The Spectrum of Ocular Inflammation Caused by Euphorbia Plant Sap

CLINICAL SCIENCES The Spectrum of Ocular Inflammation Caused by Euphorbia Plant Sap

Tom Eke, MA, FRCOphth; Sahar Al-Husainy, FRCS(Edin); Mathew K. Raynor, FRCS(Edin)

Objective: To report the spectrum of clinical findings provided a specimen of the plant for formal identifica- in patients with ocular inflammation caused by plant sap tion. from Euphorbia species. Results: Initial symptoms were generally burning or sting- Design: Clinical case series. ing pain with blurred vision. In most cases, visual acuity was reduced between 1 and 2 Snellen lines. In 1 patient with age- Setting: Ophthalmology emergency referrals in the relatedmaculopathy,acuitydroppedfrom20/80tohandmo- United Kingdom. tions before recovering. Clinical findings varied from a mild epithelial keratoconjunctivitis to a severe keratitis with stro- Patients: We examined 7 patients, all of whom gave a maledema,epithelialsloughing,andanterioruveitis.Allsigns history of recent ocular exposure to the sap of Euphor- and symptoms had resolved by 1 to 2 weeks. bia species. Conclusions: These cases illustrate the range of severity Interventions: All patients were treated with antibi- of Euphorbia sap keratouveitis. The condition seems to be otic drops or ointment (chloramphenicol). Cycloplegic self-limiting when managed supportively. People who work and steroid drops were also used for some patients. Pa- with Euphorbia plant species should wear eye protection. tients were observed until all signs and symptoms had Clinicians managing keratopathy caused by Euphorbia spe- resolved. cies should be aware of the danger of sight-threatening infection and uveitis, particularly during the first few days. Main Outcome Measures: Symptoms, visual acuity, and clinical signs of inflammation. All patients Arch Ophthalmol. 2000;118:13-16

HE FAMILY Euphorbiaceae in- We present 7 cases of ocular toxic- cludes trees, succulents, and ity caused by Euphorbia sap, including the herbaceous plants.1 Species first recorded cases caused by the decora- of Euphorbia grow in all 5 tive garden plants E palustris, E chara- continents, either wild or as cias, and E characias subsp wulfenii, and Tcultivated specimens in the house or gar- the “crown of thorns” houseplant E milii. den. The latex or sap of many Euphorbia plants is toxic, and may cause inflammation of skin1 and the eye2,3 on contact. Ocu- REPORT OF CASES lar inflammation varies from a mild con- CASE 1 From the Departments of junctivitis to severe keratouveitis, and there A 74-year-old woman with known age- Ophthalmology, Leicester Royal have been several case reports of perma- related maculopathy was trimming her E Infirmary (Mr Eke and nent blindness resulting from accidental ex- milii houseplant (crown of thorns or cru- Ms Al-Husainy) and posure to the sap.2-4 If the cornea is in- cifixion plant) (Figure 1, A) when she Southampton Eye Unit volved, changes generally follow a typical accidentally touched her right eye with her (Mr Raynor), United Kingdom. sequence, with worsening edema and epi- gloved hand. Twenty minutes later, the eye Messrs Eke and Raynor were thelial sloughing on the second day.2,5 While became painful, with lacrimation and previously affiliated with the the literature regarding ocular damage from gradual blurring of vision. Taunton and Somerset Hospital, United Kingdom, where one of Euphorbia sap is relatively sparse, it is be- She was assessed in a general emer- the patients was treated. coming apparent that some species are more gency unit 4 hours later. Visual acuity, None of the authors has a toxic than others. When treated early and which had been measured the previous commercial interest related to managed appropriately, cases generally re- month at 20/80 OD, was reduced to 20/ this report. solve without sequelae.2,5,6 200 OD. There was conjunctival hyper-

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 dium phosphate drops 4 times daily. Corneal epithe- A lium gradually healed over 4 days, and by 2 weeks all symptoms and signs had resolved.

