rt Photokeratitis and UV-Radiation Burns Associated With Damaged Metal Halide Lamps David L.. Kirschke, MD; Timothy P. Jones, MD; Nicole M, Smith, PhD, MPH, MPP; William Schaffner, MD Background: Damaged metal halide lamps are known to cause outbreaks of photokeratitis and UV-radiation burns among children and adults, which has prompted the Food and Drug Administration, Rockville, Md, to pub- lish consumer recommendations to prevent stich inju- Hes. We investigated 3 outbreaks of photokeratiis and UY-radiation burns in gymnasiums associated with fal- ure to heed these recommendations. Objectives To determine the cause ofthe outbreaks and promote interventions to prevent further injuries, Design and Setting: A cohort study of persons ex: posed to damaged metal halide lamps during the index ‘outbreak in community gymnasiuim and a descriptive epidemiologic study of 2 subsequently identified out- breaks in other gymnasiums Participants: 4 total of 273 persons potentially ex- posed during events in 3 gymnasiums Main Outcome Measure: Phoiokeratitis with onset within 12 hours ofthe event, The intensity of UV radia- tion was measured, and an occupational exposure stan- dard applied, Results: Investigation of the index outbreak identified 18 (approximately 3%) persons who met our case de nition lor photokeratitis. The median incubation period \was 7 hours, and health care visits were reported by 11 persons (61%). Ofthe 18 patients, 17 (04%) were seated im the back of the gymnasium. Among 37 persons sit- ting in this high-risk area, the attack rate was 46%. Only 1 (6%) of 11 persons wearing glasses or contact lenses with UV-radiation protection in the high-risk area de- veloped photokeratitis (relative risk, 0.15; P2.01). The safe occupational exposure limit in the high-risk area was 10 to 15 minutes, but exposures of 1 to 3 hours were re ported. Prevention recommendations had not been it- stituted at any of the 3 facilities, Conel Injuries from metal halide lamps are avoidable, but prevention recommendations may not be widely observed. all facilities using metal halide lamps in areas where children may be exposed should follow the Food and Drug Administration recommen- dations; amending the National Electric Code may be warranted. Arch Pediatr Adolesc Med. 2004;158:372-376 HOTOKERATITISIS DAMAGETO. the comeal epithelium from UV radiation (UVR) from natural oF artificial sources." eeognized examples in- clude snow blindness and welders’ are burns. Peak symptoms typically occur 6 10 12 hours alter exposure and include pho- tophobia, foreign-body sensation, tearing, and blurry vision, Characteristic clinical findings include conjunctival injection and puncluate erosions of the corneal epithe- lum with an intrapalpebral distribution. slic finding is UVR burns of the exposed skin around the eyes. Pho- is usually resolves spontaneously in 24 to 48 hours with symptomatic treal- Clusters of photokeratitis among children and adults associated with dam- aged mercury vapor or metal halide lamps, which are commonly used to light gymna- From the Epidemic Intelligence ‘Service, Epidemiology Program ‘Ofie (Drs Kischke and Smith) ‘and the National Center for Environmental Health (Dr Smith), Centers fr Disease ‘Control and Prevention, Adanta, {Gay the Tennessee Department of Health, Nashville (Drs Kirsehke «and Jones); and Vanderbilt University School of Medicine, [Nashuille (Drs Jones and Schaffer). Dr Kirsch is now withthe Department of ternal ‘Medicine, james H. Quillen College of Medicine, East Teniessce State University the James H. Quillen Veteran Administration Medical Center ‘and the Tennessee Department fof Health, Northeast Tennessee Regional Health Ofce Jolson City. Well: Another charact okerat siums, have been reported (aepnu\ reo) ARCH PEDINTRABOUSC MEBTVOL TSS ATT (©2004 American Med Metal halide lamps contain an inner are tube, analogous toa welder'sarc, that emits tense UVR along with visible light (Figure 1). The UVR is normally attenu- ated by the outer glass envelope so that UVR, exposure is negligible. However, a UVR ha ard can occur when the outer glass enve- lope is broken, as by a flying object, and the inner are tube continues to function and emit UVR that is no longer attenuated by the glass envelope. Nevertheless, injuries {rom metal halide lampsate preventable. Be- cause they are radiation-emnitting devices, the Food and Drug Administration (FDA), Rockville, Md, has issued consumer re ommendations for safe operation, which ‘must be displayed on lamp packaging." However, nonadherence to these preven- tion measures may be widespread, In February 2003, a local health de- partment notified the Tennessee Depart- ment