A 74-year-old man presented to the Emergency Department at King Khaled Eye Specialist Hospital 3 days after self-application of latex from C. procera in his left eye (OS). He reported a painless decrease in vision. There was no history of previous trauma, surgery, or other ophthalmic disorder. Apart from hypertension, the patient had no medical illness.\nOphthalmic examination revealed best-corrected visual acuity of 20/40 in the right eye (OD) and hand motion vision in the OS. Intraocular pressure using applanation tonometry was within normal range in both eyes. Examination of the OD was unremarkable except for a mild cataract. Slit-lamp examination of the OS revealed quiet conjunctiva, no corneal epithelial defect, diffuse corneal edema with significant Descemet's folds and small pigmented keratic precipitates [ and ], nuclear sclerosis of the lens, and a hazy view of the fundus. B-scan ultrasonography of the OS showed no pathology of the posterior pole. Specular microscope SP-3000 P showed 2224 endothelial cells/mm2 in the OD and 593 cells/mm2 in the OS, with abnormal morphology.\nThe patient was started on topical prednisolone acetate 1% four times a day for the first week, after which it was tapered. In addition, topical cyclopentolate 1% drops three times a day were prescribed for the first 2 weeks. In the first follow-up at 1 week after presentation, his best-corrected visual acuity in the OS improved to 20/300. Slit-lamp examination showed a reduction in corneal edema and an increase in clarity with fewer Descemet's folds. In the second follow-up at 2 weeks after presentation, his best-corrected visual acuity improved to 20/200. Slit-lamp examination showed a clear cornea with no residual edema []. One month later, his best-corrected visual acuity was 20/80 in the OS. Six months later, the cornea remained clear with best-corrected visual acuity of 20/60 in the OS. The latex was sent for analysis and revealed the elements shown in . The result of phytochemical screening of petroleum ether and methanol leaf extracts of C. procera revealed the presence of glycosides, protein, triterpenoids, steroids, and flavonoids. The presence of these components in this species is an indication that it may have some medicinal potential. The latex of the C. procera was tested and was found completely varying in pH values. It has an acidic nature with pH of 4.2 at room temp of 25°C. The amount of magnesia was found in highest amount in latex. The level of chromium was completely absent [].
A 60-year-old Pakistani male with a history of acute exacerbation of open angled glaucoma of the right eye underwent branding of the right temple and vertex by a faith healer. Four days later, he presented to the hospital with blurry vision in the right eye and cellulitis over the right temporal region. Further examination revealed chemosis, corneal haziness, severe restriction of ocular movements and multiple well circumscribed round full-thickness burns ranging from 2 to 5 cm with no evidence of active drainage. Fundoscopy showed papilledema and hemorrhages with engorgement of veins. On day five, similar signs appeared in the contralateral eye. His past medical history was insignificant except for glaucoma. He had no prior history of sinus headaches or ear infections. Since local infection is the major reason for cavernous sinus thrombosis (CST), the diagnosis was suspected in our patient as the typical sequelae had started after branding. Acute glaucoma can sometimes present with CST; however, he was already on treatment for open angled glaucoma and had no previous infection. The fact that he had acute exudative wounds after branding and had no prior history of ear or sinus infections points towards branding as a cause of CST. Our diagnosis was confirmed by magnetic resonance imaging (MRI). We believe this local inflammation and infection may have spread and reached one of the cavernous sinuses which may turned into an infected clot. The patient partially responded to intravenous broad-spectrum antibiotics (Amoxicillin with clavulanic acid and Ceftriaxone) and local wound management, but suffered permanent blindness.