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Symptoms ⬇

Moderate-to-severe ocular pain, foreign body sensation, red eye, tearing, photophobia, and blurred vision; often a history of welding or using a sunlamp without adequate protective eyewear. Symptoms typically worsen 6 to 12 hours after the exposure. Usually bilateral.

Signs ⬆ ⬇

Critical

Dense, confluent punctate epithelial defects in an interpalpebral distribution highlighted with fluorescein staining.

Other

Conjunctival injection, mild-to-moderate eyelid edema, mild-to-no corneal edema, relatively miotic pupils that react sluggishly, and mild anterior chamber reaction.

Differential Diagnosis ⬆ ⬇

  • Toxic epithelial keratopathy from exposure to a chemical (e.g., solvents, alcohol) or drug (e.g., neomycin, gentamicin, antiviral agents, anesthetic drops).
  • Thermal burn/keratopathy: Often from contact with curling iron, boiling fluid, fire ember, or flame. Injury usually limited to corneal epithelium; may have marked superficial corneal opacification or eschar. Treat with possible debridement of involved area and then as for corneal abrasion. See 3.2, CORNEAL ABRASION.
  • See 4.1, SUPERFICIAL PUNCTATE KERATOPATHY.

Work Up ⬆ ⬇

Workup
  1. History: Welding? Sunlamp use? Topical medications? Chemical exposure? Prior episodes? Use of protective eyewear?
  2. Slit lamp examination: Use fluorescein stain. Evert the eyelids to search for a foreign body.
  3. If chemical exposure suspected, check pH of tear lake in upper and lower conjunctival fornices. If not neutral (6.8 to 7.5), treat as chemical burn. See 3.1, CHEMICAL BURN.

Treatment ⬆ ⬇

  1. Cycloplegic drop (e.g., cyclopentolate 1%).
  2. Antibiotic ointment (e.g., erythromycin or bacitracin) four to eight times per day.
  3. Oral analgesics as needed.
NOTE:

A bandage soft contact lens with prophylactic topical broad-spectrum antibiotic drop may be used in place of frequent antibiotic ointment.

Follow Up ⬆

  1. If a bandage soft contact lens was placed, the patient is seen in 1 to 2 days.
  2. Reliable patients without a bandage soft contact lens are asked to assess their own symptoms after 24 hours.
    • If much improved, the patient continues with topical antibiotics (e.g., erythromycin or bacitracin ointment q.i.d.).
    • If still significantly symptomatic, reevaluate. If significant punctate staining is present, retreat with a cycloplegic, antibiotic as discussed previously.
  3. Unreliable patients or those with an unclear etiology should not have a bandage soft contact lens placed. Such patients should be reexamined in 1 to 2 days.