of Health, Nashville, of 8 persons 1 Association, All rights reserved. jamanetvrork.com/ by a Mexico | Access Provided by JAMA User on 10/18/2021up Figure 1. Phtagraph of 00-W mt aide lamp. The ine ar tube, ‘heh contin meeiy vapor and ate gses, mis inianes UV radon long wath visa ign The ou glass emelope fan tact mp ataratas the WV raion, who reported severe eye symptomsafter attending a fund- rising event ina nonprofit youth center gymnasium, An epidemiologic and environmental investigation was per- formed. Asa result of publicity from this outbreak, 2 other ‘outbreaks of photokeratitis were reported and investi- gated. One occurred 2 weeks later at a high school that had hosted a 3-day wrestling tournament in its gymna- sium; the other was among volleyball players at a mu- nicipal gymnasium. This article describes the findings from these 3 outbreak investigations, ss} ‘We performed a cohort study of persons who attended the fund raising event atthe youth center gymnasium. A case was de- fined as acute eye symptoms (including =5 ofthe following: ‘conjunctival injection, burning or itching, photophobia, foreign- body sensation, tearing, blurry vision, periorbital edema, and skin erythema) with onset within 12 hours of the event occur- fing in persons who attended it ad who had no preexisting ‘eye symptoms, Case finding consisted of identifying and call ing atleast 1 representative from each table and all persons in the area where most injures oceurred (defined as the high- riskarea).A questionnaife was administered toll persons con- tacted to determine the location of thei table, whether they had any of the above symptoms, and whether they wore eye- lasses or contact lenses with UVR protection. Consent was ob- tained, and the medical records of those who sought medical attention were reviewed To determine the dose of UVR to which persons were &x- posed, we measured the elfecive irradiance, o biological ef Fectiveness of UVR, from a damaged metal halide lamp in the high school gymnasinm, The outer glass envelope, which nor- mally attenuates UVR, was broken and completely missing Evaltation of effective irradiance could not be performed at the youth center gymnasium because the damaged lamp ‘vas unavailable. However, all of the gymnasiums had high- bay lighting ixtares with aluminum reflectorsand used 400-W, Relype metal halide lamps, which wete 6.2 m above the floor Therefore, data collected atthe high school gymnasium were considered to be representative of effective irradiance during theindex outbreak. Measurements were taken witha radiometer! photometer (IL model 14004; International Light Inc; New- buryport, Mass), which spectrally matches the UVR hazard (aepnu\tED) ARCH PEDINTRABOUSC MEBTVOL TSS APY (©2004 American Med Wo oa eg TETTTTTTTine Tine h Figure 2. Te of ent of photooraiis n 18 persone are undalang et The xxi represents mein hours a vot ated by he arom) Te The clsting of ase suggests a port-sure outbreak witha incubation petied aft 11 hous. bbandwidth (190-400 nm) to generate effective irradiance in mi- crowatls per centimeter squated. Measurements were taken at 1.3 mabove the floor (to simulate the height of a seated pet- son's head) ata point directly below the damaged lamp (cen- ter point) and at I-m intervals off the center point. Measure- ments were taken with the radiometer probe oriented horizontally (0° toward the centr point to simulate line of sight To estimate the hazard to children and adults, ellective iradi- ance was converted to occupational exposure limits by using a lable published by the American Conference of Governmental Industrial Hygienists, Cincinnati, Ohio.” Exposure time re- quired to reach minimal erythemal dose (MED) was caleu- lated by using the formula 5.83 pW/em*=1 MED/h Statistical analyses were performed using y tests calculated with Epi Info 2002 software (Centers for Disease Control and Prevention, Adanta, Ga). (es An estimated 600 persons attended the evening fund- raising event, which lasted 2 to 3 hours (6-9 PM), in the youth center gymnasium. Attendees were seated at tables: arranged throughout the gymnasium for a catered meal and presentations by several speakers, including a na- tionally recognized sports figure. Of the approximately (600 persons who attended, we contacted 119 (approxi ‘mately 20%), including at least 1 person from each of the 52 prepaid tables and 10 general admission tables along, the back of the gymnasium. All persons contacted com- pleted the questionnaire Eighteen persons (approximately 3%) met our ease definition for photokeratitis (Figure 2). Among the 18 patients, 13 (72%) also had UVR burns on their faces, ‘most commonly on the forehead