eMedicine Specialties > Emergency Medicine > Ophthalmology
Ultraviolet Keratitis: Treatment & Medication
Updated: Feb 4, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Prehospital Care
- Flush eyes for several minutes with water or saline solution.
Emergency Department Care
- Administer a short-acting cycloplegic drop (eg, cyclopentolate 1%) to relieve the pain of reflex ciliary spasm.
- Administer a topical antibiotic ointment or drops, such as erythromycin or gentamicin. If an eye patch is used with an antibiotic ointment, the patient should use antibiotic drops after the eye patch has been removed.
- Application of a semipressure dressing with the eye well closed underneath was once the standard of care, but today this method of treatment is controversial. While these dressings may offer good pain relief, they may also delay reepithelialization. Moreover, some patients find the loss of sight and depth perception (in the case of single-eye patching) more traumatic than the pain itself.
- When used, the dressing is to be left on for 24 hours.
- The dressing should not be replaced by the patient without professional assistance because excessive pressure can cause further damage to the eye.
- Because of the severely painful nature of this type of injury, patients should be treated with nonsteroidal anti-inflammatory drugs and oral narcotic analgesics.
- All patients without contraindications should take ibuprofen 600 mg qid and oxycodone with acetaminophen for breakthrough pain.
- Topical anesthetic may be administered only in the ED; frequent use retards epithelial healing and may lead to corneal ulcer formation. The relief provided by topical anesthetics is so immediate and dramatic that patients are highly motivated to take a bottle home with them. Be careful not to allow the patient to take the bottle surreptitiously.
- Topical NSAIDs are not approved for this indication but are used for many other painful and allergic eye conditions. Topical NSAIDs for UV keratitis and corneal abrasions is an off-label use but has become common practice in many places.
Consultations
Ophthalmologic consultation usually is not necessary for this condition but may be obtained at the discretion of the emergency physician in the ED or if substantial healing has not occurred within 24-48 hours.
Medication
The goal of therapy is to treat the pain associated with damage in the corneal epithelium resulting from UV light exposure and to prevent infection while the cornea heals. Some medications include ophthalmic antibiotics, topical cycloplegics, ophthalmic anesthetics, NSAIDs (both ophthalmic and parenteral), and other analgesics.
Ophthalmic anesthetics
These agents are indicated for pain relief. Local anesthetics stabilize the neuronal membrane and prevent the initiation and transmission of nerve impulses, thereby producing the local anesthetic action.
Proparacaine 0.5% (Alcaine, Ophthetic)
Has rapid onset of anesthesia that begins 13-30 sec after instillation. However, has short duration of action of about 15-20 min. Since prolonged eye anesthesia can eliminate patient's awareness of mechanical damage to the cornea, drug should not be used outside the ED. Frequent use of anesthetics may retard healing. Least irritating of all topical anesthetics. Prevents initiation and transmission of impulse at nerve cell membrane by stabilizing and decreasing ion permeability.
Adult
2-3 gtt in affected eye q15-20min during ED examination
Pediatric
Administer as in adults
Increases effects of phenylephrine and tropicamide
Documented hypersensitivity; prolonged use
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in cardiac disease or hyperthyroidism and with abnormal or reduced levels of plasma esterases
Cycloplegics
These agents relax ciliary muscle spasm that can cause a deep aching pain and photophobia. Cycloplegics are used to facilitate eye examination and provide relief of symptoms in patients with moderate-to-severe eye injury. Cycloplegic agents also are mydriatics, thus before using them it is important to ensure that the patient does not have glaucoma. This medication could provoke an acute angle-closure glaucoma attack in a susceptible patient.
Cyclopentolate 0.5-1% (Cyclogyl)
Prevents muscle of ciliary body, and sphincter muscle of iris from responding to cholinergic stimulation. Induces mydriasis in 30-60 min and cycloplegia in 25-75 min.
