September 2018


Cornea editor’s corner of the world
Volcanic eruptions present unique challenges

by Rich Daly EyeWorld Contributing Writer

When patients present with dry eye symptoms, one of the initial management strategies is to optimize their surrounding environment. For example, one should avoid direct air from heating or air conditioning vents from hitting the eyes, use a humidifier, lower a computer screen and reduce the computer brightness, take breaks from screen time, and wear sunglasses and even moisture chamber goggles in more severe cases. The prevalence of dry eye symptoms has been shown to be higher in cities with high levels of air pollution and in high altitude areas.
Little has been shared about what patients experience who live in areas close to active volcanic eruptions. In this month’s “Cornea editor’s corner of the world,” Susan Senft, MD, an ophthalmologist in Hawaii, shares some anecdotes about unique cases she has seen locally related to the intermittent ash blowing in from the Kilauea volcano. “Laze,” another form of volcano-related pollutant, is discussed, and methods to best treat these patients are reviewed.

Clara Chan, MD,
Cornea editor

Hawaiian ophthalmologist describes unique patients she has begun to see since volcanoes became active in recent months

Susan Senft, MD, has long seen conjunctival inflammation cases from intermittent vog (volcanic air pollution secondary to sulfur dioxide) among her patients on the Hawaiian island of Kailua-Kona. But striking new cases appeared after the Kilauea volcano became more active in recent months.
Kailua-Kona, which is about 100 miles away from the active volcano, has received an unexpectedly large amount of volcanic air pollution.
“In the past, some days were better than others,” Dr. Senft said. “From [normal pollution] people usually have itchy, burning eyes like an allergic conjunctivitis pattern. But what I have seen is different from that.”
In recent weeks, Dr. Senft has had two patients from Naalehu and South Point, which are located on her island and are the southern- most areas of the United States. Both patients came in with irritation on the surface of their eyes on a day of “exceptional heavy active ash fall.”
“They had a punctate epithelial keratitis that was just in the interpalpebral fissure area—only the area that was exposed to where wind or air would hit the surface of the cornea,” Dr. Senft said. “Underneath the lids was fine. But in that little area, it was a stipple pattern of punctate epithelial erosion.”
The patients complained of pain, tearing, light sensitivity, and decreased vision.
“It was different from the run of the mill allergic conjunctivitis that people get from the day-to-day volcanic output, secondarily to sulfur dioxide in the air,” Dr. Senft said.
Residents of the Naalehu and South Point areas have received much more ash blowing in from the volcano than the rest of the Big Island, which is further northwest.
“The trade winds blow from southeast to southwest normally around that area,” Dr. Senft said. “If we are having a north wind, then it is all clear. If it is blowing from over there, for example the Hilo volcano side, which is only 12 miles away, it is clear air, but if it is from the Kilauea site, which is 100 miles away, we get the air pollution.”
Dr. Senft treated the patients, who presented the same day with the same complaints, with a combination of mydriatics, mild steroids, and a long-lasting nonsteroidal, like bromfenac.
“It only took a day or so for that to get better,” Dr. Senft said.
Ongoing treatments included lubricants and nonsteroidals once a day and steroids drops twice a day.
“That seemed to help, and they haven’t had it again,” Dr. Senft said. “But it was at a time when there was a lot of ash in the air. Right now, I think the activity of the volcano is better.”
She noted that at that point up to 22 fissures were open and spewing volcanic gases in the air. By July, only one main fissure and eight actively flowing sites remained in the area of about 10 square acres of the volcanic activity.

No laze patients

Dr. Senft has yet to see any patient from the airborne volcanic pollutant that results from the volcanic eruption hitting ocean waves—known as laze—which forms glass particles that can be very irritating.
“I haven’t seen anyone who has had that because it is too far away, only in the immediate vicinity of where the lava hits the ocean, where new land is forming and the steam is coming off the water area,” Dr. Senft said.
The two serious cases she treated were from the affected area and offered no other explanation for their conditions.
The recent cases were beyond the common cases she has treated stemming from volcanic smog, which is sulfur dioxide that produces swelling, redness, and mild irritation on the surface of the eye, similar to allergic conjunctivitis symptoms. That clinical challenge has affected island residents since 1983, when there was a major eruption of Kilauea.
“These cases were a punctate keratitis, it looked like a toxic chemical had gone in,” Dr. Senft said. “Like if someone were to get into some type of industrial accident and spill battery acid in their eye, it looked like that.”
Local authorities have advised residents to stay indoors and use air conditioning or air purifiers on days of heavy volcanic activity.
“In Hawaii, not a lot of people have air conditioning,” Dr. Senft said. “It is usually windows open and trade winds, so this is a new thing for people.”
However, her use of air purifiers appeared to effectively counteract the volcanic air pollution, as well as working in an air conditioned environment.

Suspected causes

Dr. Senft thinks the accumulation of volcanic air pollution in the tear film was causing the problems she has seen.
Other ophthalmologists in Hawaii have told her they haven’t seen such serious cases. But that would be expected since their areas are not receiving winds from the areas of the active volcano.
“We’re the ones who are getting the bad air and also the South Point area,” Dr. Senft said.
“They may occasionally get a Kailua-Kona wind that blows something over their way, but it’s diluted by the time it gets over there compared to what we have here.”
Not much has been written about how to treat patients in the area of an active volcano because it is unusual, she said.
“It was striking that both of these people who had this had it just in the interpalpebral fissure area,” Dr. Senft said.
The striking difference from similar serious cases was that patients with a chemical irritation usually have the entire cornea involved.
“This was unique to the interpalpebral fissure zone,” Dr. Senft said. “It is only the part that was exposed. That’s what made it so impressive.”

Editors’ note: Dr. Senft has no financial interests related to her comments.

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