Posters

Ayurvedic topical medication induced bilateral toxic endothelitis

Poster Details

First Author: A.Ghosh Dastidar INDIA

Co Author(s):    D. Khedia   I. Gupta   M. Mukherjee   T. Basu   E. Nigam        

Abstract Details

Purpose:

Toxic endothelitis is endothelial dysfunction after topical, systemic or intraocular use of substances leading to corneal stromal edema, endothelial pigment deposits with anterior chamber reaction. Unprescribed ayurvedic medication are frequently used as over the counter drugs in India.Lack of awareness regarding the side effects of the same exists. We report a rare case of acute bilateral toxic endothelitis caused by topical ayurvedic medication and its successful management.

Setting:

Tertiary eye centre in Eastern India

Methods:

History taking to rule out other pre existing corneal conditions (Fuchs endothelial dystrophy,raised intraocular pressure), infection (herpes virus keratitis) ,other topical drug use and blunt trauma. Examination at baseline and follow up visits included vision,slit lamp examination, intraocular pressure,corneal pachymetry,specular microscopy and funduscopy.

Results:

A 51 year old female presented with bilateral sudden onset painful diminution of vision associated with redness and watering. There was no significant systemic disease. There was no history suggestive of similar previous episodes, herpes simplex virus keratitis,trauma,other drug use. On examination, best corrected visual acuity (Snellen’s) was 6/60 in both eyes with slit lamp showing diffuse conjunctival congestion, intact epithelium, stromal edema, descement folds and keratic precipitates (Figure 1a & 1b). Anterior chamber showed mild reaction and lens was clear. The intraocular pressure was 10 mm Hg in both eyes. On fundus examination, right eye had epiretinal membrane (ERM) and left eye was within normal limits. Specular microscopy of both eyes showed polymegathism and pleomorphism of endothelial cells. Pachymetry was 590 microns and 587 microns in right and left eye, respectively. The patient gave history of use of ayurvedic eye drops since one week prior to onset of symptoms (each 10ml consisting of Allium cepa-onion juice-1.68ml, juice of Zingiber officinaleginger juice-1.66ml, juice of Citrus aurantifolia-lemon juice1.66ml, honey-5.00ml, preservative: Benzalkonium chloride solution 0.1% v/v). Patient was diagnosed as drug induced acute toxic bilateral endothelitis and the causative drug was stopped. She was successfully treated with tapered steroid coarse. At 2 month follow up regained vision and resolution of corneal edema . She maintains her vision and endothelial cell count at 1 year follow up.

Conclusions:

The causes for corneal edema can be classified based on mechanism: damage to corneal epithelium, raised intraocular pressure, endothelial dysfunction and idiopathic. In our case since there was no epithelial compromise, normal intraocular pressure and no other significant positive history contributing to clinical picture. Corneal edema due to use of topical medications and toxins has been documented. We propose the acute corneal edema caused by use of the topical ayurvedic medication as the most viable etiology. This case report highlights the side effect of non- prescribed ayurvedic drug, the need of urgent medical care and patient awareness for the same.

Financial Disclosure:

None