treatment plan

UV Keratitis

BY BRUCE E. ONOFREY, RPH, OD
JANUARY 1999

Well, you got the new ski equipment that you wanted for Christmas and you're booked for one of those ubiquitous continuing education ski meetings. You've also replaced those old ski pants that seemed to

pants that seemed to have shrunk two sizes while in the closet. It's probably time to reassess the most forgotten yet important piece of equipment -- goggles.

Feel the Burns

B.J., a 40-something weekend warrior, presented to the emergency room one evening following a full day of skiing at the Santa Fe ski basin with severe burning, redness and tearing of the eyes. He also complained of a throbbing headache behind both eyes. He attempted to medicate himself with Visine eye drops, which only increased his discomfort. Unable to open his eyes, B.J. graded his pain as "11 out of 10." Instilling a drop of proparacaine in each eye enabled me to examine him, yielding the following results:

BVA -- 20/100 OD; 20/60 OS

PEH -- Corneal ulcer associated with contact lens wear. S/P LASIK OU X 1 year.

Medical History -- Controlled systemic hypertension.

Allergies -- Penicillin.

Slit Lamp Exam -- Anterior chamber: +4 deep OU, trace flare OU, (-) cell; Lids/face: moderate sunburn; Conjunctiva: +3 erythema of bulbar conjunctiva OU; Cornea: +2 diffuse punctate keratitis OU.

Skiers Beware

Like many other tourists from the eastern and midwestern states who associate sunburn with only the beaches, B.J. had no idea how intense the UV radiation can be at altitudes ranging well over 10,000 feet above sea level. During a full day of skiing, the radiation reflected from the surface of the snow can create severe burns on unprotected areas. The eye protection B.J. had worn that day was a pair of "blue-blockers" he purchased from a vendor at the local flea market -- a bad choice.

Inform patients of the dangers of UV light. People often mistakenly believe that sunglasses offer increased eye protection if they block visible light. In reality, the iris dilates in response to reduced visible light, allowing greater exposure of the lens and retina to the invisible UV light.

Easing the Pain

The acute damage produced by UV exposure in B.J. was limited to solar burns of his eyelids and cornea, but could have included acute solar retinopathy. In managing this condition, advise patients that, although dramatic and painful, their symptoms will usually resolve within 24 hours. Cool compresses, aspirin and a dark room are the best treatment. Patching, bandage contact lenses and the short-term use of steroid/antibiotic ointments are useful in moderate to severe cases. A mild to moderate iritis may accompany the keratitis, which should be managed with a cycloplegic/mydriatic agent such as Cyclogyl 1%.

B.J.'s treatment included Tobradex ointment t.i.d. OU, one drop of Cyclogyl 1% OU in the office, Genteal artificial tears as needed (which can be refrigerated for greater relief), cold compresses and a prescription for Vicodin. If you are not able to prescribe narcotic analgesic agents, I recommend 400mg of ibuprofen and 500mg of acetaminophen taken every six hours.

It's important to avoid the use of topical anesthetics by the patient. The drops I instilled promptly removed B.J.'s pain, so its not surprising that he requested them for self administration. Advise patients that repeated use of topical anesthetics induces significant epithelial toxicity, prevents re-epithelialization and results in indolent corneal ulcers and scarring.

Dr. Onofrey, editor and author of various ophthalmic texts, practices in Albuquerque, New Mexico.