Journal of Ayurvedic and Herbal Medicine 2017; 3(1): 1-4

Case Report

ISSN: 2454-5023
Exposure to Snuhi Ksheera (Euphorbia caducifolia Haines.
J. Ayu. Herb. Med. latex) resulting in ocular injury: A case report
2017; 3(1): 1-4
January- March 1 2 3 4
Krushnkumar Taviad , Shweta Vekariya , Hitesh Bhati , B.J.Patgiri
© 2017, All rights reserved 1 Ph.D. Scholar, Department of Rasashastra & Bhaishjya Kalpana, Institute for Post Graduate Teaching and Research
www.ayurvedjournal.com in Ayurveda (I.P.G.T. & R.A.), Gujarat Ayurved University, Jamnagar-361008, Gujarat, India
Received: 03-03-2017 2 Ph.D. Scholar, Department of Dravyaguna, Institute for Post Graduate Teaching and Research in Ayurveda (I.P.G.T.
Accepted: 19-03-2017 & R.A.), Gujarat Ayurved University, Jamnagar-361008, Gujarat, India
3 Ph.D. Scholar, Department of Shalakyatantra, Institute for Post Graduate Teaching and Research in Ayurveda
(I.P.G.T. & R.A.), Gujarat Ayurved University, Jamnagar-361008, Gujarat, India
4 Professor & Head, Department of Rasashastra & Bhaishjya Kalpana, Institute for Post Graduate Teaching and
Research in Ayurveda (I.P.G.T. & R.A.), Gujarat Ayurved University, Jamnagar-361008, Gujarat, India

ABSTRACT

Objective: To report the case of Snuhi Ksheera (Euphorbia caducifolia Haines. latex) exposure causing ocular injury.
Design: Single case study. Setting: Shalakyatantra department, IPGT & RA, Jamnagar, Gujarat, India. Case: A 28 year old
male research scholar complaining of acute severe pain in right eye with a history of accidentally touched Snuhi Ksheera
with his gloved hand during the preparation of Ksharasutra (medicated caustic thread). Interventions: Patient was
treated with topical steroid and antibiotic drops along with Ghrita Manda (supernatant layer of ghee) as eye drops.
Patient was observed until all sign and symptoms had resolved. Main Outcome Measures: Symptoms, visual activity
and clinical signs of inflammation. Patient provided a specimen of the plant for formal identification. Results: Initial
symptoms were burning, redness, irritation, lacrimation and stinging pain with blurred vision. All signs and symptoms
had resolved within 3 days. There was moderate lid edema and conjunctival congestion. On examination, the patient
had a visual acuity of 6/12 in right eye and intraocular pressures were 13.9 mmHg bilaterally. Conclusion: Individuals
who work with Euphorbia plants should be cautioned to wear eye protection and gloves. Our suggestion for managing
of Snuhi ksheera (Euphorbia sap) ocular injury is administered drops of Ghrita Manda as supportive therapy.

Keywords: Euphorbia caducifolia, Ocular injury, Side effects, Snuhi Ksheera.

