CHAPTER 25
Ultraviolet Keratoconjunctivitis
(Welder’s or Tanning Bed Burn)
Presentation
The patient arrives in the ED or clinic complaining of severe, intense, burning eye pain, usually bilateral, beginning 6 to 12 hours after a brief exposure without eye protection to a high-intensity ultraviolet (UV) light source, such as a sunlamp or welder’s arc. The eye examination shows conjunctival injection and tearing; fluorescein staining may be normal or may show diffuse superficial uptake (discerned as a punctate keratopathy under slit-lamp examination). The patient may also have first-degree burns on his skin.
What To Do:
Apply topical anesthetic ophthalmic drops (e.g., proparacaine [Ophthetic], tetracaine [Pontocaine]) once to permit examination.
Perform a complete eye examination, including best-corrected visual acuity assessment, funduscopy, anterior chamber bright-light examination, fluorescein staining, and conjunctival sac inspection. There may be mild visual impairment.
Prescribe cold compresses, rest, and analgesics (e.g., oxycodone, hydrocodone, ibuprofen, naproxen) to control pain.
Provide lubricating ophthalmic ointment (erythromycin 0.5%, 3.5 g, or polymyxin B/bacitracin, 3.5-g tube applied inside the lower lid [1- to 2-cm ribbon] qid), or, if drops are preferred, polymyxin B/trimethoprim (Polytrim), 10 mL, 1 drop q2-6h. However, no evidence supports this practice. Use of a bland ointment (e.g., Lacri-Lube) may be all that is required to reduce pain.
Prescribe analgesic nonsteroidal anti-inflammatory drug (NSAID) eye drops (diclofenac [Voltaren] 0.1%, 5 mL, or ketorolac [Acular] 0.5%, 5 mL, 1 drop qid).
Administration of a short-acting cycloplegic drop (e.g., cyclopentolate 1%) may help relieve the pain of reflex ciliary spasm.
Warn the patient that pain will return when the local anesthetic wears off but that the oral medication and topical NSAID prescribed should help relieve it. Symptoms should resolve after 24 to 36 hours. Medications can be stopped after symptoms resolve.
What Not To Do:
Do not give the patient a topical anesthetic for continued instillation, which can slow healing, blunt protective reflexes, and allow damage to the corneal epithelium.
Do not use the traditional eye patches. These dressings have been found to be of no value and might actually delay reepithelialization. Moreover, some patients find the loss of sight and depth perception (in the case of single-eye patching) to be unacceptable and wearing the patches to be more uncomfortable.
Do not be stingy with pain medications. This is a painful, albeit short-lived, injury.
Discussion
The history of brief exposure to a welder’s arc torch or other source of UV light exposure may be difficult to elicit because of the long asymptomatic interval. Longer exposures to lower-intensity UV light sources may resemble a sunburn. Healing should be complete in 12 to 24 hours. If the patient continues to experience discomfort for longer than 48 hours, an ophthalmologist should be consulted.
Other sources of UV phototoxicity can be found in scientific research and manufacturing technology. Several epidemic outbreaks of UV keratoconjunctivitis have been reported as the result of exposure to UV light from broken high-intensity mercury vapor lamps, such as those found in community gymnasiums. Another common source of UV phototoxicity is the intense sunlight exposure found in water sports and sunny snow conditions (known to the layperson as snow blindness).
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