Corneal Epitheliopathy After Trauma by Fake Snow Powder in a 7-year-old Child.

Fake snow is a polymer of sodium polyacrylates used in games and celebrations. Despite the product leaflet that indicates safety, contact with the ocular surface can cause injury. We report a case of a child with corneal epitheliopathy due to a chemical burn injury after ocular surface contact with fake snow. The case was managed with epithelial debridement and a bandage contact lenses and topical antibiotics with complete resolution.

INTRODUCTION

Fake snow (“silly string” or “party foam”) is a polymer manufactured from sodium polyacrylates that are used during festival celebrations. It may be acidic resulting in mild acidic chemical burns on contact with the eye.12

However, there are no reports on the chemical behavior of fake snow.

To our knowledge, there are no reports of corneal epitheliopathy caused by accidental exposure to fake snow in the ophthalmic literature.3 We present a case of corneal epitheliopathy due to fake snow in a young child, documenting the symptoms and treatment.

CASE REPORT

A 7-year-old male presented to the emergency room complaining of redness, pain tearing, and reduced vision in both eyes after artificial snow clumps hit his face and some entered his left eye 3 h before the presentation. The child was playing with this substance with his friends at home. The patient was otherwise healthy with no significant medical or ophthalmic history.

The eyes were irrigated with balanced salt solution (BSS) for 30 min. Ophthalmic examination in the emergency room indicated that a best-corrected visual acuity was 20/30 in both eyes. Slit lamp examination showed bilateral conjunctival injection, corneal superficial punctate keratitis, right eye, and corneal epithelial defect in the left eye measuring 3 mm × 4 mm with pale redundant sick epithelial flaps with tiny white dots sticking to the undersurface of these epithelial flaps, with mild edema surrounding the defect and hazy stromal base [Figure 1a and b]. The anterior chamber was quiet in the right eye and had occasional cells in the left eye; the rest of the anterior segment examination was unremarkable in the left eye. The posterior segments were within normal limits, bilaterally.

Figure 1

(a) slit lamp photography of the left cornea showing large epithelial defect with sick, pale redundant epithelial flap with white granules of fake snow sticking to its undersurface; (b) stromal haziness with toxic reaction

We elected to perform epithelial debridement in the left eye. Topical benoxinate was instilled into the conjunctival sac and the pathologic epithelium, and sticky white matter was scraped with a sterile Weck-cel sponge. The left eye was patched after application of erythromycin eye ointment and cyclopentolate 1% drops; the right eye was prescribed lubricating eye drops.

At follow-up on the next, the eye patch was removed and the left eye was cleansed with BSS and cotton balls. The patient complained of continuing severe eye pain in the left eye. The left eye was injected. On examination, the corneal epithelial defect had increased to 5–6 mm. The epithelium was pale and redundant, and stromal haze remained even after debridement [Figure 1b]. There were no frank stromal infiltrates, and occasional cells were present in the anterior chamber of the left eye. The patient underwent epithelial scraping with a sterile Weck-cel sponge. A bandage contact lens was placed on the left eye, and the patient was prescribed moxifloxacin hydrochloride ophthalmic solution 0.5% drops, 4 times a day.

One day and 3 days after treatment, the defect remained in the left eye. The patient underwent debridement of the edges at two additional consecutive visits. At 1-week follow-up, the epithelium healed well, the surrounding edema resolved, the stroma was clear, and the vision was 20/25 in both eyes.

A sample of the white colored substance was examined. The substance was composed of loose granules that converted to a snow-like matter after adding some water [Figure 2a and b]. This substance was sent to the research department for further evaluation.

Figure 2

(a) sample of the fake snow granules (dry state); (b) the granules will expand about 100 times its original volume after adding water and becoming fluffy and sticky; (c) the scanning electron microscope showing the polymer nature of the granules; (d) energy dispersive X-ray spectrometer of the fake snow granules showing its mineral composition

Electron microscopy [Figure 2c] and energy dispersive X-ray spectrometry [Figure 2d] indicated the polymeric nature of the granules, and the substance was composed mainly of minerals including oxygen, carbon, sodium, magnesium, calcium, and sulfur, and traces of aluminum, silicon, and iron.

DISCUSSION

Ocular chemical injury is common and can cause variable ocular damage based on the nature and type of chemical substance. Devastating outcomes may occur from alkaline injury and some types of acidic substances.1

Fake snow is composed of granules which consisted of sodium polyacrylate (CH2-CH [CO2 Na]) as per the label attached to the product package, but it can be produced as a foam spray.2

To our knowledge, there are no reports of corneal epitheliopathy due to fake snow products such as granules in English literature. When mixed with water, fake snow absorbs water and expands to 100 times its original volume as a gelatinous snow-like material. It can be dried and reused again, and it is used in games, parties, decoration, hobbies. Although safe, fake snow powder should not be used by children without adult supervision and cannot be ingested.

In our case, the composition and structure of the fake snow material were determined by the scanning electron microscopy and x-disparate spectrometry analysis. These analyses showed that the powder granules were composed of a polymer and minerals confirming the chemical nature of this polymer (sodium polyacrylate).

Electron microscopy of these granules demonstrated the skeletal structure as main granules and connecting bond-like structures. These bond-like structures had varying mineral content including magnesium, sulfur, and calcium.

We previously reported a case of corneal toxicity after use of local traditional eyeliner containing the heavy metal cadmium which may induce its toxic effect by inhibition of Na+/K+ – ATPase and C + ATPase. The temperature of the chemical substance plays a role in the effect that it causes on tissue.3 For example, hot substances create more damage than the same colder substances because the reactivity is greater as temperature increases. The fake snow granules are converted to snow-like semi-sticky matter when exposed to water. In our case, some of the fake snow granules were sticking to the damaged epithelium. This adherence may allow more time to cause toxic effects on the epithelium and delay epithelial healing. Solid corrosives such as cement powder and lime powder may remain in place even longer, especially if they are not discovered on the ocular surface or in the conjunctival sac.4

Contact of the chemical substance to the ocular surface may play a role in the toxic effects.3 Chronic exposure to chemical substance such as common disinfectants including hydrogen peroxide can result in ocular damage causing pseudo-cicatricial changes.5 Hence, common household chemicals that are labeled safe do not preclude the possibility of damage to the ocular surface (safe does not mean beneficial). The fake snow material expands and forms a gel-like substance, which may stick to the ocular surface, possibly resulting in a change in PH and the osmolality gradient. These changes will affect the propagation of the reaction and effects of the noxious substance.6 In our case, we believe that this mechanism could explain the delayed epithelial healing with little involvement of the superficial stromal layers. Acidic substances cause protein coagulation, which may involve the epithelial layer, preserving and protecting the deep stromal layers from the devastating sequelae seen in alkaline chemical burns.7

CONCLUSION

Fake snow granules caused toxic corneal epitheliopathy. This is likely the first report in English ophthalmic literature of corneal epitheliopathy due to fake snow powder. We strongly urge close supervision of children playing with this substance to minimize potential toxic effects and ocular damage.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.