Blinded By The Light
aka Ophthalmology Befuddler 018
A 22 year-old male had a session on the sunbed in the morning, went for a surf around lunchtime, and helped his mate with some welding in the afternoon. Fortunately there were no mountains nearby.
It’s late evening now and he has presented to the emergency department with intense bilateral eye pain and is refusing to open his tightly clenched eyelids.
Questions
Q1. What is the likely diagnosis?
Answer and interpretation
Ultraviolet keratitis/ keratopathy
Other names for this condition are solar keratitis, photokeratitis, welder’s flash, arc eye, bake eyes, and snow blindness.
Q2. Who are at risk of this condition?
Answer and interpretation
Anyone exposed to excess UV radiation:
- welders
- sunbed users
- people in high altitude environments
(UV levels increase by about 4% for every 1000 feet/ 305 m) - people exposed to sunlight reflection from:
water (sea foam reflects about 25% of UV, sandy beaches about 15%) or
snow (fresh snow reflects about 80% of UV)
Q3. What are the features to look for on history?
Answer and interpretation
History:
- Patient at risk? (see Q2) — symptoms typically emerge 6 to 12 hours following the at-risk activity.
- Symptoms — intense pain, red eyes, blepharospasm and tearing; usually bilateral.
- Use of eye protection? Previous episodes?
Q4. What are the features to look for on examination?
Answer and interpretation
Examination:
Apply topical anesthesia ASAP — you’re unlikely to see anything if the patient refuses to open their eyes!
- Visual acuity — usually near normal
- Pupils — relatively miotic, sluggish reaction to light
Slit lamp
- Conjunctival injection
- Cornea — widespread superficial punctate epithelial defects that stain with fluorescein and are often bilateral. Mild or minimal corneal edema.
- Anterior chamber — mild AC reaction
Rule out a foreign body, chemical injury and exposure keratopathy (do the eyelids close correctly?)
Q5. What is the management?
Answer and interpretation
- oral analgesia (may need opioids) and topical cycloplegia (e.g. 1% cyclopentolate) for comfort for up to about 3 days
- topical antibiotics are often given
- some authorities advise a pressure patch to the most affected eye for 24 hours
- patients should return if there is not significant improvement after 24 hours
Educate the patient about the risk of UV, the use of equipment and protective gear
The topical anesthesia was so effective, the patient asks if he can take some home.
Q6. Will you give him a topical anesthetic to take home?
Answer and interpretation
No
Repeated use of topical anesthesia may lead to:
- a delay in corneal healing
- chronic corneal ulceration
- inhibition of the corneal blink reflex
Q7. Why do thermal injuries tend to affect the eyelid more than the globe?
Answer and interpretation
The eye itself is protected by reflex blinking and Bell’s phenomenon (when the eye closes, the front of the globe rolls upwards)
Q8. How are thermal burns to the eye and lids managed?
Answer and interpretation
It depends on severity of injury and the structures involved.
Eyelid burns
- superficial burns — irrigation and topical antibacterial ointment
- partial thickness or worse — get an ophthalmology review.
Eye burns
- superficial thermal eye burns — most can be managed like a corneal abrasion if there is only epithelial involvement.
- more severe injuries (e.g. hot metal injuries) — these can result in globe perforation, and should be treated along the lines of a globe rupture
Q9. …Ask Dr Carlo
Video Overview
- Ehlers JP, Shah CP, Fenton GL, Hoskins EN. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease Lippincott Williams & Wilkins
- NSW Statewide Opthalmology Service. Eye Emergency Manual — An illustrated Guide. [Free PDF]
CLINICAL CASES
Ophthalmology Befuddler
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
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