Julia Garr, OD, of Washington, DC, always educates patients that, while UV-blocking contact lenses help to protect parts of the eye from UV radiation, sunglasses should also be used to shield the entire eye and the surrounding skin.
Optometrists and eye care professionals are well versed in relaying the importance of daily sun protection to their patients—but do patients really follow through with these recommendations? Profiling patients and providing them with reasons why they specifically are at risk for damage from UV radiation may help to improve their compliance in using UV protection.

UV radiation is harmful to eyes. Overexposure to UV can have short-term effects such as UV keratitis and long-term effects like pinguecula and pterygia, acceleration of cataracts, and an increased risk of retinal damage. In addition, the skin of the lids—particularly the lower lids and the skin surrounding the orbits—need to be shielded from the sun’s harmful rays in order to decrease the chance of cancerous growths in these areas.

Because UV light is a part of the natural world, we need to find out how much time our patients spend outdoors and in what types of environments. Not only does an individual’s genetic makeup, physical characteristics, age and family history matter when assessing their risk of potential damage from UV, their everyday surroundings and habits matter as well. Taking a thorough patient history is the first step in formulating personalized recommendations for UV protection.

Let’s look at five profiles of patients who need UV protection—and some information that you can give them about why they specifically should guard against UV radiation.

Construction/Outdoor Workers
People who work outdoors are exposed to 10% to 20% more UV light than the average indoor worker.1 Pair that with the fact that UV radiation is usually most intense between the hours of 10 a.m. and 4 p.m.—which coincides with the typical hours of a dayshift or workday—and one can see why outdoor workers must make sun protection a priority.

Even if an outdoor worker wears a hat, the brim only blocks his or her eyes from UV light coming from directly overhead. Hats do not protect from indirect UV radiation that is reflected off the ground and low-level, angled surfaces.

Most patients realize that direct UV radiation is dangerous, but are not aware that indirect or reflected UV radiation can also be hazardous. When it comes to the amount of UV light that is reflected off of an object, the surface of the object matters. Some surfaces are more reflective than others. A surface painted bright white, for example, reflects about 22% of the sun’s UV radiation.2

Even surfaces that don’t seem to be inherently reflective can be a source of indirect UV radiation. For example, dry grass in winter bounces about 3% to 5% of the sun’s radiation back up toward our eyes.

Another little-known precaution for outdoor workers: Sunglasses are essential for partly cloudy days. The worst exposure conditions can be with a high sun and light overcast because the light clouds further scatter the UVR to lower elevation angles.3 So, ocular exposure on a partly cloudy day is actually greater than on a clear, sunny day.

Be sure to prescribe high quality UVA/UVB protection to outdoor workers in order to shield them from direct and indirect UV radiation.
Jeffrey Roth, OD, of Syracuse, NY, always educates patients on the importance of  protection from reflected UV radiation during snowy, wintery months.

Outdoor Enthusiasts
Even if patients don’t work outdoors, they may play outdoors. Outdoor enthusiasts who spend a lot of time outside after work or on the weekends also require appropriate UV protection. Boaters, swimmers and beachgoers need to take note and protect themselves properly while spending a day by the waves because sea foam reflects up to 30% of UV light, while dry sand can reflect more than 15%.2

Fresh snow and ice can reflect 80% to 90% of ultraviolet radiation, so everyone should use UV protection during the winter months. However, those who spend a considerable amount of time outdoors in the snow, like skiers and snowboarders, are at an even higher, more imminent risk for damage from UV radiation. Intense, indirect UV radiation for even as few as two hours can cause UV keratitis or “snow blindness.”4 UV-blocking goggles are a must while out on the slopes to ensure protection against the dangerous amounts of UV reflected off the snow, which can cause this temporary but debilitating and painful corneal condition.

Boaters and beachgoers should also wear polarized UVA/UVB-blocking sunglasses because they too are at risk for UV keratitis due to the potential for the high reflectance of UV radiation off of the water.

Climbers and trailseekers, beware: Altitude also influences the intensity of UV radiation. When traveling to higher elevations, UV radiation is more dangerous whether or not there are snow-capped mountains. For every 1,000 feet that we ascend in altitude, our eyes are subjected to 5% to 7% more UV radiation.5 This is due not only to snow, but because the atmosphere is thinner at higher altitudes and filters out less UV.

Again, eye care professionals need to nudge their outdoorsy patients to proactively protect themselves from UV so that they can enjoy the sunshine and the great outdoors guilt-free and without detriment to their short-term or long-term ocular health.

Every parent knows the importance of protecting their children’s skin from the sun, but what about their eyes? Kids, who tend to spend more time outdoors than adults, make up another patient population that needs UV-blocking sun protection. Up to 50% of the total UV we’re exposed to by age 60 occurs before we reach age 20.6

Because the long-term effects of sun damage are cumulative, the longer that people are left unprotected from the sun’s harmful rays over the course of their lifetime, the more likely they will suffer damage to their eyes.

