Basics
Description
- 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:
- Photophobia
- Tearing
- Foreign-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 lesions
- Otherwise unremarkable
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
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 conjunctivitis
- Corneal 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 pressure
- If 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 meals
- Acetaminophen 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 " 8h
- Cyclopentolate 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)