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Editor,—I congratulate Scott and Karp for their excellent paper on Euphorbia sap keratopathy,1 but would like to emphasise that the sap of certain plants of this genus can cause blindness.
Clinicians should be aware of the sight threatening uveitis caused by some euphorbias. Duke-Elder has reviewed the older literature, citing reports of severe keratouveitis caused by the sap of the European perennial herb Euphorbia esula (previouslyTithymalus esula) and a Cuban species recorded as E antiquorum.2 Uveitis with hypopyon has been described with sap of the European perennial herb E cyparissias (previously T cyparissias),2 and the Indian succulent E royleana.3 4 It is possible, however, that the hypopyon uveitis in some late presenting cases may simply represent a response to secondary microbial keratitis. The sap of the common European herbaceous weed E peplus (petty spurge) causes a marked fibrinous uveitis in association with ‘typical’Euphorbia keratopathy, in the absence of secondary infection.5-7 Petty spurge sap has traditionally been used as a wart cure, and it is in this context that ocular toxicity may occur.6 7 Cases presenting early, and managed supportively, have had a good outcome.
Keratoconjunctivitis without significant uveitis has been described in relation to several species of the genusEuphorbia.1 2 Though this resolves without sequelae if appropriately managed,1 there is a risk of corneal ulceration and subsequent blindness in neglected cases.2 3
As with other cases of plant toxicity, the patient should be asked to provide a specimen of the offending plant for identification. Flowering or fruiting parts will greatly assist the botanist. Our understanding of Euphorbia ocular toxicity is still limited, and would benefit from the publication of further well prepared case reports.
The author wishes to thank Dr R J Gornall, curator of Leicester University Botanic Garden, for advice on taxonomy.
Editor,—We thank Dr Eke for his comments. It is important that ophthalmologists are aware of the potential complications of ocular exposure to Euphorbia sap.
Euphorbia sap may lead to conjunctivitis, keratitis, and uveitis. As demonstrated in our series,keratoconjunctivitis resulting from Euphorbia sap exposure may resolve without visually significant residue. However, as Eke’s comments emphasise, sight threatening complications, including severe uveitis, corneal ulceration, scarring, and subsequent blindness, may result from Euphorbia sap exposure. Therefore, patients require careful follow up and prompt treatment.
Ophthalmologists need to be aware of the potential ocular complications of Euphorbia sap exposure, and the importance of closely following patients with Euphorbia sap ocular toxicity. Patients who work with Euphorbia plants should be cautioned to wear eye protection.
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