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Corneal Edema in a Gardener

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A woman in her 60s with a history of bilateral proliferative diabetic retinopathy complicated by a recent vitreous hemorrhage in her left eye presented with an acute onset of redness, irritation, and blurred vision in her left eye. Her symptoms started 1 day after she rubbed her left eye with her hands after handling the milky latex (a fluid found in 10% of flowering plants) of a plant in her garden. She had no recent history of recent eye surgery, eye trauma, cold sores, or new illnesses.

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Corneal endothelial toxicity secondary to Asclepias milkweed plant exposure

B. Start topical corticosteroid eyedrops

In this case, the patient’s corneal edema was secondary to direct exposure to a plant of the genus Asclepias (milkweed family), which is commonly found in the tropics, subtropics, grasslands, and gardens. Plants in the Asclepiadaceae family are known to contain cardiac glycosides in their latex, leaves, stems, and roots. Cardiac glycosides can inhibit the Na+-K+-ATPase enzyme found in the corneal endothelium and are able to penetrate the cornea with minimal injury to the corneal epithelium.1 Two previous cases have described isolated endothelial decompensation and stromal edema after exposure to the milky latex of Asclepias curassavica2 and Asclepias fruticose.3

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Article Information

Corresponding Author: Audina Berrocal, MD, Bascom Palmer Eye Institute, University of Miami, 900 NW 17th St, Miami, FL 33136 (aberrocal@med.miami.edu).

Published Online: July 23, 2020. doi:10.1001/jamaophthalmol.2020.1325

Conflict of Interest Disclosures: Dr Berrocal reported personal fees from Alcon, PROQr, Novartis, Zeiss, Dutch Ophthalmic Research Center, and Allergan and nonfinancial support from Applied Genetic Technologies Corporation outside the submitted work. No other disclosures were reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Abbott  AJ , Holoubek  CG , Martin  RA .  Inhibition of Na+,K+-ATPase by the cardenolide 6′-O-(E-4-hydroxycinnamoyl) desglucouzarin.   Biochem Biophys Res Commun. 1998;251(1):256-259. doi:10.1006/bbrc.1998.9453 PubMedGoogle ScholarCrossref
2.
Chakraborty  S , Siegenthaler  J , Büchi  ER .  Corneal edema due to Asclepias curassavica.   Arch Ophthalmol. 1995;113(8):974-975. doi:10.1001/archopht.1995.01100080024013PubMedGoogle ScholarCrossref
3.
Amiran  MD , Lang  Y , Yeung  SN .  Corneal endothelial toxicity secondary to Asclepias fruticosa.   Eye (Lond). 2011;25(7):961-963. doi:10.1038/eye.2011.59 PubMedGoogle ScholarCrossref
4.
Hatou  S , Yamada  M , Mochizuki  H , Shiraishi  A , Joko  T , Nishida  T .  The effects of dexamethasone on the Na,K-ATPase activity and pump function of corneal endothelial cells.   Curr Eye Res. 2009;34(5):347-354. doi:10.1080/02713680902829624 PubMedGoogle ScholarCrossref
5.
Rowe  AM , St Leger  AJ , Jeon  S , Dhaliwal  DK , Knickelbein  JE , Hendricks  RL .  Herpes keratitis.   Prog Retin Eye Res. 2013;32:88-101. doi:10.1016/j.preteyeres.2012.08.002 PubMedGoogle ScholarCrossref
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