is a diverse plant genus consisting of more than 2000 species with worldwide distribution, chiefly in subtropical and temperate regions. 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
Though there are few case reports in literature, it is apparent from them that ocular changes follow a typical course, and the severity of the ocular inflammation may vary with the species of the plant.[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 mild diminution of vision, but may diminish further to 20/200 or counting fingers to hand movements within 24 h as Case 2 in this report. On initial examination, the corneal epithelium may be intact or with mild punctate epitheliopathy, but eventually it may show frank epithelial defect on the next day.[10
] It takes around four to seven days for the epithelium to heal completely. There is stromal edema with Descemet's fold which decreases with time. The degree of anterior uveitis is variable and is particularly marked with certain species as in Case 1 and Case 3 in this report.[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
The species of Euphorbia
causing ocular toxicity reported earlier were mostly with E. royaleana, E. lathyris
and E. tirucalli.[4
] Only one case of ocular toxicity with E. trigona
was reported earlier by Scott et al.
] 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.
] and the patient presented with corneal epithelial defect and edema with mild anterior uveitis which was similar to our third case. To the best of our knowledge which includes MEDLINE search, we could not find any case report of ocular toxicity by the sap of E. neriifolia
(Indian Spurge tree). If the patient presents early within 24 h, the treatment is antibiotic eye drops, topical corticosteroids, cycloplegics, tears substitute and IOP-lowering medications if necessary. No patching is required. With appropriate supportive therapy and close daily observation, the condition generally resolves completely within 10-15 days. In case of suspected bacterial infection and in the presence of a hypopyon, topical corticosteroids may be started later once the epithelial defect gets healed.[10
In conclusion, the clinical course may be affected by particular species of Euphorbia, the amount of sap exposure, the time between exposure and irrigation, and host factors. Ophthalmologists managing Euphorbia keratouveitis should warn the patient that vision may get worse on the next day before it improves. 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.