INTRODUCTION

The Euphorbiaceae are mostly monoecious herbs, shrubs, and trees, sometimes succulent and cactus-like,
comprising one of the largest families of plants with about 300 genera and 7,500 species that are further
[1]
characterized by the frequent occurrence of milky sap. Euphorbia caducifolia Haines. grows in stony
ground on barren coastal plains and in the hilly tracts of the Indian desert on well-drained limestone soils
[2]
as well on sandy soil, and therefore the substrate varies from slightly alkaline to slightly acidic. It is
[3]
popularly known as Thor, Danda-thor and leafless Milk Hedge. Species of Euphorbia grow in India, either
[4]
wild or as cultivated specimens in the house or garden. E. caducifolia is considered poisonous and not
used as food or fodder except for the juicy leaves, which can be consumed as a vegetable. Latex is present
[5]
in great abundance in the entire plant. The latex or sap of many Euphorbia plants is toxic and may cause
[6] [7,8]
inflammation of skin and the eye on contact. The spectrum of ocular injuries from the family of
Euphorbiaceae consists of contact or photo dermatitis, conjunctivitis, mild to severe keratitis, corneal
[9,10]
ulceration, uveitis with hypopyon, corneal scarring, miosis and blindness. Ocular inflammation varies
from a mild conjunctivitis to sever keratouveitis and there have been several case reports of permanent
[11]
blindness resulting from accidental exposure to the sap. If cornea is involved, changes generally follow a
[11,12]
typical sequence with worsening edema and epithelial sloughing on the second day. When treated
[13]
*Corresponding author: early and managed appropriately, cases generally resolve without sequelae.
Dr. Krushnkumar Taviad
Ph.D. Scholar, Department of Beside these hazardous effects, the latex of E. caducifolia is considered to have medicinal value and used
Rasashastra & Bhaishjya Kalpana, [5]
by shepherds and local inhabitants for treating bleeding wounds caused by accidental injury. It is also
Institute for Post Graduate
Teaching and Research in
used to cure the skin infections, cutaneous eruption, leukoderma, applied to cuts and wounds for speedy
[5,14]
Ayurveda (I.P.G.T. & R.A.), healing, earache and to expel guinea worms. Snuhi (E. caducifolia Haines.) is one among the Upavisa
Gujarat Ayurved University, (the group of drugs which were less toxic in nature and not so lethal but produces certain toxic symptoms
Jamnagar-361008, Gujarat, India
Email: drkrishnat[at]gmail.com

1
on consumptions or administration) and a well-known plant in Indian
system of medicine. Snuhik ksheera is used in the formulations after
only proper Shodhana (purification / detoxification) in Chinchapatra
[15]
Swarasa (Tamarindus indica leaves juice). It is used as Bhavana
Dravya in most of the Vati (tablets), Varti (suppositories) and Rasa
[16]
aushadhies (herbomineral compound formulation). Ksharasutra is a
medicated device or an Ayurvedic cutting set on or coated thread
prepared by repeated smearing of latex of E. caducifolia or E. nerifolia
plant, alkali of Achyranthes aspera plant and turmeric powder on a 20
[17]
zero Barber’s surgical linen thread.

In present study, ocular toxicity caused by Euphorbia caducifolia

Haines. Latex that used in the preparation of Ksharasutra (medicated Figure 1: Natural habitat of Snuhi (Euphorbia Figure 2: Latex of Euphorbia
caustic thread) in Indian system of medicine in Jamnagar, India was caducifolia Haines.) caducifolia Haines.
reported.

CASE REPORT
th
On 14 February 2017, a male research scholar of 28 year old
presented with the case No. 96738 to the OPD of Shalakyatantra,
Institute for Post Graduate Teaching and Research in Ayurveda, Gujarat
Ayurved University, Jamnagar, India complaining of acute severe pain
in right eye. He gave a history of accidentally touched Snuhi Ksheera
(Euphorbia caducifolia Haines. latex) in his right eye with his gloved
hand during the preparation of Ksharasutra. He experienced severe
burning sensation, redness, foreign body sensation, blurring of vision
and marked lacrimation despite immediate rinse with tap water. He
administered eye drops of Ghrita Manda (supernatant layer of ghee) as
supportive therapy to overcome the pain. He had no past history of
ocular trauma, ocular surgery, glasses, or contact lens wear. Past
medical history was unremarkable, and he was not on any medications. Figure 3: Moderate lid edema, conjunctival congestion with mild chemosis
and inflamed tear duct after half hour of exposure to Euphorbia sap
He was assessed by an ophthalmologist later the same morning. The
eye was painful and there was marked lacrimation. There was
moderate lid edema and conjunctival congestion with mild chemosis
(Figure 3). Immediately Proparacaine (0.5%) (pH 3.5 to 6.0) local
anaesthetic eye drops are used to reduce eye pain, which can help in
better eye opening for detailed examination. After that copious
irrigation with Ringer's solution (pH 7.3-7.4) was done for 20 minutes
up to achieve physiological pH level. After irrigation, eye was again
checked for any remnants of the sap of euphorbia at bulbar and
palpebral part of the conjunctiva. A sterile ear bud was also passed in
both the fornix for removal of any debris.

