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45 year old male presents to the Emergency Department with bilateral eye pain upon waking up this morning. Patient works as an electrician and has been working on high voltage power lines this past week. Pain is severe, rated 10/10, and sharp. Pain is worse with opening his eyes and improved with keeping his eyes closed. Reports blurred vision. Patient denies any trauma to the eye, headaches, nausea, vomiting, fevers, chills, and/or eye drainage. On exam, the patient appears uncomfortable keeping his eyes shut. He has erythema to bilateral maxillary and frontal region. Visual acuity 20/50 unilaterally and bilaterally. Fluorescein exam reveals punctate corneal staining and pain is significantly improved with application of anesthetic. Eye pressures are obtained and are 14 in the right eye and 16 in the left. What is the most appropriate treatment at this time?

1. Ciprofloxacin 

2. Diclofenac 

3. Tetracaine and Erythromycin ointment 

4. Erythromycin ointment and oral pain control 

Answer: D. Erythromycin ointment and oral pain control

The patient is presenting with signs of UV keratitis, also known as photokeratitis (or snow-blindness), from working on a high voltage power line. Onset of symptoms occurs 6-12 hours after exposures. The damage is caused by UV rays damaging the epithelium of the cornea. Most damage is caused by UV-B and UV-C light. Visual acuity is diminished secondary to pain. On fluorescein exam, punctate uptake may be present in the cornea. Pressures should be within normal limits. Treatment is supportive with oral medications. Often pain is so severe that opiates are required. NSAIDS and acetaminophen are beneficial as well. Topical anesthetics are not recommended for long term pain control at this time and should be limited to initial evaluation. Topical antibiotics such as erythromycin, bacitracin or polymyxin are recommended for lubrication and to prevent superinfection.

Resources:

Walker R.A., & Adhikari S (2020). Eye emergencies. Tintinalli J.E., & Ma O, & Yealy D.M., & Meckler G.D., & Stapczynski J, & Cline D.M., & Thomas S.H.(Eds.),  Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill. https://accessemergencymedicine-mhmedical-com.ezproxy.rowan.edu/content....