How to Treat Euphorbia Sap in the Eye

Samar K Basak1Disha Eye Hospitals and Research Centre, Barrackpore, Kolkata – 700 120, West Bengal, IndiaFind articles by

Received 2008 Jun 25; Accepted 2008 Aug 8. © Indian Journal of Ophthalmology

This is an open-access article shared under the Creative Commons Attribution License, which lets anyone use, share, and copy the work in any way, as long as they give credit to the original author.

Euphorbia plant latex, which is milky sap, is very poisonous and hurts the eyes and skin. This report illustrates the spectrum of ocular inflammation caused by accidental inoculation of latex of Euphorbia plant. Three patients presented with accidental ocular exposure to the milky sap of Euphorbia species of recent onset. The initial symptoms in all cases were severe burning sensation with blurring of vision. Visual acuity reduced from 20/60 to counting fingers. Different types of symptoms were seen, such as keratoconjunctivitis, mild to severe corneal edema, epithelial defects, anterior uveitis, and secondary high intraocular pressure. All symptoms and signs had resolved by 10-14 days with active supportive medication. People who handle Euphorbia plants should wear eye protection. It is always advisable to ask the patient to bring a sample of the plant for identification.

Keywords: Euphorbia sap, keratitis, uveitis

The Euphorbiaceae family includes trees, succulents and herbaceous plants. There are many species of Euphorbia plants that grow in the wild or as house or garden plants all over the world. The milky latex or sap is toxic and may cause intense inflammation of the skin and the eye. [2] Ocular toxic reaction varies from mild conjunctivitis to severe kerato-uveitis. There are a few reports of people going permanently blind after accidentally getting Euphorbia sap in their eyes. [2–4] Corneal involvement usually happens in a standard order, with edema getting worse and epithelial sloughing on the second day. [3,5] It is believed that some species are more toxic than the others. [6] When treated early and managed meticulously, the inflammation generally resolves without sequelae. Here, we present three cases of ocular toxicity caused by three different species of Euphorbia, namely, E. trigona (African milk tree), E. neriifolia (Indian Spurge tree) and E. milii (Crown-of-thorns houseplant).

A 60-year-old male was trimming his garden hedge E. trigona plant (African milk tree) [Fig. 1a] and got sprayed with milky sap into his right eye (RE). He had an immediate burning sensation and pain which was relieved partially by irrigation with water. After 16 h, he presented to us with pain, burning with gross dimness of vision in the RE. Best corrected visual acuity (BCVA) was 20/200 in the RE and 20/20 in the left eye (LE). On examination of the RE, there was mild lid edema and moderate conjunctival congestion and chemosis. There was loss of corneal epithelium and stromal edema. There was moderate anterior chamber reaction with 2+ cells and 2+ flare [Figs. 1b and c]. Intraocular pressure (IOP) was higher digitally. Fundus details appeared normal. The LE was essentially normal.

(a) Picture of the Euphorbia trigona plant, also known as the African milk tree; (b and c) Corneal epithelial defect, edema, stromal edema, and moderate anterior uveitis one day after being exposed to E trigona sap.

The eye was once again irrigated copiously with normal saline and treated with gatifloxacin (0. 3%) eye drops four times a day, 1% prednisolone acetate eye drops four times a day, 2% homoatropine eye drops three times a day, tear substitutes without preservatives, and 0% timolol maleate eye drops 5%) eye drops twice daily. The patient was observed closely as an outpatient. Over the course of four days, the corneal epithelium slowly healed. Ten days later, all signs and symptoms were gone, and the patient had 20/20 vision again.

A 51-year-old man was pruning his overgrown species of E. neriifolia plant (Indian Spurge tree) [Fig. 2a] in his garden when he felt some sap enter into his LE. The eye became irritable and was immediately irrigated with tap water.

A part of the Euphorbia neriifolia plant, also known as the Indian Spurge tree; B and C: A large corneal epithelial lesion with stromal edema and mild anterior uveitis, two days after being exposed to E neriifolia sap.

He presented four hours later. On examination, BCVA in the RE was 20/20 and in the LE 20/40. There was conjunctival hyperemia, moderate corneal edema and mild anterior chamber reaction. He had also a healed corneal pannus. The IOP was 13 mm Hg. The next day, the visual acuity had reduced to counting fingers at 1 meter. There was moderate lid edema and conjunctival congestion. Slit-lamp examination revealed a large corneal epithelial defect and moderate stromal edema [Figures 2b and c]. The IOP was higher digitally. The RE was unaffected and within normal limits. The patient was treated and followed up similar to Case 1. The corneal epithelium completely healed by the seventh day. By two weeks all signs and symptoms were resolved and the patient regained full vision.

