eyes with closed lids may provide temporary relief. Oral analgesia may also be administered
ED Treatment/Procedures
- Topical anesthetic to facilitate slit-lamp exam
- Provide adequate oral analgesia as needed
- Initiate short-acting cycloplegic agent
- Apply topical antibiotic ointment
- May apply eye patching for comfort although controversial as it may delay re-epithelialization:
- Soft double patching with mild pressure
- If both eyes involved, either patch both eyes or patch the eye that is more severely affected
- Should be left on for 24 hr
Medication
- Topical anesthetic agent (for ED only):
- Tetracaine hydrochloride ophthalmic solution 0.5%: 1-2 drops into affected eye
- Proparacaine 0.5%: 1-2 drops into affected eye
- Do not prescribe topical anesthetic agents for outpatient use as this may impair healing and increase corneal ulcer formation
- Oral analgesics:
- Ibuprofen 600-800 mg t.i.d with meals (peds: 10 mg/kg/dose)
- Acetaminophen with oxycodone 325 mg/5 mg, q4-6h p.r.n for breakthrough pain
- Cycloplegic agent (helps relieve pain of reflex ciliary spasm):
- Scopolamine hydrobromide ophthalmic solution 0.25%: 1 or 2 drops into affected eye q6-8h
- Cyclopentolate hydrochloride ophthalmic solution 0.5-1%: 1 or 2 drops into affected eye q6-8h
- Topical antibiotic ointment (routine use remains controversial)
- Erythromycin ophthalmic ointment 0.5%, apply to affected eye q.i.d
- Gentamicin
Disposition
Admission Criteria
Consider admission in cases of severely decreased visual acuity, evidence of secondary infection, or bilateral patching
Discharge Criteria
Nearly all patients may be discharged from the ED following treatment with oral analgesics, topical antibiotics, cycloplegics, and /or patching:
- Lesions should heal completely in 24-48 hr
Follow-up Recommendations
- Avoid the use of contact lenses until symptoms are completely resolved
- Follow up with ophthalmologist within 24-48 hr to monitor healing and symptom resolution
- If unable to follow up with ophthalmologist, should return to ED if symptoms not resolved in 24-48 hr
- JacobsDS. Photokeratitis. In: BasowDS, ed. UpToDate. Waltham, MA: UpToDate; 2013.
- MarxJA, HockbergerRS, WallsRM. Rosen's Emergency Medicine: Concepts and Clinical Practice. 8th ed.Philadelphia, PA: Elsevier/Saunders; 2014.
- YenYL, LinHL, LinHJ, et al. Photokeratoconjunctivitis caused by different light sources . Am J Emerg Med. 2004;22(7):511-515.
See Also (Topic, Algorithm, Electronic Media Element)