THE APPLE ON MY EYE – A CASE OF CUSTARD APPLE INDUCED TOXIC KERATOCONJUNCTIVITIS.

To describe a case of bilateral Annona squamosa (custard apple) induced ocular toxicity and to review the relevant literature.

Department of Ophthalmology, Cork University Hospital, Ireland.

Case report of a 55 year old female who presented with a 1 day history of severe bilateral eye pain and redness. She reported use of a home made exfoliating face cream partly consisting of ground custard apple seed. Exam revealed bilateral diffuse conjunctival injection, 80% and 70% corneal epithelial defect in the right and left eye respectively with no limbal ischemia. Considering the atypical presentation, a literature review was immediately conducted and confirmed the principal cause of her ocular toxicity as the ground seeds.

Targeted treatment for custard apple toxicity was commenced with vigilant avoidance of topical steroid. Treatment constituted immediate copious irrigation, inpatient management with intensive hourly lubricants (trehalose, sodium hyaluronate), preservative free chloramphenicol QDS and cycloplopentolate 1% TDS with eye padding between drops. Within 48 hours the patient symptomatically improved. Re-epithelialisation occurred with no infiltrates or scarring and conjunctivae were white. At follow up 2 weeks later the patient was off all drops, asymptomatic and was discharged. To our knowledge this is the first reported case of custard apple seed ocular toxicity described in Europe. The medicinal qualities of which are valued in traditional Indian medicine where the sparse reports of ocular side effects originate.

There is importance in patient education regarding traditional herbal remedies and their potential for ocular toxicity. Clinicians must be aware of custard apples as a rare cause of ocular toxicity. The use of steroids in such cases is associated with worse outcomes including vision threatening microbial keratitis and need for penetrating keratoplasty. Although the current literature is limited, management with avoidance of topical steroids led to an excellent outcome on our case consistent with what has been described previously.