or eyelids. In addition, we identified 2 persons who were wearing UVR protec” Live eyeglasses who had UVR burns on their faces with- out eye symptoms. The duration of exposure for most persons with photokeratitis (04%) was 2 to 3 hours; 1 person was present for only 1 hour. The median incu- bation period was 7 hours (range, 4-11 hours). Health care visits were reported by 11 persons (61%); 4 were awakened from sleep and visited an emergency depart- 1 Association, All rights reserved. jamanetvrork.com/ by a Mexico | Access Provided by JAMA User on 10/18/2021Pas Preseason Cwatt \ ssmasecmite ‘Figur 3. Scherate raving of persons inthe lghisk aoa ata fundrasing vet. The eles rprasentpeteone aed or eaning atound ‘abe inthe highs ata Pink shaded mes rapraventphotoeratt, staded ils represent UVadaton (WV) burs, and back shated ojos feposen UVR protective eyedasas or contat ences Only 1 ptson eating LVR- protective ses developed phtokrts ("an ely inthe omer ff ein an te aly ot covery he nes. ment before 4 AM after the event, and 7 visited an oph- thalmologist the next day, resulting in missed work. Punc- late keratitis was noted in the medical records of § patients Purther characteristics of the persons with photokerati- lis are listed in the Fable, ‘Of the 18 patients, 17 (0496) were seated at orstand- ing near 1 of 5 adjacent tables in the back of the gymna- sium, The other patient was seated atthe front of the gyim- nasitim looking toward the back. We contacted all 37 persons sitting in this high-risk area and performed a co- hort analysis, They were all white individuals, and 28 (76%) were men. The attack rate for persons sitting in this high-risk area was 403%, Wearing glasses or contact lenses did not significantly reduce the risk of develop- ing photokeratitis. However, only 1 (8%) of 11 persons in the high-risk area who were wearing glasses or con- tact lenses with UVR protection developed photokerati- tis, compared with 16 (62%) of 26 persons who were not ‘wearing them (relative risk, 0.15; P=.01) (Figure 3) Silat we ‘cba ‘ 7 : z g / KE bus / SE g & fo he I i es ‘ : le a owe Oe Figure 4. Eecve radiance and ecupatonal exposure ts assorted vith damaged metal had amps. The bars represent the occupational “npeere hts in hous assodaed wth th ec nadanes (ne) Ieasuted det under damaged meta hal amp at the gyaraium and {1 em otra ener, Parson nthe ight are otha nde utbrak were sented om of centr, whch responds t 0-10 "Ssmintoceupatonal xpos ts. ‘The person who developed photokeratitis despite wear- ing glasses with UVR protection was affected only in the corner of his left eye in an area not covered by the glasses, ‘The gymnasium was lit by 20 high-bay lighting fix- tures with metal halide lamps and aluminum reflectors. When the investigators arrived at the gymnasium 2 days later, no damaged lamps (ie, broken outer glass enve lopes) were identified. However, an employee verified that lamp with a broken outer glass envelope had been re- placed since the event. This lamp was located above and in the line of sight of persons atthe 5 tables in the high- risk area as they looked toward the stage. The alumi num reflectors of several lighting fixtures throughout the gymnasium were dented or ulted, indicating possible dam- age [rom flying objects. The 5 high-risk tables were es- UUmated to have been 3 to 6 m off center from a point on the floor directly below the implicated lamp. ‘The environmental investigation demonstrated that the peak effective irradiance, which is a measure of the biological effectiveness of UVR, was 5.2 pW/em? at 4.5 m off center with the sensor in a horizontal position (Figure 4). When an occupational standard is applied, that effective irradiance corresponds to an occupational exposure limit of 5 10 10 minutes according to the Amer can Conference of Governmental Industrial Hygien- ists." The effective irradiance at 6 m off center was 3.8 Wem, which corresponds to an occupational ex- poste limit of 10 to 15 minutes. When the effective it radiance measured during the environmental investiga- don was converted to MED, it was determined that MED would be reached by 0.7 hour at 3 m and 2.1 hours at 6m in a person with fair skin, ‘Asa result of publicity from this outbreak, we were notified of and investigated 2 other outbreaks of photo- keratitis. The first occurred 2 weeks later ata high school that hosted a 3-day wrestling tournament in its gymna- sium. It was noted that L of the metal halide lamps in the gymnasium was damaged. We interviewed 149 (about (apna TED) XECH PEDIATR ADOLESC MED VOL ISS APE SIOY WOW ARCHFEDIATHICS COM (©2004 American Med 1 Association, All rights reserved. ‘Downloaded From: