A severe bilateral sodium amide eye injury was followed by prolonged epithelial healing and recurrent fibrovascular pannus despite multimodal treatment, although 1 eye ultimately recovered substantially better vision than the other over 3 years.
Investigators reported the 36-month course of a 23-year-old man with no prior ocular or medical history who was injured when a glass container of sodium amide exploded while he was cleaning it at an industrial plant. Chemical material and glass fragments struck his eyes, face, and neck. He irrigated his eyes with tap water for 15 minutes before presenting to the emergency department, where they were irrigated with 7 L of sterile water and normal saline. Initial examination showed dense opacification of the lower two-thirds of both corneas and extensive bilateral limbal blanching. Treatment included topical prednisolone and moxifloxacin, oral vitamin C and doxycycline, preservative-free artificial tears, and subsequent amniotic membrane application and anti-inflammatory therapies.
The investigators followed epithelial healing, tissue melting, fibrovascularpannus, symblepharon, pain and photophobia, and visual acuity. At the first outpatient ophthalmology visit on day 6, uncorrected distance visual acuity was 20/300 in the right eye and 20/200 in the left eye. Both eyes had extensive limbal ischemia, corneal epithelial defects, and dense corneal opacification. Amniotic membranes were placed over both corneas.
Epithelial recovery was prolonged in both eyes but occurred more quickly in the left eye. The left corneal epithelium was 60% sealed by 2.5 weeks, 85% intact by 7.5 weeks, and completely healed by 2 months. In the right eye, the epithelial defect had decreased to 1 mm by 3.25 months and was sealed when the patient returned at 4.75 months following a gap in follow-up related to insurance issues. The authors estimated that epithelial healing in the right eye was completed between 90 and 143 days.
Visual outcomes also diverged between the eyes. In the left eye, uncorrected distance visual acuity improved from 20/200 at the first outpatient visit to 20/70 by 2 months and 20/50 by 3 months. During months 30 to 36, no uncorrected visual acuity measurement was worse than 20/40, and refraction at 36 months yielded 20/25 vision. The right eye remained more impaired: during months 30 to 36, uncorrected visual acuity ranged from 20/100 to 20/300, and no pinhole acuity was better than 20/80.
Fibrovascular pannus began invading both corneas at 2.75 months and continued to grow despite anti-inflammatory treatment. In the better-seeing left eye, the tissue threatened the pupillary zone, prompting resection of nasal and superonasal fibrovascular tissue at 6.5 months with amniotic membrane application and topical triamcinolone. The pannus recurred, and a larger resection was performed at nearly 7 months. Following those procedures, pannus did not recur in the superonasal quadrant during 29 months of follow-up.
Progression nevertheless continued elsewhere. Fibrovascular tissue in the right eye gradually increased, while pannus progressed in the inferonasal quadrant of the left eye. Both eyes underwent additional resection at 13.5 months, accompanied by triamcinolone and amniotic membrane placement. New inferonasal fibrovascular invasion began in the left eye approximately 2 months later. At 36 months, the pannus remained, although there had been no further inferonasal corneal ingress during the preceding 16 months.
Other complications included tissue melting and recurrent symblepharon. At 3 weeks, the right eye developed scleral thinning that progressed to 50% before improving. Peripheral corneal thinning occurred in the left eye but was not visually significant. A right-eye symblepharon was removed at 10.25 months but recurred; by 20 months, it extended inferonasally with 10 mm of attachment between the globe and upper lid. Following repeat removal at 34 months, the inferior symblepharon remained lysed at 2 months, but the upper lesion had recurred as a 2-mm-wide strand.
The investigators also searched PubMed and Embase without date restrictions, as well as multiple chemistry databases, for previous reports of sodium amide ocular injury. They found no specific cases using their English-language search terms. Chemical databases identified sodium amide as capable of causing caustic burns of the eyes and skin but did not provide specific ocular cases. The authors acknowledged that limiting the database searches to English terms could have missed relevant reports.
The report had several important limitations. It described only 1 patient, so the authors could not determine whether sodium amide generally produces the complications observed in this case. Multiple treatments were used during the patient's course, preventing determination of the contribution of any individual intervention. The presumed fibrovascularpannus was identified clinically without histopathologic or immunohistochemical confirmation, and quantitative assessments of corneal opacification, vascularization, and inflammation were unavailable. In addition, healing remained ongoing at 3 years, leaving the patient's ultimate outcome uncertain.
The findings document a prolonged course following severe bilateral sodium amide exposure, with delayed epithelial healing and recurrent fibrovascular pannus despite medical and surgical management. Although treatment was accompanied by prolonged arrest of pannus in some areas and the left eye recovered good functional vision, fibrovascular tissue recurred elsewhere and substantial visual limitation persisted in the right eye.
“Both eyes have so far avoided the devastating ocular problems associated with many severe chemical injuries, but at 3 years postinjury the healing is still in progress,” wrote lead study author Gretchen Weiss, of the Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, and colleagues.
Disclosures: The authors reported no funding or conflicts of interest.