Adult
1 gtt of 1% solution to induce cycloplegia; repeat in 5-10 min prn
Pediatric
<1 year: 1 gtt of 0.5% into each eye 5-10 min before examination
>1 year: 1 gtt of 0.5%, 1%, or 2% solution; repeat in 5-10 min prn
Decreases effects of carbachol and cholinesterase inhibitors
Documented hypersensitivity; narrow-angle glaucoma
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients (eg, elderly patients) in whom increased intraocular pressure may be present; can cause toxic anticholinergic systemic adverse effects, but incidence is rare when used sparingly (more common in children, especially infants); compressing the lacrimal sac with digital pressure for 1-3 min following application may minimize systemic absorption
Antibiotics, ophthalmic
The routine use of topical antibiotics remains controversial. Many emergency physicians have stopped its use for minor injuries, although others continue routine treatment with a broad-spectrum antibiotic ointment for lubrication and infection prophylaxis. This treatment persists despite its unproven efficacy, discomfort, and evidence that ointments may retard corneal epithelial healing.
Erythromycin 0.5% ointment (Ilotycin, AK-Mycin)
Indicated for treatment of infections caused by susceptible strains of microorganisms and for prevention of corneal and conjunctival infections.
Adult
Apply 0.5-inch (1.25-cm) ribbon 2-8 times/d, depending on severity of the infection
Pediatric
Administer as in adults
None reported
Documented hypersensitivity; viral, mycobacterial, and fungal infections of the eye; patients using steroid combinations after the uncomplicated removal of a foreign body from the cornea should avoid using this product
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Not for use to treat ocular infections that are likely to become systemic; prolonged or repeated therapy may result in bacterial or fungal overgrowth of nonsusceptible organisms and may lead to a secondary infection; take appropriate measures if superinfection occurs
Gentamicin (Genoptic, Garamycin)
Aminoglycoside antibiotic used for gram-negative bacterial coverage.
Adult
Ointment: Apply 0.5-inch (1.25-cm) ribbon bid/tid to the affected eye q3-4h
Solution: 1-2 gtt in affected eye q2-4h, as often as q1h for severe infections
Pediatric
Administer as in adults
None reported
Documented hypersensitivity; mycobacterial, viral, and fungal infections of the eye; patients taking steroid combinations after uncomplicated removal of a foreign body from cornea should also avoid using this product
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use to treat ocular infections that may become systemic; prolonged or repeated antibiotic therapy may result in bacterial or fungal overgrowth of nonsusceptible organisms that may lead to a secondary infection; take appropriate measures if superinfection occurs
Analgesics
Although most NSAIDs are used primarily for their anti-inflammatory effects, they are effective analgesics and are useful for the relief of mild to moderate pain. Pain control is essential to quality patient care. Although oral narcotics may be sedating they should be prescribed and are nearly always needed to gain adequate pain control. Prescribing adequate pain medications on the first visit is essential to prevent a revisit solely for pain control. Only a small quantity is needed since this is a self-limited problem with short duration.
Ibuprofen (Motrin, Advil, Nuprin, Rufen)
Usually the DOC for mild to moderate pain, if no contraindications exist; inhibits inflammatory reactions and pain, probably by decreasing cyclooxygenase activity, which results in the inhibition of prostaglandin synthesis
Adult
200-800 mg PO q4-6h, while symptoms persist; not to exceed 3.2 g/d
Pediatric
10-70 mg/kg/d PO divided tid/qid
Probenecid may increase the concentrations and possibly the toxicity; may decrease the effect of loop diuretics when administered concurrently; PT may increase when administered concurrently with anticoagulants (monitor PT closely, and instruct patients to watch for signs and symptoms of bleeding); may increase serum lithium levels and risk of methotrexate toxicity
Documented hypersensitivity; because of potential cross-sensitivity to other NSAIDs, do not give these agents to patients in whom aspirin, iodides, or other NSAIDs induce hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function
Oxycodone and acetaminophen (Percocet, Tylox, Roxicet)
Drug combination indicated for the relief of moderate to severe pain.