On examination, the patient had a visual acuity of 6/12 in right eye (RE)
and 6/6 in the left eye (LE) with his spectacles using the Snellen’s visual Figure 5: Lower palpebral congestion
Figure 4: Bulbar congestion
acuity chart at distance. Slit lamp examination revealed no signs of
corneal edema, and the anterior segment was quiet. His LE was within
normal limits and the RE showed marked congestion at bulbar and
DISCUSSION
palpebral conjunctiva in green filter (Figure 4, 5). There is no signs of
iridocyclitis like aqueous flare or cells in anterior chamber. No Euphorbiaceae is one of the largest of the plant families and includes
conjunctival and limbal ischemia was found while performing slit lamp thousands of plants found all over the world. They are distinguishably
examination. Fluorescein staining was negative hence it can be different by their peculiar flower and milky latex that contains irritant
assumed that corneal epithelium was intact. Intraocular pressures was and carcinogenic diterpine esters.
[18]
Sticky milky latex of
13.9 mmHg bilaterally. Euphorbia plants flows out in abundance when a slight injury is caused
to the phylloclade. The latex is reported to have phytosterols and
He was treated with ofloxacin (0.3% w/v) and prednisolone acetate (10 [19,20]
triterpenes (euphol, tirucallol, Cycloartenoland cyclocaducinol).
mg/10 ml) eye drops for four times daily. The patient was observed
The terpenester composition determines that it is irritating to the skin.
closely as an outpatient. On next day, the pain was less marked but
rd In contact with mucous membranes (eyes, nose, mouth), the latex can
swelling was seen in lower eyelid and nasolacrimal duct. On 3 day all [21]
produce extremely painful inflammation.
signs and symptoms were resolved and patient regained 6/6 vision
bilaterally with his own spectacles. The offending plant was presented Chemical eye injury is an ophthalmic emergency, which may be caused
to the Pharmacognosy Laboratory, IPGT & RA, Gujarat Ayurved by exposure to an acidic (pH<4) or an alkali (pH>10) solution to the
University, Jamnagar and was subsequently identified as Euphorbia eye.
[22]
It is the only eye injury that requires emergency treatment
caducifolia Haines. also known as the Thor in local language (Figure 1, without formal clinical assessment. Symptoms usually start
2). immediately on contact with the milky latex. There is burning
sensation, pain, photophobia and lacrimation which may worsen over