CASE 2

A 73-year-old man was trimming his garden plant E characias when sap sprayed into his right eye. The eye was immediately painful and was irrigated with water. He was assessed by an ophthalmologist later the same morning. The eye was still painful and there was marked lacrimation. Visual acuity was 20/30 OD. The conjunctiva was hyperemic, and the interpalpebral corneal epithelium and nasal conjunctiva took up fluorescein. There B was no edema of the corneal stroma, the anterior chamber was quiet, and intraocular pressure was normal. He was treated with chloramphenicol ointment 4 times daily. When he returned 2 days later, the pain was less marked, though visual acuity had decreased to 20/60 OD. The area of corneal staining had extended to include the inferior cornea, though there was no epithelial sloughing. No stromal edema was seen, and the anterior chamber re- mained quiet. Treatment with topical ointment was continued for 2 weeks, after which the eye had returned to normal.

CASE 3 C A 66-year-old man was pruning E characias subsp wulfenii in his garden when he felt a stinging sensation as sap hit his right eye. He did not irrigate the eye until 10 minutes later, by which time he was suffering increasing pain and blepharospasm. Irrigation was repeated when he was seen by an ophthalmologist later the same day. Visual acuity was 20/40 OD and 20/20 OS. There was marked conjunctival hyperemia and the central cornea showed punctate staining with fluorescein. There was no stromal edema, the anterior chamber was quiet, and intraocular pressure was the same in each eye. He was treated with chlorampheni- Figure 1. A, Euphorbia milii (crown of thorns houseplant). B and C, Corneal edema, epithelial sloughing, and mild anterior uveitis, 2 days after exposure col drops 4 times daily. The following day, visual acuity to E milii sap. was still 20/40 OD and corneal signs were improving. Lid swelling and erythema were noted. After 2 days of topical treatment visual acuity returned to its previous level emia but no corneal uptake of fluorescein. The eye was of 20/20 OD, and by 1 week all the symptoms and signs irrigated and treated with chloramphenicol ointment and had resolved. a firm pad. Sixteen hours after the injury, acuity had decreased to hand motions only. There was moderate lid CASE 4 edema and marked conjunctival injection. Slitlamp examination revealed loss of central corneal epithelium, stro- A 43-year-old woman was pulling up an overgrown speci- mal edema, and folds in the Descemet membrane. Intra- men of E palustris (Figure 2, A) in her garden when she ocular pressure was 16 mm Hg OD, and no inflammatory felt some sap spray into her left eye. The eye became pain- signs were seen in the anterior chamber. She was treated ful, and was immediately irrigated with water. with a drop of 1% homatropine, chloramphenicol oint- Slitlamp examination 2 hours later revealed con- ment, and repadding for a further 24 hours. Two days junctival hyperemia with small areas of punctate opaci- after the injury, visual acuity had improved to 20/200 OD, fication of the corneal epithelium. There was no stro- and the central corneal epithelium was starting to heal mal edema, and the eye was otherwise quiet, with visual (Figure 1, B and C). There was a moderate anterior uve- acuity of 20/20 OS. The eye was treated with a topical itis with cells (+/++) and flare (+), but no inflammation 2% homatropine drop and chloramphenicol eye oint- of the posterior segment. Intraocular pressure was 14 ment 4 times daily. The next day, the eye was more com- mm Hg OD and 17 mm Hg OS. Treatment continued with fortable, and corneal signs were improving (Figure 2, B). chloramphenicol ointment and 0.5% prednisolone so- All symptoms had resolved by 4 days.

