What is the treatment for eye irritation caused by plant sap?

Eye Irritation from Plant Sap: Diagnosis and Treatment

For eye irritation caused by plant sap—particularly Euphorbia species—immediate copious irrigation followed by supportive treatment with topical antibiotics, corticosteroids, and cycloplegics is the standard approach, with most cases resolving within 1-2 weeks. 1, 2, 3, 4

Diagnosis and Clinical Presentation

The most likely diagnosis is Euphorbia keratouveitis, which presents with a characteristic spectrum of findings:

Acute Symptoms (within hours of exposure):

• Severe burning or stinging pain with blurred vision 3, 4
• Visual acuity typically reduced by 1-2 Snellen lines, though severe cases may drop to counting fingers or hand motions 1, 3, 4

Clinical Findings (mild to severe):

• Mild cases: Epithelial keratoconjunctivitis with conjunctival injection 4
• Moderate cases: Corneal edema with Descemet membrane folds, epithelial defects 3, 4
• Severe cases: Stromal edema, epithelial sloughing, anterior chamber inflammation with exudate, and secondary elevated intraocular pressure 1, 2, 3, 4
• Eyelid edema and ciliary injection are common 1

Critical Diagnostic Step:

• Always ask the patient to bring a sample of the plant for formal identification to confirm Euphorbia species exposure 3, 4

Treatment Algorithm

Immediate Management (First 24 hours):

1. Copious irrigation with saline or water to remove residual sap 5

2. Topical antibiotics to prevent secondary bacterial infection during the epithelial healing phase:

   • Chloramphenicol drops or ointment 4
   • Alternative: Ofloxacin 3 mg/mL 2
   • Continue for 7-10 days 3, 4

3. Topical corticosteroids for inflammation control:

   • Prednisolone acetate 1% is the standard choice 2
   • For less severe cases, loteprednol etabonate may be considered as it has a lower risk of IOP elevation 6
   • Frequency depends on severity: every 2-4 hours initially for severe cases 2, 5

4. Cycloplegic agents when anterior chamber inflammation is present:

   • Prevents posterior synechiae formation 5
   • Provides pain relief by reducing ciliary spasm 5

Monitoring Requirements:

• Close follow-up within 24-48 hours to rule out bacterial endophthalmitis, particularly in severe cases with anterior chamber reaction 2
• Monitor intraocular pressure if corticosteroids are used, especially in patients with prior glaucoma surgery 6, 2
• Baseline and periodic IOP measurement is mandatory when using topical corticosteroids 6
• Pupillary dilation to evaluate for cataract formation with prolonged steroid use 6

Expected Timeline:

• Resolution typically occurs within 10-14 days with active supportive treatment 3, 4
• All signs and symptoms should resolve by 1-2 weeks in most cases 4

Critical Pitfalls and Caveats

Photoallergic Reactions:

• Protect the damaged eye from light exposure as photoallergic reactions are possible with Euphorbia sap 5
• Consider patching or dark glasses during the acute phase 5

Risk of Permanent Damage:

• Immediate treatment is essential to prevent sequelae like corneal scarring 1
• The first few days carry the highest risk of sight-threatening complications including infection and severe uveitis 4

Differential Diagnosis Considerations:

• In severe cases with anterior chamber reaction, bacterial endophthalmitis must be ruled out, especially in patients with prior ocular surgery 2
• The self-limiting nature of Euphorbia keratouveitis helps distinguish it from infectious causes 4

Prevention:

• Eye protection should be worn by anyone handling Euphorbia plants 3, 4
• Educate patients about the highly toxic and irritant nature of Euphorbia latex 3

Special Considerations

The condition is self-limiting when managed supportively 4. However, aggressive initial treatment prevents complications and accelerates recovery. Unlike allergic conjunctivitis where corticosteroids are used cautiously and briefly 7, 8, Euphorbia keratouveitis requires more aggressive anti-inflammatory therapy due to the direct toxic injury mechanism 2, 3, 4.