A 54-year-old woman was pruning her Euphorbia milii (crown-of-thorns) houseplant [Fig. 3a] when she felt a stinging sensation as a drop of sap entered her LE. She did not wash her eyes immediately. Fifteen minutes later she felt severe pain, blepharospasm and dimness of vision in the LE.

For (a) Euphorbia milii (crown-of-thorns) parts; white milky sap can be seen at the cut end; (b and c) Punctate epithelial lesions, corneal edema, Descemets folds, and moderate anterior uveitis one day after being exposed to E milii sap.

She presented three hours later and irrigation was done immediately with copious Ringers lactate solution. On examination, BCVA in the RE was 20/20 and in the LE 20/120. There was conjunctival hyperemia, punctate localized corneal epithelial lesions, and moderate corneal edema with Descemets folds. We saw front-facing uveitis and a moderate front-facing chamber reaction with two cells and two flares (Figures 3b and c). The IOP was 14 mm Hg. The RE was within normal limits. The patient was treated and followed up similar to Case 1, except for timolol eye drops. The punctate epitheliopathy had completely resolved by Day three. By Day 15 all signs and symptoms had resolved and the patient regained BCVA of 20/20.

The genus Euphorbia includes more than 2,000 species that grow all over the world, mostly in subtropical and temperate climates. Some species have thick succulent stems and are spiny, closely resembling cacti. They are distinguishably different by their peculiar flower and milky latex that contains irritant and carcinogenic diterpine esters. [7–9].

Although there aren’t many case reports, the ones that are there show that changes in the eyes usually happen in a certain way. The severity of the inflammation in the eyes may depend on the type of plant involved. [6] Symptoms usually start immediately on contact with the milky latex. There is burning sensation, pain, photophobia and lacrimation which may worsen over hours even after copious irrigation. At first, there is a slight loss of vision, but it can get worse to 20/200 or only seeing hand movements within 24 hours, as happened in Case 2 of this report. The corneal epithelium may be whole or have mild punctate epitheliopathy on the first exam, but by the next day, it may have a full epithelial defect. [10] It takes around four to seven days for the epithelium to heal completely. There is stromal edema with Descemets fold which decreases with time. What kind of anterior uveitis there is varies, and some species, like the ones in Cases 1 and 3, have very bad cases. [3] The degree of ocular inflammation may also vary with the amount of sap that enters the eye. Neglected cases can progress to blindness due to corneal scarring, complicated uveitis, and anterior staphyloma. [3,4].

The species of Euphorbia causing ocular toxicity reported earlier were mostly with E. royaleana, E. lathyris and E. tirucalli. [4,5,11,12] Only one case of ocular toxicity with E. trigona was reported earlier by Scott et al. [5] and they reported only corneal epithelial defect without edema and anterior chamber reaction. But in our Case 1, there was gross corneal edema with moderate anterior uveitis and secondary elevated IOP. This was possibly due to a greater amount of sap entering into the RE in our case. There was only one case report on E. milii by Eke et al. [6] and the patient had a corneal epithelial defect, edema, and mild anterior uveitis, which was the same as our third case. We looked through MEDLINE and other sources, but couldn’t find any case reports of eye damage caused by the sap of E. neriifolia (Indian Spurge tree). If the patient comes in within 24 hours, antibiotic eye drops, topical corticosteroids, cycloplegics, tears substitutes, and, if needed, IOP-lowering drugs are given. No patching is required. With appropriate supportive therapy and close daily observation, the condition generally resolves completely within 10-15 days. If a bacterial infection is suspected and there is a hypopyon, topical corticosteroids may be used after the epithelial defect has healed. [10].

Finally, the clinical course might be different depending on the type of Euphorbia plant, the amount of sap exposure, the time between exposure and irrigation, and host factors. Eye doctors who treat Euphorbia keratouveitis should let their patients know that their vision might get worse the next day before it gets better. It is always advisable to ask the patient to bring a sample of the plant for identification. People who work with Euphorbia species should wear protective goggles while handling the plant.

We acknowledge the contribution of Mr. Volker Buddensiek, Editor, Euphorbia World, and Mr. A plant called Euphorbia neriifolia was sent to Tim Marshall, Seed Bank Secretary, International Euphorbia Society, 17 High Street, Wighton, Norfolk, NR23 1AL, UK, to be identified.

Articles from Indian Journal of Ophthalmology are provided here courtesy of Wolters Kluwer — Medknow Publications

Euphorbia Plant SHOOTS Seattle Woman In EYE With POISONOUS Sap as She Gardens!!

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