Severe Ocular Symptoms Caused by Succulent Sap

[[{"type":"media","view_mode":"media_crop","fid":"57609","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_7713938107205","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"7253","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 347px; width: 435px; float: right;","title":" ","typeof":"foaf:Image"}}]]History: A 53-year-old man presents to the ED for one day of right eye burning and redness that is associated with blurry vision, which only started in the past 2 hours. He had been seen earlier the same day for severe burning in that eye after rubbing it with a finger that had been lightly contaminated by sap from a succulent plant that had oozed liquid onto his hands while he was gardening. At the time of his initial visit, his eye had not been as bad as it is now and his vision had been normal.

Exam: See Figure above. His vision in the involved eye was 20/20 earlier, but now it is 10/200 (he must be 10 feet from eye chart to see the big “E” at the top). His vision is no better even when the goop in his eye is cleared away. His cornea shows no fluorescein uptake.

What should be the initial treatment?  

What type of succulent sap did this patient most likely get in his eye?

Answer and Discussion on next page>>

Answer: Initial treatment should be copious irrigation, followed by topical steroids, antibiotic eye drops, cycloplegics, tears substitute, and medications to lower intraocular pressure if necessary.

The culprit plant is likely a succulent of the Euphorbia group, the sap from which is widely known for its ocular toxicity.^1,2

Discussion

Chemical exposure to the eye is most often due to an irritant agent that poses no long-term danger. However, some agents can cause permanent eye damage, especially to the cornea. Simple irritants include things like soap and shampoo as well as pepper spray. Treatment is usually just irrigation and a slit lamp exam to make sure the patient did not rub the eye enough to cause a corneal abrasion. More dangerous exposures include acids or alkalis, both of which can cause permanent damage. See Chart below for a list of alkali agents.

Initial management of chemical exposure to the eye in the ED should include anesthetic eye drops followed by immediate irrigation, either with an eye sink or Morgan lens. A complete eye exam can be done later. If neither is available, the patient can be taken to a shower and water allowed to run freely into his or her eyes.

Once irrigation with at least 2 liters per eye has occurred a detailed eye exam with attention to the cornea, pH testing, and tonometry should be performed. Normal eye pH is 7.4. Elevated pH signifies an alkali exposure, which is high risk. Low pH signifies and acid exposure. Irrigation should be continued until pH is 7.4 10 minutes after irrigation stops. Most patients can be discharged home after treatment and phone consultation with an ophthalmologist. Outpatient management usually includes analgesics and sometimes topical antibiotics and/or steroids. Follow up with the eye specialist in 1-2 days should also be arranged.

In one case series, clinical findings related to exposure to Euphorbia sap ranged from a mild epithelial keratoconjunctivitis to a severe keratitis with stromal edema, epithelial sloughing, and anterior uveitis. In these patients, signs and symptoms had resolved by 1 to 2 weeks.²

Excerpt on CHEMICAL EYE EXPOSURE from the EYE TRAUMA page of QUICK ESSENTIALS: Emergency Medicine 1-minute Consult pocketbook[[{"type":"media","view_mode":"media_crop","fid":"57610","attributes":{"alt":"","class":"media-image","id":"media_crop_1615428944556","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"7254","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 192px; width: 620px;","title":" ","typeof":"foaf:Image"}}]]

Click on image for additional details.

[[{"type":"media","view_mode":"media_crop","fid":"57611","attributes":{"alt":"","class":"media-image","id":"media_crop_4475984485710","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"7255","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","title":" ","typeof":"foaf:Image"}}]]

References:

1. Basak SK, Bakshi PK, Basu S, Basak S. Keratouveitis caused by Euphorbia plant sap. Indian J Ophthalmol. 2009 57:311–313. doi:  10.4103/0301-4738.53060

2. Eke T, Al-Husainy S, Raynor MK. The spectrum of ocular inflammation caused by Euphorbia plant sap.  Arch Ophthalmol. 2000;118:13-16. doi:10.1001/archopht.118.1.13