Management of Welder's Flash (Photokeratitis)
Immediate symptomatic treatment with topical antibiotics, lubricants, and cycloplegics is the cornerstone of management, with complete resolution expected within 24-72 hours. 1, 2
Immediate Assessment
Document the following key features:
- Visual acuity in both eyes—any vision worse than 20/40 requires urgent ophthalmology consultation 3
- Fluorescein staining pattern—photokeratitis characteristically shows punctate epithelial erosions limited to the palpebral fissure (the area exposed between the eyelids) 1
- Presence of conjunctival hyperemia, lacrimation, photophobia, and blepharospasm—these are hallmark features of UV-induced keratitis 1, 4
- Timing of exposure—symptoms typically appear within a few hours after UV exposure and resolve within 72 hours 2
Treatment Protocol
Topical Antibiotic Prophylaxis
- Initiate broad-spectrum topical antibiotics (moxifloxacin or levofloxacin four times daily) to prevent secondary bacterial keratitis, especially when corneal epithelial defects are present 5
- Continue antibiotics until epithelial healing is complete, typically 2-3 days 1
Intensive Lubrication
- Apply preservative-free lubricant eye drops (hyaluronate or carmellose) every 2 hours to maintain corneal epithelial integrity and promote healing 5
- Continue frequent lubrication throughout the acute phase until symptoms resolve 5
Cycloplegic Agents for Pain Control
- Consider cycloplegic drops (cyclopentolate 1% or homatropine 2%) for significant pain and photophobia to reduce ciliary spasm 6
- This provides substantial symptomatic relief in the acute phase 6
Oral Analgesia
- Prescribe oral NSAIDs or acetaminophen for pain management as needed 1
- Avoid topical NSAIDs due to risk of delayed corneal healing 7
Critical Management Pitfalls
Never patch the affected eye or use therapeutic contact lenses in the acute phase—this significantly increases the risk of secondary bacterial keratitis 5
Avoid topical corticosteroids without ophthalmology supervision—steroids can mask infection signs and worsen conditions such as herpetic keratitis if misdiagnosed 5, 3
Do not prescribe topical anesthetics for home use—these prevent healing and can cause severe corneal toxicity with repeated use 7
Follow-Up and Red Flags
Arrange ophthalmology referral if:
- Symptoms persist beyond 72 hours—photokeratitis should resolve completely within this timeframe 2
- Visual acuity remains worse than 20/40 after initial treatment 3
- Pain worsens or new symptoms develop (suggesting secondary infection or misdiagnosis) 3
- Any corneal infiltrate or stromal involvement is noted—this suggests bacterial or fungal keratitis rather than simple photokeratitis 7, 6
Expected Outcome
Complete resolution with restoration of normal visual acuity (10/10) is expected within 24-72 hours with appropriate treatment 1, 2. The corneal epithelium regenerates rapidly once the UV insult is removed and supportive care is provided 2.
Prevention Counseling
Emphasize the absolute necessity of UV-blocking protective eyewear during all welding activities—even brief exposures can cause photokeratitis, and repeated exposures increase risk of chronic ocular surface changes including pingueculae 4, 8. While chronic endothelial damage from welding appears minimal, acute photokeratitis episodes are entirely preventable with proper eye protection 8.