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hours even after copious irrigation. The degree of ocular inflammation Consent
may also vary with the amount of sap that enters the eye. Neglected
cases can progress to blindness due to corneal scarring, complicated The patient consent was received for this case report to be published.
[18]
uveitis, and anterior staphyloma. There are other reports in the
literature of corneal injury following contact with plant species known REFERENCES
to produce irritant saps. In cases of suspected corneal contact with the
sap of Euphorbia spices, there are published recommendations for 1. Available from: http://www.botany.hawaii.edu/faculty/carr/euphorbi.htm
(Last Accessed on26/02/2017).
treatment. People who work with the milky latex of Euphorbia plant
2. Available
species must use goggle, gloves and mask as preventive aspect. In first from:http://www.llifle.com/encyclopedia/succulents/family/Euphorbiacea
aid, Patients with a history of plant sap entering directly or indirectly e/28041/euphorbia_caducifolia (Last Accessed on26/02/2017)
into their eyes should be immediately irrigated with copious tap water 3. Available
[23]
Ringer’s solution or normal saline and requirement to maintain pH. from:http://www.flowersofindia.net/catalog/slides/leafless%20milk%20H
It is suggested to continue rinsing the eye for no less than 10 edge.html(Last Accessed on26/02/201.
[24] 4. Available from: https://en.wikipedia.org/wiki/Euphorbia(Last Accessed on
minutes. Topical anesthesia of the eye is an important adjunct to the
workup of emergency department patients with ocular complaints. Not 26/02/2017).
5. Goyal M, Sasmal D, Nagori BP. GCMS analysis and antimicrobial action of
only is topical eye anesthesia important in relieving discomfort and
latex of Euphorbia caducifolia. Journal of Intercultural Ethnopharmacology
allowing a thorough examination, it also is important diagnostically to 2012;1(2):119-23.
help differentiate pain from superficial problems such as corneal 6. Webster GL. Irritant plants in the spurge family (Euphorbiaceae.). Clin
abrasions and foreign bodies from pain arising from deeper structures Dermato 1986;4:36-45.
[25]
as in acute iritis. Treatment should include the use of topical 7. Grant WM, Schuman JS. Toxicology of the eye. 4th ed. Springfield, III:
antibiotics, steroids and pain killer drugs. It is important to closely Charles C Thomas Publisher; 1993:680-2.
follow up in the first few days to control inflammation and to prevent 8. Duke-elder S. System of Opthalmology. Vol 14. London, England:Kimpton;
infection and complications. Topical corticosteroids play a critical role 1972-1185.
9. Eke T, Al-Husainy S, Raynor MK. The spectrum of ocular inflammation
in controlling acute inflammation after chemical injuries. They reduce
caused by Euphorbia plant sap. Arch Ophthalmol 2000;118:13-6.
inflammatory cell infiltration and stabilize neutrophilic cytoplasmic and 10. Scott IU, Karp CL. Euphorbia sap keratopathy: four cases and a possible
lysosomal membranes. They also help resolving anterior chamber as pathogenic mechanism. Br J Ophthalmol 1996;80:823-6.
[26]
well as conjunctival inflammation. 11. Sofat BK, Sood GC, Chandel RD, Mehrotra SK. Euphorbia royleana latex
Keratitis. Am J Opthalmol1972;74:634-7.
On other hand, Ayurveda point of view Snuhi Ksheera toxicity can be 12. Grant WM, Schuman JS. Toxicology of the eye. 4th ed. Springfield, III:
manage by application of Chinchapatra (Tamarindus indica Linn.) paste Charles C Thomas Publisher; 1993:680-2.
to affecting body part and drinking of Swarna Gairika (red ochre) 13. Antcliff RJ, Hodgkins PR, Bowman R, Keast-Butter J. Euphorbia lathyr is
[27] latex keratoconjunctivitis. Eye1994;8-696-8.
processed water. Ghrita manda which always remains in a liquid
14. Goyal M, Sasmal D, Nagori BP. Review on medicinal plants used by local
state is rich in unsaturated fatty acids, esp. omega-3 and omega-4, community of Jodhpur district of thar desert. Int J Pharmacol 2011;7:333-
which are essential for vision and have a good effect on dry eye 9.
[28]
syndrome due to their anti-inflammatory effects. Follow-up should 15. Anonymous, TheAyurvedic Formulary of India. Vol I, Part B; Shodhana-52.
