Family Euphorbiaceae includes over 1500 species of trees, herbaceous plants and succulents [1]. The milky latex of many Euphorbia plants is toxic, and results in profuse inflammation of the skin and the eye [2,3]. Though many cases may be self-limiting without consequences if managed appropriately, the spectrum of ocular injuries due to plant sap splash varies from minimal discomfort to contact dermatitis, mild to severe keratoconjunctivitis, epithelial sloughing, corneal scarring, uveitis with hypopyon, miosis and even blindness secondary to superimposed infection. Alkaloids, cyanogenic glycerides, cardioactive glycerides, plant acids, amino acids, essential oil poly-acetylene compounds, proteins furanocoumarins and peptides, saponins and terpenes have been identified as toxic constituents of plant sap [4].

A 56-year-old agriculturist with controlled systemic hypertension and history of cataract surgery to the left eye, reported to eye OPD after he had an accidental contact with the Euphorbia plant juice, while working in the field. The plant juice squirted in his eye, while trying to cut twig of a plant. The patient reported of redness, excruciating pain, foreign body sensation and diminished vision since then. He rinsed his eye with running tap water, but the symptoms didn’t subside (Figures 1 and 2).

Figure 1: Central corneal epithelial defect as a result of spillage of plant juice into eye.

Figure 2: Stromal edema is well evident in pseudophakia left eye

On examination, there was intense superficial conjunctival congestion 0S. Visual acuity was 6/6 OD and FC at 2 feet OS. On SLE there was an oval epithelial defect measuring 6 into 3 mm covering the central cornea. Stromal edema and Descemet’s folds were also present. IOP Was 14 and 17 mm Hg. AC revealed no activity in left eye. The ocular pH was checked using hydrion pH paper and found to be alkaline (pH 9) in left eye. She received immediate irrigation with normal saline 0.9% and the pH normalized (pH 7.0) after 2 litres were instilled in left eye. Examination of the right eye was unremarkable.

The patient was started on topical antibiotic chloramphenicol 1 percent, tear substitute Carboxy Methyl Cellulose 1 percent, hypertonic saline solution 5 percent and eye was patched for one day. Analgesics (diclofenac and serattiopeptidase) were prescribed for pain.

Subsequent follow up on 3^rd and 7^th day revealed partial and complete healing of epithelial defect. The patient was asked to bring the twig of the plant. Botanical examination revealed this to be Sapium insigne (Figures 3 and 4).

Figure 3: Descemet’s folds in central cornea

Figure 4: Descemet’s folds as a result of exposure with plant sap.

Tiger's Milk Spruce or Sapium insigne is a small tree, 5-10 m high, with horizontal branches, exuding poisonous milky juice. It belongs to the family Euphorbiaceae. Members of this genus are invariably venomous (Figure 5).

Figure 5: Twig of Sapium insigne also known as tiger milk spruce (Euphorbiaceae-Castor family)

Agonizing pain instantly upon exposure followed by blurred vision is the hallmark of ocular injuries by the sap of Euphorbia plants. Redness, photophobia and lacrimation can also result. Profuse irrigation with tap water at the scene is advised at the earliest in order to dilute the concentration of the sap inside the eyes and to cut short the duration of exposure. A sample of the offending plant should be taken for identification.

Topical antibiotic and steroid can limit the risk of corneal oedema and bacterial infection. Topical cycloplegics for pain relief should also be prescribed.

Ophthalmologist should be aware of the vision threatening complications from Euphorbia plant saps and detailed assessments using slit-lamp examination for corneal defects should be carried on similar to other cases of plant toxicity, the patient should be asked to bring a specimen of the offending plant for identification. Flowering or fruiting parts can assist the botanist in identification of plant. When handling the Euphorbia plant, the use of gloves is recommended. Successive loss of man-days can be easily halted by a simple intervention in the form of protective glasses.