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Cover page of the Journal of Health Sciences


 
 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 14  |  Issue : 2  |  Page : 279-281

Photokeratitis following exposure to germicidal ultraviolet lamps during the COVID pandemic


Department of Ophthalmology, Institute of Medical Sciences and SUM Hospital, SOA (Deemed to be) University, Bhubaneswar, Odisha, India

Date of Submission22-Feb-2021
Date of Acceptance03-May-2021
Date of Web Publication31-May-2021

Correspondence Address:
Dr. Pradeep Kumar Panigrahi
Department of Ophthalmology, Institute of Medical Sciences and SUM Hospital, SOA (Deemed to be University), 8-Kalinga Nagar, Bhubaneswar - 751 003, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.kleuhsj_31_21

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  Abstract 


Twelve patients presented with symptoms of pain, redness, watering, and photophobia following exposure to germicidal ultraviolet (UV) lamp. Anterior segment examination showed varying degrees of ciliary congestion and superficial corneal punctate epithelial erosions in all patients. Diagnosis of post-UV photokeratitis was made. Patients were treated with topical antibiotics and artificial lubricating drops. All patients were symptom free 1 week following presentation. The use of standard protective gear and closely following manufacturer guidelines can prevent such complications.

Keywords: COVID, germicidal, pandemic, photokeratitis, ultraviolet


How to cite this article:
Das S, Panigrahi PK, Pareek D. Photokeratitis following exposure to germicidal ultraviolet lamps during the COVID pandemic. Indian J Health Sci Biomed Res 2021;14:279-81

How to cite this URL:
Das S, Panigrahi PK, Pareek D. Photokeratitis following exposure to germicidal ultraviolet lamps during the COVID pandemic. Indian J Health Sci Biomed Res [serial online] 2021 [cited 2021 Jun 17];14:279-81. Available from: https://www.ijournalhs.org/text.asp?2021/14/2/279/317406




  Introduction Top


Ultraviolet (UV) rays associated photokeratitis is a well-known clinical entity characterized by corneal epithelial damage by the exposed UV rays. Symptoms range from varying degrees of pain to severe photosensitivity. The spectrum of clinical findings ranges from mild superficial punctate keratitis to total corneal epithelial desquamation. Exposure of the underlying subepithelial nerve plexus is responsible for the pain experienced by the subjects.[1] It is usually seen in patients involved in outdoor activities with exposure to direct or reflected natural UV rays.[2] However, cases following exposure to artificial sources of light have also been reported.[3],[4],[5]

The prevailing global pandemic of coronavirus disease 2019 (COVID-19) has caused significant morbidity and mortality.[6] Consumer-grade UV lamps have been used at individual and business levels as a means of sterilization to prevent the transmission of the virus. However, improper use of these lamps can lead to complications. We report a series of 12 patients who presented with features of UV-associated photokeratitis following inadvertent exposure to consumer-grade germicidal UV lamps.


  Case Reports Top


A total of 12 patients presented in the outpatient department with complaints of pain, irritation, redness, and photophobia in both eyes of a few hours' onset following exposure to a germicidal UV lamp. There were 8 males and 4 females. All patients gave a history of exposure to consumer-grade germicidal UV lamp at their place of work. There were 2 separate incidents of exposure. Seven patients presented in the first incident. The second incident involved five patients. Both the accidental exposures occurred at different places of work. All patients presented more than 8 h following exposure to UV lamp. All patients reported not following proper manufacturer instructions and nonuse of skin or eye protector. The duration of exposure ranged from 15 min to 2 h. All patients complained of bilateral symptoms ranging from foreign body sensation, mild watering, and redness to marked photophobia. None of the patients gave prior history of any dry eye disorder or connective tissue disorder like rheumatoid arthritis. The best-corrected visual acuity in both eyes ranged from 20/20 to 20/40 in all cases. Slit-lamp examination revealed varying degree of ciliary congestion and corneal punctate epithelial erosions bilaterally [Figure 1]. Examination findings were symmetrical in both eyes of each patient. There was no intraocular inflammation. Intraocular pressure measured using noncontact tonometer was within normal limits. Fundoscopy done using indirect ophthalmoscope was normal in all eyes. Salient demographic and clinical findings have been highlighted in [Table 1].
Figure 1: (a and b) Slit-lamp photographs of right and left eye showing ciliary congestion. (c and d) Slit-lamp photographs of right and left eye showing diffuse corneal punctate epithelial erosions

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Table 1: Demographic and clinical characteristics

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All patients were treated with frequent instillation of topical lubricating eye drops (hydroxypropyl methyl cellulose) and topical 1% moxifloxacin eye drops 4 times per day. Because of the prevailing COVID pandemic, most of the patients preferred following up through either teleophthalmology or phone calls. Only one patient (P1) [Table 1] could come physically to the outpatient department for a follow-up examination. Most of the patients reported resolution of their symptoms 3 days after starting treatment. By the end of 1st week, all patients were symptom free. Follow-up examination at 1 week after presentation of P1 showed complete resolution of ciliary congestion and punctate epithelial erosions. Manufacturer details were available for both the lamps. Both the lamps were 36 W and UVC lamps with the trade names of LAGO and ULVIO, respectively.


  Discussion Top


Germicidal UV-C (wavelength 100–280 nm) waves are specifically well suited for disinfection activity.[7] The shorter wavelength UV-C rays belonging to the more damaging end of the UV spectrum are almost fully absorbed by the cornea. Greater proportion of UV-A and UV-B rays passes through the cornea.[8] Both longer wavelength UV-A and shorter wavelength UV-C rays are therapeutically used in the field of ophthalmology.[9],[10],[11] Inadvertent, uncontrolled, and suprathreshold exposure to UV rays can lead to damage to conjunctival and corneal epithelium.

