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The Spectrum of Ocular Inflammation Caused by Euphorbia Plant Sap

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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 in- fection and uveitis, particularly during the first few days. Main Outcome Measures: Symptoms, visual acu- ity, 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 inflamma- tion 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- ARCH OPHTHALMOL / VOL 118, JAN 2000 WWW.ARCHOPHTHALMOL.COM 13 ©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 chara- cias when sap sprayed into his right eye. The eye was im- mediately 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 conjunc- tiva was hyperemic, and the interpalpebral corneal epi- thelium and nasal conjunctiva took up fluorescein. There B was no edema of the corneal stroma, the anterior cham- ber 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 stro- mal edema was seen, and the anterior chamber re- mained quiet. Treatment with topical ointment was con- tinued for 2 weeks, after which the eye had returned to normal. CASE 3 C A 66-year-old man was pruning E characias subsp wulfe- nii in his garden when he felt a stinging sensation as sap hit his right eye. He did not irrigate the eye until 10 min- utes later, by which time he was suffering increasing pain and blepharospasm. Irrigation was repeated when he was seen by an oph- thalmologist later the same day. Visual acuity was 20/40 OD and 20/20 OS. There was marked conjunctival hy- peremia and the central cornea showed punctate stain- ing 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 topi- cal 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 de- creased to hand motions only. There was moderate lid CASE 4 edema and marked conjunctival injection. Slitlamp ex- amination 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. ARCH OPHTHALMOL / VOL 118, JAN 2000 WWW.ARCHOPHTHALMOL.COM 14 ©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 vi- sual 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, symp- toms 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 inflam- matory signs in the posterior segment. Treatment continued, and after 1 week all symptoms and signs re- solved. 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.
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