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Ultraviolet Keratitis, Emergency Medicine

Basics

Description

- 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

- Oral analgesics: - Ibuprofen 10 mg/kg TID with meals - Acetaminophen with oxycodone 500 mg/5 mg, q4 " 6h PRN for breakthrough pain

  • Corneal epithelial damage caused by direct exposure to ultraviolet (UV) light.
  • Also known as photokeratitis, UV conjunctivitis, snow blindness, and welders flash.

Etiology

  • Work-related exposures seen in welders, electricians, and mechanics
  • Recreational exposures, 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 nocireceptor axons, destroying them and triggering pain from subendothelial nerve stimulation
  • Related to intensity and duration of exposure

Diagnosis

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.
  • In addition to pain, complaints may include:PhotophobiaTearingForeign-body sensation

Physical Exam

  • Visual acuity may be mildly diminished.
  • Eye exam reveals chemosis, injection, tearing.
  • Slit-lamp exam with topical ophthalmic anesthetics and fluorescein:Multiple superficial punctate corneal lesionsOtherwise unremarkable

Essential Workup

  • Accurate history including:Type, timing, and duration of exposure
  • Visual acuity
  • Complete ocular exam including:Extraocular movementsExam of conjunctiva/sclera/cornea with fluoresceinAnterior chamber checking for cell and flareEversion of lids to check for foreign bodies

Diagnosis Tests & Interpretation

Lab

Blood testing will not be necessary unless widespread severe sunburn is present.

Imaging

A careful history should obviate need for orbital US/CT/MRI for foreign body.

Differential Diagnosis

  • Infection:Bacterial or viral conjunctivitisCorneal ulcers
  • Allergic conjunctivitis
  • Corneal abrasion
  • Traumatic iritis
  • Foreign bodies
  • Acid, alkali, or thermal burns

Treatment

Pre-Hospital

When diagnosis is unambiguously established, pressure patching or applying mild pressure to eyes with closed lids may provide temporary relief.

Ed Treatment/Procedures

  • Topical anesthetic to facilitate slit-lamp exam.
  • Provide adequate oral analgesia as needed.
  • Apply topical antibiotic ointment.
  • Initiate short-acting cycloplegic agent.
  • May apply eye patching for comfort (patching has not been shown to accelerate healing):Soft double patching with mild pressureIf both eyes involved, either patch both eyes or patch the eye that is more severely affected.

Medication

  • Topical anesthetic agent (for ED only):Tetracaine hydrochloride ophthalmic solution 0.5%: 1 " 2 drops into affected eye:Do not prescribe for outpatient as this may impair healing and increase corneal ulcer formation.
  • Oral analgesics:Ibuprofen 10 mg/kg TID with mealsAcetaminophen with oxycodone 500 mg/5 mg, q4 " 6h PRN for breakthrough pain
  • Topical antibiotic ointment:Erythromycin ophthalmic ointment 0.5%, apply to affected eye QID
  • Cycloplegic agent:Scopolamine hydrobromide ophthalmic solution 0.25%: 1 or 2 drops into affected eye q6 " 8hCyclopentolate hydrochloride ophthalmic solution 0.5%: 1 or 2 drops into affected eye q6 " 8h

Follow-Up

Disposition

Admission Criteria

Consider admission in cases of severe decreased visual acuity, bilateral patching, or in situations when self-care and follow-up are difficult.

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 " 72 hr.

Follow-Up Recommendations

  • Follow up with ophthalmologist within 24 " 48 hr to monitor healing and symptom resolution.
  • 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.

Pearls and Pitfalls

  • Determining UV exposure 6 " 12 hr prior is the key to diagnosis and prevention:The patient may not be aware of exposure
  • Those at risk for occupational exposure must wear UV safety goggles, not glasses or lenses.
  • Exquisitely painful but self-limited injury; risks from repeated exposures are not well defined.

Additional Reading

  • Jacobs DS. Photokeratitis. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate, 2013.
  • Marx JA, Hockberger RS, Walls RM. Chapter 22. Rosens Emergency Medicine: Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Elsevier/Saunders, 2014.
  • Yen YL, Lin HL, Lin HJ, et al. Photokeratoconjunctivitis caused by different light sources. Am J Emerg Med. 2004;22:511 " 515.

See Also (Topic, Algorithm, Electronic Media Element)

  • Conjunctivitis
  • Corneal Burn
  • Red Eye

Codes

ICD9

  • 368.13 Visual discomfort
  • 370.24 Photokeratitis

ICD10

  • H16.131 Photokeratitis, right eye
  • H16.132 Photokeratitis, left eye
  • H16.133 Photokeratitis, bilateral
  • H16.139 Photokeratitis, unspecified eye
  • H16.131 Photokeratitis, right eye
  • H16.13 Photokeratitis
  • H53.141 Visual discomfort, right eye
  • H53.142 Visual discomfort, left eye
  • H53.143 Visual discomfort, bilateral
  • H53.149 Visual discomfort, unspecified
  • H53.14 Visual discomfort

SNOMED

  • 1714005 photokeratitis (disorder)
  • 3282008 welders keratitis (disorder)
  • 22075008 Snow blindness (disorder)
  • 409668002 photophobia (finding)