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 CASE 5 A A 60-year-old woman used some cut stems of E mar- ginata as part of a flower arrangement. She was aware of the toxic nature of Euphorbia sap, and took care to pro- tect her skin while trimming the stems. As she threw the stems into the bin, she felt something hit her left eye. “Burning” pain followed within seconds, and the eye was immediately irrigated with water. The eye became red and photophobic with blurred vision. She was examined 2 hours after injury. Unaided visual acuity was 20/30 −1 OS and 20/30 +2 OD. The left eye was hyperemic, with a small (2-mm) area of corneal epithelial loss. The anterior chamber was quiet, and intraocular pressures were 18 mm Hg OU. She was treated B with topical chloramphenicol ointment 4 times daily and 1% cyclopentolate drops twice daily. Two days later, symptoms were much improved and the corneal epithelium was healing. Intraocular pressures were 17 mm Hg OS and 16 mm Hg OD. There was a mild anterior chamber reaction with cells (+/−) and flare (+/−) and no inflammatory signs in the posterior segment. Treatment continued, and after 1 week all symptoms and signs resolved.

CASE 6

Figure 2. A, Cutting of Euphorbia palustris. B, Mild keratoconjunctivitis, A 68-year-old woman was cutting a E platyphyllos plant 2 hours after exposure to sap of E palustris. in the garden. She remembered rubbing her eyes at the time, but did not develop symptoms until some hours later. She was assessed the following day, with com- to blindness, and the literature includes reports of cor- plaints of blurred vision and itching. Visual acuities were neal scarring, iris synechiae, and anterior staphyloma.2-4 20/30 OD and 20/40 OS. Her lids were erythematous and It seems that most or all of these cases involved second- slightly swollen, and there was bilateral chemosis. The ary bacterial infection. Recently, the self-limiting nature corneas showed mild epithelial edema, but intraocular of appropriately managed cases has been emphasized.5 pressures were normal and the anterior chambers were While there are still relatively few case reports in the lit- quiet. She was treated with chloramphenicol ointment erature, it is becoming apparent that there is a typical syn- 4 times daily. The next day, symptoms were settling and drome of “Euphorbia keratopathy,”5 and that the sever- all signs and symptoms had resolved by day 5. ity of the ocular inflammation may be related to the species of plant. CASE 7 After exposure to Euphorbia sap, ocular changes usually follow a typical course.2,5 Symptoms generally A 77-year-old woman with previous bilateral macular begin immediately on contact with the sap. There is hemorrhages was pruning an E robbiae plant in her gar- burning pain, photophobia, and lacrimation, which den when she felt some white sap enter the left eye. The may worsen over hours or days despite irrigation. eye became painful and was irrigated with water. Visual acuity is at first mildly reduced, but may dete- She was assessed in a general emergency unit 3 hours riorate to 20/200 or worse the following day. On initial later. The left conjunctiva was hyperemic and there was examination, the corneal epithelium may be edema- punctate uptake of fluorescein. Visual acuity was count- tous and/or show focal areas of epithelial loss. The ing fingers OU. Chloramphenicol ointment was in- stroma may also be edematous, with folds in the Des- stilled. Twelve hours later, slitlamp examination re- cemet membrane. The degree of associated conjuncti- vealed punctate corneal epithelial loss, a slight reduction vitis and anterior uveitis is variable and is particularly in intraocular pressure (12 mm Hg OS, 14 mm Hg OD), marked with certain species.2 The central corneal epi- and a quiet anterior chamber. Treatment continued with thelium may slough off on the second day and may chloramphenicol ointment 4 times daily and 1% cyclo- take more than a week to heal. With appropriate sup- pentolate drops twice daily. Two days later, all signs and portive therapy and close observation, the condition symptoms had resolved. generally resolves completely within 1 to 2 weeks. In published cases, the degree of ocular inflam- COMMENT mation seems to be related to the species of Euphorbia plant sap, and also to the amount of sap that enters the There is a spectrum of ocular inflammation associated eye. Petty spurge (E peplus) sap causes a typical with Euphorbia sap exposure. Neglected cases can progress Euphorbia keratopathy with a fibrinous anterior

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 management of acute Euphorbia sap keratouveitis Suggested Management appear in the Table. of Acute Euphorbia Sap Keratouveitis