Adult
1-2 tab or cap PO q4-6h prn
Pediatric
0.05-0.15 mg/kg/dose PO q4-6h prn; not to exceed 5 mg/dose of oxycodone
Phenothiazines may decrease analgesic effects; toxicity increases when administered concurrently with CNS depressants or tricyclic antidepressants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Duration of action may increase in elderly patients; be aware of the total daily dose of acetaminophen; maximum dose of acetaminophen is 4,000 mg/d, higher doses may cause liver toxicity
Ophthalmic analgesic
Some ophthalmologists are advocating that diclofenac (Voltaren) or ketorolac (Acular) drops be used despite lack of official indications. These topical agents have been shown to relieve pain in multiple situations including corneal abrasions, allergies, and postsurgical pain.
Ketorolac tromethamine 0.5% (Acular)
Inhibits prostaglandin synthesis by decreasing activity of the enzyme, cyclooxygenase, which results in decreased formation of prostaglandin precursors, which, in turn, results in reduced inflammation.
Adult
1 gtt into each affected eye qid, continue for a maximum of 2 wk
Pediatric
<12 years: Not established
>12 years: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Perform ophthalmologic studies in patients who develop eye complaints during therapy; discontinue therapy if changes are noted; changes may include blurred or diminished vision, corneal deposits and retinal disturbances, scotomata, changes in color vision, and macula degeneration
Diclofenac (Voltaren)
Inhibits prostaglandin synthesis by decreasing the activity of the enzyme cyclooxygenase, which results in decreased formation of prostaglandin precursors.
Adult
1 gtt into affected eye qid, continue for a maximum of 2 wk
Pediatric
<12 years: Not established
>12 years: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Corneal thinning may occur
More on Ultraviolet Keratitis |
| Overview: Ultraviolet Keratitis |
| Differential Diagnoses & Workup: Ultraviolet Keratitis |
 Treatment & Medication: Ultraviolet Keratitis |
| Follow-up: Ultraviolet Keratitis |
| Multimedia: Ultraviolet Keratitis |
| References |
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References
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Brown MD, Cordell WH, Gee AS. Do ophthalmic nonsteroidal anti-inflammatory drugs reduce the pain associated with simple corneal abrasion without delaying healing?. Ann Emerg Med. Oct 1999;34(4 Pt 1):526-34. [Medline].
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Crumpton KL, Shockley LW. Ocular trauma: a quick illustrated guide to treatment, triage, and medicolegal implications. Emerg Med Rep. 1997;18:223-34.
Daxecker F, Blumthaler M, Ambach W. Ultraviolet exposure of cornea from sunbeds. Lancet. Sep 24 1994;344(8926):886. [Medline].
Schein OD. Phototoxicity and the cornea. J Natl Med Assoc. Jul 1992;84(7):579-83. [Medline].
Spencer WH. The Cornea. Ophthalmic Pathology. 4th ed. Philadelphia, Pa: WB Saunders Co; 1996:233-35.
Weaver CS, Terrell KM. Evidence-based emergency medicine. Update: do ophthalmic nonsteroidal anti-inflammatory drugs reduce the pain associated with simple corneal abrasion without delaying healing?. Ann Emerg Med. Jan 2003;41(1):134-40. [Medline].
Wittenberg S. Solar radiation and the eye: a review of knowledge relevant to eye care. Am J Optom Physiol Opt. Aug 1986;63(8):676-89. [Medline].
Yen YL, Lin HL, Lin HJ, et al. Photokeratoconjunctivitis caused by different light sources. Am J Emerg Med. Nov 2004;22(7):511-5. [Medline].
Further Reading
Keywords
actinic keratitis, snow blindness, flash burn, welder's flash, arc eye, ultraviolet keratitis, UV keratitis, UV radiation injury, corneal damage, corneal abrasion, corneal ulceration, corneal laceration, superficial punctate keratitis, SPK, UV keratoconjunctivitis, ultraviolet keratoconjunctivitis