What makes the eyes of kids especially vulnerable to UV radiation, besides the amount of time they spend outside during childhood? Children’s crystalline lenses are usually clear as glass at birth, so UV light is able to pass right through. Adults experience a natural discoloration or slight yellowing of the lenses as the crystalline lenses mature, which actually helps to filter out some short wavelength light.7 Because of this, adults with nuclear sclerotic lens changes are slightly better protected against potential cumulative retinal damage from UV radiation compared to children who have immature, clear crystalline lenses.

Of course, as adults’ lenses mature, they’ll eventually need cataract surgery; and, unless they receive UVA-blocking and blue-violet light-filtering IOLs, they’ll again be at an increased risk for retinal damage.

Every time a parent remembers to smear sunscreen on their child’s face before heading out the door, the parent should also remember to grab their child’s UVA/UVB-blocking sunglasses. Parents will be doing their children a great favor by getting their kids into the healthy habit of proactively protecting their eyes from the sun early on in life.

In sunny Los Angeles, Maylin Gonzalez, OD, (left) tells her patients that sunglasses are not just fashionable, they are part of a healthy lifestyle that includes eating right, exercising and avoiding environmental hazards like UV.
Contact Lens Wearers
Some patients may think they don’t need to bother wearing sunglasses because their contact lenses block UVA/UVB. This is simply not true. Yes, UVA/UVB-blocking contact lenses prevent UV radiation from reaching the cornea and structures behind it, like the lens and the retina, but contacts don’t cover everything. The conjunctiva is left vulnerable to UV radiation, as well as the skin of the lids and brow bone. In addition, the lids and brow bone are typically areas of the face where most people avoid applying sunblock because they fear they will get sunblock in their eyes.

But these spots need protection, too. Approximately 5% to 10% of all skin cancers occur in the eyelids.8,9 Basal cell carcinoma is the most frequently encountered (90% to 95%) type of eyelid tumor, followed by squamous cell carcinoma, sebaceous cell carcinoma and, lastly, malignant melanoma. Although basal cell carcinoma tends to grow slowly and does not frequently metastasize, it can be very destructive if left untreated, extending into deeper layers of the skin and invading periorbital tissues and bone.10

Tumors need to be removed early before they cause damage to vital ocular structures, but detection can be difficult due to their inward growth pattern.8,9,11 Eyelid tumors can grow under the skin for years before any clue appears on the surface.8,9,11

Displaying a few pairs of sunglasses in your contact lens dispensary may remind both you and your contact lens patient that the conjunctiva, lids and unprotected areas of periocular skin also require proper UVA/UVB protection. The good news is that because contact lenses have taken care of the patient’s prescription, a pair of non-Rx, high quality sunglasses will take care of the rest, and then the patient can walk out of the eye doctor’s office fully protected.

Health-Conscious Individuals
Today’s health-conscious individuals are concerned with their genetic predispositions for certain diseases and illnesses. They also have a desire to take charge and minimize their interaction with common toxins and environmental hazards. Living a healthy lifestyle helps patients feel empowered, knowing they are doing what they can to directly protect and improve their health. Eating right, exercising and avoiding environmental hazards are all parts of living a healthy lifestyle.

UV protection can help safeguard our patients’ eyes from environmental hazards posed by UV light. Patients who suffer from or are at risk for retinal damage need to make sun protection a priority. Epidemiological studies have found a relationship between chronic sunlight exposure and AMD.12 Add to this the increasing magnitude of macular degeneration among the rapidly growing elderly population. Specifically, researchers predict that the number of Americans with early AMD is expected to nearly double by 2050—from 9.1 million to 17.8 million.13

If patients have a family history of AMD and other risk factors that make them vulnerable to UV damage—such as fair skin, light eyes and a fair retina—urge them to take action against UV radiation by wearing sun protection for their eyes when outdoors.

As with much of optometry and medicine, patient education is crucial when attempting to cultivate successful compliance with recommended precautions and treatments. Most patients take what their doctors say seriously, but what matters most is what they do after they leave the office. Individualized care and prescribed recommendations tend to hold more weight than a blanket statement that UV is bad.

By providing each patient with personalized suggestions, as well the scientific explanations and evidence behind those suggestions, eye care professionals stand a better chance of the patient taking their doctor’s directions to heart and protecting themselves from UV radiation.

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8. Cook BE Jr, Bartley GB. Treatment options and future prospects for the management of eyelid malignancies: an evidence-based update. Ophthalmology 2001 Nov; 108(11):2088-98.
9. Abraham J, Jabaley M, Hoopes JE. Basal cell carcin­oma of the medial canthal region. Am J Surg. 1973 Oct; 126(4):492-5.
10. Wong CS, Strange RC, Lear JT. Basal cell carcinoma. BMJ. 2003 Oct 4;327(7418):794-8.
11. Collin JR. Basal cell carcinoma in the eyelid region. Br J Ophthalmol. 1976 Dec;60(12):806-9.
12. Sui GY, Liu GC, Liu GY, et al. Is sunlight exposure a risk factor for age-related macular degeneration? A systematic review and meta-analysis. Br J Ophthalmol. 2013 Apr;97(4):389-94.
13. Rein DB, Wittenborn JS, Zhang X, et al; Vision Health Cost-Effectiveness Study Group. Forecasting age-related macular degeneration through the year 2050: the potential impact of new treatments. Arch Ophthalmol. 2009 Apr;127(4):533-40.