A 55-year-old man presented to the emergency room with chief complaints of decreased vision, severe pain, tearing, and photophobia of his left eye after administering a drop of Kermes topical eye drops, which he obtained from a homeopathic/folk medicine man. Apart from hypertension, the patient’s medical history was unremarkable.\nOphthalmic examination revealed best corrected visual acuity of 20/30 in the right eye (OD) and 20/200 in the left eye (OS). Examination of the OD was unremarkable except for mild cataract. Examination of OS revealed swelling and black pigmentation over the upper eyelid. There was conjunctival chemosis along with well-demarcated black elevated areas inferonasally. Evidence of early cicatrization involving the fornix of the conjunctiva and symblepharon formation were present. Some particulate material from the lower fornix was removed and submitted for chemical analysis. Administration of topical fluorescein hydrochloride revealed a large epithelial defect involving the whole cornea []. There was no evidence of perilimbal ischemia. Intraocular pressure was normal in both eyes.\nThe left eye was immediately irrigated with normal saline for 30 min. The patient was instructed to frequently lubricate the left eye with preservative-free artificial tears in addition to the administration of topical Ofloxacin 0.3% drops 4 times a day for 1 week and topical prednisolone acetate 1% 4 times a day for the first week then it was tapered. In addition, topical cyclopentolate 1% drops 2 times a day were prescribed for the first 2 weeks. Over the following several days, the patient’s best corrected visual acuity improved to 20/60. Eyelid swelling along with skin discoloration completely resolved. The corneal epithelial defect healed completely without scarring \n[].\nGas chromatography/mass spectrometry of the submitted sample revealed the main ingredient to be kermesic acid (C18H12O9) consistent with Kermes. In addition to kermesic acid, there were elements of barium, iron, manganese, potassium, and copper. Six months after presentation, symblepharon was still noted, however, the best corrected visual acuity OS was 20/25 without corneal scar.
A 35-year-old lady, who worked in the royal stable, presented with redness and decreased vision in her right eye of 15 days duration. She was initially treated at a local health center for a corneal abrasion in her right eye, after being hit by the tail of a horse while cleaning the stable. She applied honey three times everyday to her painful right eye as advised by a local traditional healer. A week later, the pain in her eye decreased, but the vision in the right eye deteriorated and redness increased.\nAt the time of presentation, she had no pain or photophobia. The best corrected vision in the right eye was counting fingers at 2 m, and left eye was 0.5 with +2.0 D sph. The right eye showed ciliary congestion. A central corneal ulcer measuring (2 × 3 mm) in size with a hypopyon was noted. Culture of the scrapings from the ulcer grew dermatophytes on Sabouraud agar, which was identified as T. mentagrophytes. There was no evidence of superficial mycoses affecting skin, nails or any other area of her body.\nThe ulcer was treated with topical antifungal drops (Fluconazole 0.3%; Zocon® FDA Ltd) every hour, and cycloplegic (Cyclopentolate hydrochloride 1%; Mydrilate® Intrapharm) three times daily. Ten days following treatment, the patient underwent therapeutic keratoplasty for a non-healing corneal ulcer with impending perforation. The graft was clear and the eye quiet with a visual acuity of 0.2 on the first postoperative day. The topical medications were continued post-keratoplasty. However, the primary infection recurred involving the graft by the fourth postoperative day, progressing relentlessly to involve the entire graft by the 15th day resulting in a vascularized central scar by 2 months (). Posterior segment of the eye and the vitreous cavity appeared normal on B scan ultrasonography. Intra ocular pressure was 10 mmHg. The final visual acuity at the end of 2 months was appreciation of hand movements in the right eye.