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CASE REPORT
Year : 2022 | Volume
: 29
| Issue : 1 | Page : 63-65
Toxic keratopathy induced by self-application of seawater
Huda AlGhadeer1, Thamer Bukhari2, Mohammed AlAmry1
1 Department of Emergency, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
2 Department of Laboratory, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
Correspondence Address:
Dr. Huda AlGhadeer
Department of Emergency, King Khaled Eye Specialist Hospital, Aruba Road, P.O. Box: 7191, Riyadh 11462
Saudi Arabia
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/meajo.meajo_ 313_21
Abstract
To report a case of toxic keratopathy secondary to the self-application of seawater eye drops. A 60-year-old male who presented with unexplained unilateral decrease in vision and corneal thinning. Best-corrected visual acuity was 20/400 OD, slit-lamp examination indicated diffuse corneal edema with central thinning, intact sensation, and no vascularization. Laboratory analysis of the eye drops in conjunction with clinical symptoms and findings was consistent with toxic keratopathy. Toxic keratopathy can masquerade as the other forms of keratopathy, and a thorough history taking and laboratory analysis may help elucidate the diagnosis and avoid significant visual morbidity.
Keywords: Keratitis, keratopathy, seawater, toxic
Introduction 
Corneal toxicity can be due to various causes including systemic or topical medications and traditional/herbal medicine prescribed by traditional therapists.[1],[2],[3] In this case report, we present a case of toxic keratopathy due to eye drops formulated from seawater prescribed by a traditional therapist to treat a recurrent red eye, which was misdiagnosed as herpetic keratopathy. To our knowledge, this is the first case in the literature of toxic keratopathy secondary to the self-application of seawater in the eye.
Case Report A 60-year-old male referred to the cornea clinic for the follow-up of inactive herpetic keratitis in the right eye. The patient underwent an extensive ophthalmic examination after the presentation. Laboratory analysis and electron microscopy were performed of the patient's eye drops at presentation. Specular microscopy was performed bilaterally. The patient was diet-controlled diabetic and denied ever receiving anti-herpetic medications and had no history of skin rashes or trauma. Ocular history included retinal detachment repair and cataract surgery in the right eye. The patient had a clear cornea for almost 4 years after the last surgery with best-corrected visual acuity (BCVA) of 20/100 that started to decrease in association with intermittent hyperemia. Ocular examination indicated corneal thinning with no documented changes in corneal sensation and no corneal vascularization. On further detailed history taking, he reported continuous administration of eye drops containing seawater that were prescribed by a traditional therapist for the intermittent hyperemia in the right eye.
On presentation, the BCVA was 20/400 OD, 20/20 OS, intraocular pressure was within the normal limits. Slit-lamp examination OD indicated normal eyelids, minimal conjunctival injection, and diffuse corneal edema with epitheliopathy [Figure 1]a. The left eye was unremarkable. The anterior chamber was deep with no signs of inflammation and no iris changes bilaterally. Specular microscopy OD could not be performed due to corneal haze and the cell count OS was 2801 cells/mm2 with normal morphology. The patient was pseudophakic with an iris-fixated intraocular lens and a flat retina with peripheral laser marks and mild nonproliferative diabetic retinopathy and clinically significant macular edema in the right eye. A sample of the seawater eye drop was sent for laboratory analysis and electron microscopy [Table 1]. The seawater eye drops were discontinued, and the patient was prescribed cyclosporine A 1% qid for 2 months, topical prednisolone acetate 1% qid for 2 weeks, followed by a tapering dose. In addition, topical cyclopentolate 1% was prescribed tid for the first 2 weeks. Two weeks after presentation, the BCVA OD improved to 20/200 with a decrease in corneal edema and an increase in corneal clarity with fewer Descemet's folds. At 2 months after presentation, BCVA was 20/100 with a clear cornea and no residual corneal edema [Figure 1]b.
Figure 1: (a and b) The anterior segment photograph of the right eye. (a) Reveals diffuse edema of the corneal in the right eye. (b) Reveals resolved corneal edema
Table 1: Analysis of a sample of seawater showing the most predominant elements Discussion Previous reports have documented corneal toxicity after topical anesthetic, glaucoma medications and secondary to preservatives in eye drops and after the use of oral medications such as amiodarone, indomethacin, and chloroquine,[4] wrongly labeled medications,[1] application of custard apple seed for head lice treatment,[5] and application of chlorhexidine for preoperative asepsis.[2] Cohen et al.[3] reported a case of corneal toxicity that masqueraded as microbial keratitis that progressed from simple corneal epitheliopathy to an epithelial defect to stromal necrosis after exposure to splashed water from the garden plant Epipremnum aureum (golden pothos). Keratopathy had been reported after insect sting fell in his eye and resides deep in the cornea near to the endothelium.[6] Ushaar keratitis is caused by Ushaar plants in the tropical, dry areas of Asia and Africa that contain a milky latex substance that can cause keratopathy and endothelial damage.[7],[8] In the current case, our patient used a seawater solution to treat his red eye resulting in surface keratopathy, stromal thinning and possibly endothelial destruction. Palytoxins are naturally occurring toxins mainly produced by soft corals and can be lethal if administered systemically.[4] The ocular effects of these toxins range from simple corneal surface erosion to perforation. In our case, laboratory analysis indicated a composition of mainly sodium, chloride, sulfur, and magnesium and some trace elements such as iron, copper, carbon, and titanium. This case was misdiagnosed with herpetic keratitis. However, other pathognomonic signs of herpetic keratitis were absent such as decreased or absent corneal sensation, corneal vascularization, keratic precipitates, and iris changes. By obtaining a thorough, extensive history, the patient revealed the long-term use of traditional eye drops composed of seawater. We believe the only possible cause of the keratopathy was the long-term administration of the highly concentrated sodium chloride component of the drops. Discontinuing these eye drops halted the corneal pathology.
In conclusion, the concise history of traditional medicine is crucial in cases of atypical presentation of herpetic keratopathy. Laboratory analysis of prescribed traditional medicines can aid in the diagnosis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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