In the present study, all patients presented with symptoms few hours following exposure to UV lamps purchased during the COVID pandemic for disinfection purposes. All patients had complaints of varying degrees of redness, watering, and photophobia. Clinical findings and course paralleled classic descriptions of UV photokeratitis. All patients reported easing of symptoms 48–72 h following exposure and were symptoms free 1 week after exposure. All patients were exposed to 36 W UVC emitting lamps. Along the UV spectrum, UV-C light is known to be the most cytotoxic to conjunctival and corneal epithelium. UV light induces apoptosis of in vitro corneal epithelial cells through activation of potassium channels.[12],[13] With prolonged exposure, there can be epithelial desquamation which can lead to corneal edema and haze.[14] Manufacturer instructions for both the lamps advocated avoiding direct contact. The use of appropriate protective eyeglasses which come with these lamps could have prevented photokeratitis in these cases.

Stripp et al.[15] reported photokeratitis in 18 of 85 restaurant employees following exposure to UV-C spectrum bulbs that were inadvertently shipped and installed in insect light traps. Leung and Ko reported a family of 3 adults with photokeratitis following exposure to UV-C germicidal lamps, early in the pandemic in Hong Kong.[16] Pertinent to our study, Sengillo et al. reported a case series of seven patients of photokeratitis following exposure to 38 W UV-C emitting germicidal lamps.[5] Similar to our study, all patients present with features 6 h after exposure. All patients were treated with abundance of artificial lubricating drops and topical antibiotics. One patient in their study was treated with topical prednisolone. In the present study, all the patients responded well to topical antibiotics and lubricating drops. None of our cases needed topical steroids. Topical steroids should be adjunctively used in severe cases where stromal involvement is clinically evident.


  Conclusion Top


The present study confirms the association between photokeratitis and exposure to improperly used germicidal UV lamps during the COVID pandemic. Such germicidal lamps are being aggressively marketed as disinfecting agents in the present COVID scenario. It is important for physicians and ophthalmologists to be aware of the potential complications following UV exposure and educate the patients. The authors' take-home message is to be careful while using germicidal UV lamps and to follow all manufacturer instructions closely.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bergmanson JP, Pitts DG, Chu LW. The efficacy of a UV-blocking soft contact lens in protecting cornea against UV radiation. Acta Ophthalmol (Copenh) 1987;65:279-86.  Back to cited text no. 1
    
2.
Izadi M, Jonaidi-Jafari N, Pourazizi M, Alemzadeh-Ansari MH, Hoseinpourfard MJ. Photokeratitis induced by ultraviolet radiation in travelers: A major health problem. J Postgrad Med 2018;64:40-6.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Banerjee S, Patwardhan A, Savant VV. Mass photokeratitis following exposure to unprotected ultraviolet light. J Public Health Med 2003;25:160.  Back to cited text no. 3
    
4.
Ting MA, Saha K, Robbie S. Mass photokeratitis following ultraviolet light exposure at a nightclub. Cont Lens Anterior Eye 2016;39:316-7.  Back to cited text no. 4
    
5.
Sengillo JD, Kunkler AL, Medert C, Fowler B, Shoji M, Pirakitikulr N, et al. UV-photokeratitis associated with germicidal lamps purchased during the COVID-19 pandemic. Ocul Immunol Inflamm 2021;29:76-80.  Back to cited text no. 5
    
6.
Wu D, Wu T, Liu Q, Yang Z. The SARS-CoV-2 outbreak: What we know. Int J Infect Dis 2020;94:44-8.  Back to cited text no. 6
    
7.
Buonanno M, Welch D, Shuryak I, Brenner DJ. Far-UVC light (222 nm) efficiently and safely inactivates airborne human coronaviruses. Sci Rep 2020;10:10285.  Back to cited text no. 7
    
8.
Yam JC, Kwok AK. Ultraviolet light and ocular diseases. Int Ophthalmol 2014;34:383-400.  Back to cited text no. 8
    
9.
Raiskup F, Theuring A, Pillunat LE, Spoerl E. Corneal collagen crosslinking with riboflavin and ultraviolet-A light in progressive keratoconus: ten-year results. J Cataract Refract Surg 2015;41:41-6.  Back to cited text no. 9
    
10.
Sachdev GS, Sachdev M. Recent advances in corneal collagen cross-linking. Indian J Ophthalmol 2017;65:787-96.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Pidro A, Biscevic A, Pjano MA, Mravicic I, Bejdic N, Bohac M. Excimer lasers in refractive surgery. Acta Inform Med 2019;27:278-83.  Back to cited text no. 11
    
12.
Lu L, Wang L, Shell B. UV-induced signaling pathways associated with corneal epithelial cell apoptosis. Invest Ophthalmol Vis Sci 2003;44:5102-9.  Back to cited text no. 12
    
13.
Wang L, Li T, Lu L. UV-induced corneal epithelial cell death by activation of potassium channels. Invest Ophthalmol Vis Sci 2003;44:5095-101.  Back to cited text no. 13
    
14.
Delic NC, Lyons JG, Di Girolamo N, Halliday GM. Damaging effects of ultraviolet radiation on the cornea. Photochem Photobiol 2017;93:920-9.  Back to cited text no. 14
    
15.
Stripp MP, Dulaney AR, Beuhler MC, Langley RL. Photokeratitis among restaurant workers: A case series. Am J Ind Med 2018;61:780-2.  Back to cited text no. 15
    
16.
Leung KC, Ko TC. Improper use of the germicidal range ultraviolet lamp for household disinfection leading to phototoxicity in COVID-19 suspects. Cornea 2021;40:121-2.  Back to cited text no. 16
    


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