• Irrigate, take history. Accepted for publication June 18, 1999. • Full ocular assessment: acuity, lids, conjunctiva, cornea, intraocular We are grateful to Richard J. Gornall, PhD, Director pressure, anterior chamber and vitreous inflammation. of Leicester University Botanic Garden, Leicester, United • Look for secondary infection. Kingdom, for identification of the plant specimens. • Treat with topical cycloplegics and antibiotic; consider pads and anti-inflammatory drops. Corresponding author: Tom Eke, MA, FRCOphth, De- • Warn patient that vision may get worse before it improves. vers Eye Institute, 1040 NW 22nd Ave, Suite 200, Port- • Follow up closely for the first few days (danger of infective or land, OR 97210-3065. inflammatory problems, corneal slough). • Ask patient to bring in a sample of the plant for identification (best to include flowering/fruiting parts). REFERENCES

1. Webster GL. Irritant plants in the Spurge family (Euphorbiaceae). Clin Dermatol. 1986;4:36-45. uveitis.7-9 Caper spurge (E lathyris) sap gives a similar 2. Grant WM, Schuman JS. Toxicology of the Eye. 4th ed. Springfield, Ill: Charles C Thomas Publisher; 1993:680-682. clinical picture, though the uveitis appears to be less 3. Duke-Elder S. System of Ophthalmology. Vol 14. London, England: Kimpton; 1972: marked and there is no fibrin.6,10,11 The pencil tree (E 1185. tirucalli)5,12,13 and candelabra cactus (E lactea)5,13 also 4. Sofat BK, Sood GC, Chandel RD, Mehrotra SK. Euphorbia royleana latex keratitis. Am J Ophthalmol. 1972;74:634-637. cause keratopathy, with a variable degree of uveitis. 5. Scott IU, Karp CL. Euphorbia sap keratopathy: four cases and a possible patho- Our cases 3 and 4 suggest that E characias and its sub- logic mechanism. Br J Ophthalmol. 1996;80:823-826. 6. Antcliff RJ, Hodgkins PR, Bowman R, Keast-Butler J. Euphorbia lathyris latex species wulfenii cause only mild keratopathy without keratoconjunctivitis. Eye. 1994;8:696-698. uveitis. 7. Eke T. Acute kerato-uveitis associated with topical self-administration of the sap of the petty spurge (Euphorbia peplus). Eye. 1994;8:694-696. 8. Biedner BZ, Sachs U, Witztum A. Euphorbia peplus latex keratoconjunctivitis. Ann CONCLUSIONS Ophthalmol. 1981;13:739-740. 9. Hartmann K. Augenschadigung durch den Saft der Peplus (Wolfsmilch). Klin Mon- Although Euphorbia keratopathy and uveitis seem to be atsbl Augenheilkd. 1940;104:324-326. 10. Geidel K. Klinische Beobachtung und tierexperementelle Untersuchungen uber self-limiting when managed supportively, it is impor- die Wirkung vom Saft der Euphorbia lathyris (Springwolfsmilch) am Auge. Klin tant to remember that blindness can occur, particularly Monatsbl Augenheilkd. 1962;141:374-379. 11. Frohn A, Frohn C, Steuhl KP, Thiel H-J. Wolfsmilchveratzung. Ophthalmologe. in neglected cases. People who work with Euphorbia 1993;90:58-61. species should wear eye protection. Clinicians manag- 12. Desatnik H, Ashkenazi I, Avni I, Abraham F, Blumenthal M. Acute conjunctivo- ing Euphorbia keratopathy should be aware of the dan- keratouveitis caused by latex from the pencil tree. Am J Ophthalmol. 1991;112: 464-466. ger of sight-threatening infection and uveitis, particu- 13. Crowder JI, Sexton RR. Keratoconjunctivitis resulting from the sap of candela- larly during the first few days. Our suggestions for bra cactus and the pencil tree. Arch Ophthalmol. 1964;72:476-484.

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