Issue: November 2021
Disclosures: The authors report no relevant financial disclosures.
May 05, 2020
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Acute anterior uveitis with corneal edema presents after periocular castor oil application

A careful history is needed to ascertain the etiology in a case like this.

Issue: November 2021
Disclosures: The authors report no relevant financial disclosures.
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Ricinus communis seed oil, or castor oil, has been used by Indians for various ailments. Ricinoleic acid, either in its salt or ester form, is often used in skin-conditioning agents, emulsion stabilizers and surfactants in cosmetics. Connective tissue diseases, seronegative arthropathies and systemic diseases are the common causes of uveitis. Moreover, the majority of anterior uveitis cases are noted to be idiopathic and stress related. In this column, we present a case of acute anterior uveitis with corneal edema following periocular administration of indigenous castor oil. As far as we know, there is no literature showing such a complication after castor oil administration. We would like to report this event, as castor oil is a common ingredient used in India.

Amar Agarwal
Amar Agarwal

Patient history and treatment

A 55-year-old woman presented with complaints of redness, photophobia, watering, pain and reduction in vision in her right eye for 1 day. She gave a history of castor oil application 1 day prior in the periocular region. She underwent cataract surgery in both eyes 6 months prior. She also said she used castor oil previously for skin away from the eye. She had no significant systemic illness except diabetes, which was under control. On examination, her best corrected visual acuity was 20/60 in the right eye and 20/20 in the left eye. IOP was 18 mm Hg in both eyes. Slit lamp examination of the right eye revealed circumcorneal congestion and chemosis. Corneal haze with edema and endothelial dusting with iris pigments (Figure 1) were seen. The right eye was pseudophakic with anterior chamber reaction of 4+ cells and 2+ flare and a normally reacting pupil. The left eye was pseudophakic. Dilated fundus examination was within normal limits in both eyes.

evere congestion and chemosis
Figure 1. Clinical picture showing severe congestion and chemosis (a). Optical slit showing epithelial and anterior stromal haze and edema (b).
Source: Dhivya Ashok Kumar, MD, FRCS, FAICO, FICO, Anitha Manoharan, MBBS, DNB, and Amar Agarwal MS, FRCS, FRCOphth

Anterior segment OCT showed dense corneal hyperreflectivity in the anterior stroma suggestive of epithelial and anterior stromal haze (Figure 2a). Conjunctival swab of the right eye and the castor oil specimen used was negative for growth. The other tests for uveitis were negative. Acute anterior uveitis induced by castor oil was diagnosed. The patient was initiated with topical 1% prednisolone acetate hourly, homatropine 2% three times daily and moxifloxacin 0.5% four times daily. Her basic blood tests were normal. Forty-eight hours after initiation of treatment, congestion was reduced, but corneal haze and edema were still present. Anterior segment examination showed better clarity with 2+ cells and 1+ flare. On day 5, congestion resolved, BCVA improved to 20/20, and the cornea cleared (Figure 3). Repeat AS-OCT scan showed resolution of corneal haze (Figure 2b).

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Castor oil as common ingredient

Castor oil is valuable due to the high content of ricinoleic acid, which is used in a variety of applications in the chemical industry. Castor beans, the source of castor oil, contain some allergenic (2S albumin) proteins as well as ricin; however, processed or refined castor oil is free from any of these substances and can be safely used in pharmaceutical applications. This can be attributed to its wide range of biological effects on higher organisms. More recently, Durezol (difluprednate 0.05%, Novartis), a synthetic difluorinated prednisolone derivative, has proven effective for the treatment of post-cataract surgery iritis and pain. Durezol is an oil-in-water emulsion (castor oil), which allows poorly soluble drugs, such as prednisolone, to dissolve in the oil phase, eliminating the need to shake the bottle. Low-concentration castor oil eye drops also have been reported to aid in the treatment of meibomian gland dysfunction while avoiding complications such as blurred vision and a viscous sensation. Moreover, lubricants used in the treatment of dry eye also include castor oil in the preparation.

Anterior segment OCT
Figure 2. Anterior segment OCT of right eye showing stromal haze and thickened stroma at presentation (a) and resolution of haze at day 5 (b).

Atypical presentation

It is unusual for a commonly used agent in topical preparation to cause inflammation; however, because there are no risk factors in the index case and there is a definite history of application of periocular castor oil, there is a probability that the oil could have triggered the episode. The patient could have used castor oil far away from the eye previously, not as close to the periocular skin. An immune-mediated reaction in response to the formulation could have induced acute uveitis, and minimal spillover into the ocular surface could have caused the corneal edema. There is no evidence of infectious etiology because the culture report showed a negative result, and there was no deterioration in signs or symptoms after steroid usage.

day 5 after resolution of inflammation
Figure 3. Clinical picture (a) and slit illumination (b) of right eye on day 5 after resolution of inflammation.

The case illustrates a rare event of acute anterior uveitis wherein the etiology can be missed as application of castor oil may be neglected as the potential cause. Careful history, thorough examination, and ruling out other possible systemic or infectious causes can lead to a better diagnosis. Moreover, in a country such as India where many genres of medical treatment exist, there is a chance that a commonly used preparation vehicle such as castor oil can cause inflammation in the eye.

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Disclosures: The authors report no relevant financial disclosures.