be frequent in the first few days to identify such as bacterial Dept of AYUSH, Ministry of Health and Family welfare , Government of
supra-infection and uveitis. Most of the condition is self-limiting and India, New Delhi;2008.
has a full recovery without sequalae after supportive treatment over a 16. Rashmi NP, GantiBasavaraj Y, Kishore Seetarama D, Hussain Gazala,
week. Ophthalmologists should ask the patients to bring in a sample of Govinda Sharma K; A Review – On Different Yogas of Snuhi. Unique Journal
of Ayurvedic and Herbal Medicines 2015;3(4):72-5.
the plant for identification and understanding the clinical course that
17. DwivediAmarprakash P. ADR Ksharsutra kit: A Breakthrough in the
may happen. The clinical course may be affected by particular species standardization of Ksharasutra. International Journal of Research in
of Euphorbia, the amount of sap exposure, the time between exposure Ayurveda and Pharmacy 2013;4(2):304-6.
and irrigation, and host factors. Further studies are needed on this 18. Basak SK, Bakshi PK, Basu S, Basak S. Keratouveitis caused by Euphorbia
poisoning to know the chemical composition of latex and precise plant sap; Indian Journal of Ophthalmology 2009;57(4):311-3.
mechanism of action. 19. Afza N, Khan AQ, Malik A, Yasmeen B. Cyclo- caducinol, a Cycloratane Type
Triterpene from Euphor- biacaducifolia. Phytochemistry 1999;28(7):1982
CONCLUSION 84.
20. Nasim MJ, Asad MH, Sajjad A, Khan SA, Mumtaz A, Farzana K et al.
In conclusion, being aware of these toxic plants and their sap Combating of scorpion bite with Pakistani medicinal plants having ethno-
botanical evidences as antidote. Acta Poloniae Pharmaceutica
constituents, the physician can manage patients expose to the plants
2013;70:387-94.
sap successfully in rural hospital with supportive therapy. This case 21. Adedapo AA, Abatan MO, Idowu SO, Olorunsogo OO. Effects of
therefore suggests that there is a risk of considerable ocular injury chromatographic fractions Of Euphorbia hirtaon the rat serum
following contact with the latex of E. caducifolia. People must use biochemistry. African J Biomed Res2005;8:185–9.
goggle, gloves and mask as preventive aspect when handling such 22. Lim LT, Ah-Kee EY, Collins CE. Common eye drops and their implications for
plants to minimize the risk of accidental injury. pH measurements in the management of chemical eye injuries. Int J
Ophthalmol2014;7(6):1067-8.
Source of Support- Nil 23. Eslani M, Baradaran-Rafii A, Movahedan A, Djalilian AR. The ocular surface
chemical burns. J Ophthalmol 2014;2014:196827.
Conflict of Interest- None declared 24. Schrage NF, Langefeld S, Zschocke J, Kuckelkorn R, Redbrake C, Reim M.
Eye burns: an emergency and continuing problem. Burns 2000;26(8):689-
99.
Acknowledgments 25. Bartfield JM, Holmes TJ, Raccio-Robak N.A comparison of proparacaine
and tetracaine eye anesthetics. Acad Emerg Med1994;1(4):364-7.
We acknowledge the contribution of Dr. Harisha C R, Head, 26. Saud EE, Moraes HV Jr, Marculino LG, Gomes JA, Allodi S, Miguel NC.
Pharmacognosy Laboratory, Institute for Post Graduate Teaching and Clinical and histopathological outcomes of subconjunctival triamcinolone
Research in Ayurveda, Gujarat Ayurved University, Jamnagar, Gujarat, injection for the treatment of acute ocular alkali burn in rabbits. Cornea
India for identification of Euphorbia caducifolia Haines. plant. 2012;31(2):181-7.
27. Acharya Vishram, AnupanManjari, 2nded. Gujarat Ayurved University,
Jamnagar, Sahitya Sanshodhan Vibhagiya Prakasan 1996. 3-15, Pg No. 14.

J Ayu Herb Med ǀ Vol 3 Issue 1 ǀ January- March 2017

3
28. Sumitha Prakash C, Sivabalaji K. AyurvedicOpthalmology an Approach
through Holistic Diet and Regimen. International Journal of Medicinal
Plants and Natural Products2015;1(2):31-4.

HOW TO CITE THIS ARTICLE

Taviad K, Vekariya S, Bhati H, Patgiri BJ. Exposure to Snuhi Ksheera (Euphorbia
caducifolia Haines. latex) resulting in ocular injury: A case report. J Ayu Herb
Med 2017;3(1):1-4.

J Ayu Herb Med ǀ Vol 3 Issue 1 ǀ January- March 2017

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