A 12-year-old boy is brought to the emergency department by his parents due to bilateral eye pain. The patient and his family are on a ski vacation, and he had played in the snow all day. Over the past hour, the patient has had progressively worsening pain in both eyes. Temperature is 37.2 C (99 F). Visual acuity is 20/40 in both eyes. Extraocular movements are intact, and pupils are reactive bilaterally. There is no tenderness to palpation. Bilateral conjunctivae are erythematous with increased tearing of both eyes. The anterior chamber appears normal. Fluorescein examination reveals diffuse punctate corneal staining bilaterally. Which of the following most likely contributed to this patient's presentation?

Question

A 12-year-old boy is brought to the emergency department by his parents due to bilateral eye pain.  The patient and his family are on a ski vacation, and he had played in the snow all day.  Over the past hour, the patient has had progressively worsening pain in both eyes.  Temperature is 37.2 C (99 F).  Visual acuity is 20/40 in both eyes.  Extraocular movements are intact, and pupils are reactive bilaterally.  There is no tenderness to palpation.  Bilateral conjunctivae are erythematous with increased tearing of both eyes.  The anterior chamber appears normal.  Fluorescein examination reveals diffuse punctate corneal staining bilaterally.  Which of the following most likely contributed to this patient's presentation?

Quizplus · Accepted Answer

11ec25c8_d5ef_9d68_bc81_4142a842fcaf_MD0003_00 This patient's bilateral eye pain and redness after playing in the snow are concerning for photokeratitis, an acute superficial corneal injury caused by excessive ultraviolet (UV) light exposure. Without protective eyewear, the cornea absorbs UV radiation, which leads to desquamation of corneal epithelial cells. Because of the reflection of sunlight on water, sand, and snow, beachgoers and skiers are at highest risk. In addition, the atmosphere at higher elevations (eg, ski slopes) is less protective against the sun's rays. Photokeratitis typically presents 6-12 hours after UV exposure with severe bilateral eye pain and photophobia. Patients often describe a gritty foreign-body sensation in the eyes, and visual acuity may be temporarily decreased. Examination shows increased tearing with conjunctival injection and edema. The presence of a facial sunburn further supports the diagnosis of a UV-related injury. Diagnosis is confirmed with fluorescein staining of punctate defects on bilateral corneas. Management of photokeratitis includes pain relief and lubrication with a topical antibiotic ointment (eg, erythromycin). Symptoms generally resolve within 1-3 days as the corneal epithelium regenerates. Although the cornea heals with no known long-term sequelae, UV radiation can lead to other unrelated eye diseases (eg, pterygium, cataracts), and UV-protective eyewear is highly recommended. (Choice A) Acute angle-closure glaucoma (ie, aqueous humor obstruction) causes sudden eye pain and redness with vision loss. However, examination typically shows a unilateral, fixed, middilated pupil. In addition, fluorescein dye testing would be normal. Acute angle-closure glaucoma (Choice B) Bacterial conjunctivitis can cause conjunctival injection but is associated with purulent eye drainage rather than tearing. In addition, although mild discomfort may be present, progressive eye pain is not typical, and corneal defects would not be present on fluorescein staining. (Choice C) Hyphema due to blunt force trauma is typically unilateral and presents with eye pain, vision loss, and blood in the anterior chamber. This patient's bilateral findings and normal anterior chamber make hyphema unlikely. (Choice D) A retained foreign body can cause corneal abrasion, which presents with eye pain, photophobia, and tearing. However, fluorescein dye testing most commonly shows a discrete, unilateral linear stain rather than diffuse, bilateral punctate lesions. Educational objective: Photokeratitis is an acute corneal injury caused by ultraviolet (UV) light exposure in the absence of UV-protective eyewear. Patients generally seek medical attention 6-12 hours after exposure for severe bilateral eye pain and photophobia. Punctate staining of the corneas with fluorescein dye is characteristic. References: Photokeratitis induced by ultraviolet radiation in travelers: a major health problem. (http://www.ncbi.nlm.nih.gov/pubmed/29067921)

A 12-Year-Old Boy Is Brought to the Emergency Department by His