https:/jamanetwork.com/ by a Mexico | Access Provided by JAMA. User on 10/18/202140%) of the approximately 300 to 400 persons who at- tended the tournament. Among the 149 persons, 46 (319%) met our photokeratitis case definition and had expo- sure times of up to 12 hours. Spectators were dispropor- tionately affected. Among the 46 persons with photo- keratitis, 24 (529%) also reported UVR burns to the face. The most common eye symptoms were conjunctival Injection, burning, and photophobia, and 24 (52%) per- sons sought medical care Another outbreak occurred among volleyball play- cers al a municipal gymnasium. We interviewed 5 per~ sons who played together who had symptoms consis tent with photokeratitis or UVR bums on 3 occasions during a period of 3 months alter playing volleyball at the gymnasium. The duration of exposure on each ac- ‘easion was estimated to have been 1 to 3 hours. An in- vestigation initiated after complaints by patrons re- vealed a damaged metal halide lamp over the volleyball ee We investigated 3 outbreaks of photokeratitis and UVR burns associated with expostire to UVR from damaged ‘metal halide lamps in gymnasiums used primarily by chil- dren, The intensity of the UVR measured during the en- vironmental investigation ofthe second outbreak was sch that the occupational exposure limit would have been 10 to 15 minutes in the high-risk area, which is the same limit as during the index outbreak at the youth center; the actual exposure times were 2 to 3 hours, The attack rate in the index outbreak was 46% for photokeratitis and 419% for UVR burns for persons in the high-risk area, ‘Our cohort study demonstrated that UVR-attenuating eyeglasses or contact lenses were protective against photokeratitis, Photokeratitis from acute UVR exposure during these ‘outbreaks produced severe eye symptoms that resulted in emergency department and ophthalmologist visits and missed work. Although its exact role in the develop- ment of cataracts is debated, animal studies have dem- ‘onstrated cataractogenesis after acute laboratory expo- sure to UVR. In addition, an association between lifetime UV-B expostre and cataract formation has been shown in a human epidemiologic study."® Some persons ex- posed to UVR during the outbreaks we investigated also experienced UVR burns, often resulting in desquama- tion, Although the risk of cataracts or skin cancer from acute expostres stich as described in these outbreaks is unknown, any preventable increased risk warrants at- tention, The Centers for Disease Control and Preven- tion, Atlanta, Ga, has recommended minimizing expo- sure to UVR, especially among children." The 3 outbreaks described here, combined with re- ports by the Centers for Disease Control and Prevention and the FDA," suggest that injuries and outbreaks re- lated to damaged metal halide lamps may be more com- mon than currently appreciated. Indeed, on asecond visit to the high school that hosted the wrestling tourna- ment, a damaged metal halide lamp was discovered that had not been recognized by the maintenance staff even with heightened awareness following the outbreak, Metal (nepeaN TED) TECH PEDIATH ADOLESC MEDOU 158 APE IOT (©2004 American Med BS |} Several outbreaks of photokeraiis and sunburn ass0- ciated with damaged metal halide lamps were reported inthelate 1970s, and asa result, the FDA required wath ing labels on these lamps. However, our investigation demonstrates that outbreaks of photokeratitis and rash continue to occur and may be more common than pre- ‘ously apreciated. Because damaged metal halide lamps sre olien recognized only alter they ae linked toa health complaint, increased awareness ofthis hazard is neces- sary to correctly diagnosis this preventable cause of kera- Uiis and rash in school-aged children, which can be mis- taken as an infectious process. The FDA prevention recommendations are infrequently implemented in fa- cilities used by children, which has prompted the Na tional Electrical Manufacturers Association to petition that these recommendations be reflected in the Na- tional Electric Code, halide lamps that do not self-extinguish are commonly used in open fixtures in gymnasiums where they are at risk for damage by flying objects. Once damage has oc- curred, ifthe broken glass is not reported to the proper person, the problem can be difficult to detect because [amps may continue to function normally. Disincen- tives may exist for children to report damaged lamps, such as disciplinary action. Furthermore, many facilities do not have the proper equipment on site, such as a me- chanical lift, to reach the 6-m-high fixtures to change a damaged lamp. Even after a damaged lamp