Rosen & Barkin's 5-Minute Emergency Medicine Consult (739 page)

• Barotrauma
  
• Otitis Media
  

CODES

• 384.20 Perforation of tympanic membrane, unspecified
  
• 384.22 Attic perforation of tympanic membrane
  
• 872.61 Open wound of ear drum, without mention of complication
  

BASICS

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

• 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

• 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.
  

• 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
    

• 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
    

• 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
    

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

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

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

TREATMENT

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

• 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.
    

• 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

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

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 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.
  

• 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.
  

• Jacobs DS. Photokeratitis. In: Basow DS, ed.
  UpToDate.
  Waltham, MA: UpToDate, 2013.
  
• Marx JA, Hockberger RS, Walls RM. Chapter 22.
  Rosen's 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