is discov- ered, it might not e recognized as a health hazard and therefore might not be replaced until it fails, is replaced during scheduled maintenance, of causes injuries Injuries and outbreaks related to metal halide lamps are likely underreported, especially in children. Since the problem is not well recognized, when sporadic injuries fccur, the possibility of exposure toa damaged metal ha- lide lamp may not be as apparent as when an outbreak joceurs. Sporadic injuries oF small clusters might be al- uibuted to infectious causes of conjunctivitis or rash ill ness in children, To prevent these injuries, the PDA recommends that either enclosed fixtures or sell-extinguishing lamps: be used in areas where persons may be exposed for pro- longed periods."* Enclosed fixtures would protect the lamp from damage and, in the event of damage, the glass or plastic lens would attenuate the UVR. Self-ex- Unguishing lamps are designed to stop functioning, within 15 minutes if the outer glass envelope is dam- aged and may be used én open fixtures, but such lamps: are more expensive than those that do not sell-extin- guish and so are not routinely used or widely available. The National Electrical Manufacturers Association, Rosslyn, Va, has also recently published recommenda” tions for schools." The fact that outbreaks associated with metal ha- lide and mercury-vapor lamps continue to oceur indi- cates a failure of the current level of recommendations. Ulumately, a change to the National Electric Code might be required and has been proposed by the National Elec- 1 Association, All rights reserved. jamanetvrork.com/ by a Mexico | Access Provided by JAMA User on 10/18/2021trical Manufacturers Association. All facilities that use metal halide lamps where persons may be exposed for extended petiods of time should follow the FDA of Na- tional Electrical Manufacturers Association recommen- dations." Injuries or outbreaks associated with metal halide lamps should be reported to the state or local health department and the FDA (Center for Devices and Radiological Health, Office of Compliance, MS HFZ- 342, 2008 Gaither Rd, Rockville, MD 20850, telephone: 301-504-4054), ‘Accepted for publication November 17, 2003. We thank Beth Collier, RN, Middle Cumberland Regional Health Department, Nashville, Tenn, and Mary Ellen Chesser, RN, Williamson County Health Depart- ment, Franklin, Tenn Corresponding author and reprints: David L. Kir schke, MD, Tennessee Department of Health, Northeast Tennessee Regional Health Office, 1233 Southwest Ave Extension, Johnson City, TN 37604-6519 (e-mail: david hirschhe@state.n.us) EES} 1. Parish OM, Cand J. Catarauma Kanan HE, Baron 8, McDonald ds The Crea Boston, Mase: tra Haman: 2003 22-7 2 Ros RCI Pater AL Ehara a oj eta ae by na erent exposure lilt gh. JANA TO7E:242 11551156. 4. Bats LS, Smitten I. Rumack BH, Cunn A. Uneeognes trav inde arteconuncs no Ener Mad. 186151378, 4 Thun, Aan ingsan 0, MSL, Task ML. Oar compos ot (agen TED) TECH PEDIATH ADOLESC MEDOU 158 APE OT 1 2 @ e 0 ralnctining mercury vapor amps. Aon Opto 1821410171020. HipernW Abn ok Marshal Coli. Conus and kin hema outbrea cased by adanapeigh ns amp AMA 1073240 sano Camas for Dense Conta. Counts cusd by matneoning mercury apo lags: Michigan, New Jersey. AI Mr Moral Wh Rap. 17028 varia Asbury JF Sore yes duo acide exposure ori. are 184; ene ot 8, Sihernan PR Keatacanjurcbts caused by abot highiensity teu apr arg. Da Med 18558685 57 Prams. Kestocenuntis roma ig. JANA 180242:722- 7a Tels NC Cooly JM, Koger JA Mary vapor mp ini. JANA, 175; rate ater por lps maybe dangers the FD, JC. 19782821807 ighrtensiy Mercury Vapor ischarg Lamps. 210F 104030 1907) mereanCaftne of Govenmenl neal yan (AOS) Utavi- Intraditon,I L Ue and Ete: Basa Tras Vas for hei Substances and Physical ages anda posure nds Cina, bai 20081571, nfo 2002 eam progam] Vesion 1. Alana, 6a Cras or Disease Cad Proven 200 Sin) DH. UV aden cus posure dasiney, J Phtotem Pht sg.3138-77, Toyo A, st SK Rosen FS, eta Etec of uv! dian on ca rae fomation Eng J Med. 18653142013 Saal Gh K Briss, Mchols, White , Das rhe Tas Force on Carn Preven Serves on Return xposuet Ural Light Pr ving sence ning the Task Freon Conmany Pear Ser vies 0 Reducing Exposure oUt Light MMH Aacorm ep 203 sev Hazards of mercury vparlanps JAMA 19762102184, stent! Manufacturer farciaon, Recommends for he ete and mainarance of igh inansty met ha and macuy vapor Bghting in schools. avaiable at upPa.nama orgindexnema cn? ABEARAG 06-496 BUDSTCTTOOSTTR hese Jone 2, 2002 (©2004 American Medical Association, All rights reserved. Downloaded From: https:/fjamanetwork.com/ by a Mexico | Access Provided by JAMA. User on 10/18/2021