Epipremnum aureum Keratopathy: Case Report and Review of the Literature

Abstract

Objectives: To report a novel case of Epipremnum aureum toxicity masquerading as bilateral infectious keratitis and review the literature on ocular manifestations of Epipremnum exposure.

Methods: Case report and literature review.

Results: A 70-year-old man with a history of photorefractive keratectomy presented with a 3-day history of bilateral eye pain. The patient reported exposure to plant debris while performing yard work and also water exposure while cleaning his coral fish tanks. Clinical examination revealed bilateral epitheliopathy progressing to frank epithelial defects with underlying stromal necrosis 6 days after exposure. Empiric topical antibiotic drops were initiated, but multiple cultures, corneal biopsy, and confocal microscopy were all negative for an infectious agent. Over a 2-week period, the epithelial defects worsened and a suspicion for a toxic etiology was raised. The patient later recalled rubbing his eyes after exposure to Epipremnum aureum (Golden Pothos/Devils Ivy) sap. He was thus treated conservatively with artificial tears, topical corticosteroids, and amniotic membrane. After 3 months, the epithelial defects resolved, but with corneal scarring, prominently in the left eye and underwent penetrating keratoplasty. Five years after presentation, best-corrected visual acuity with hard contact lenses was 20/25 in the right eye and 20/20 in the left eye.

Conclusion: Epipremnum aureum toxicity is a rare cause of keratitis. It can mimic acanthamoeba keratitis or anesthetic abuse and should be considered in cases of culture negative nonhealing corneal ulcerations. Eliciting a history of plant sap exposure can facilitate appropriate supportive care for this toxic keratitis.

Figure 1.

Slit lamp photograph 3 days after exposure to Epipremnum aureum sap. a. Small corneal epithelial defects in the right eye and 2+ underlying corneal edema and folds. b. Central corneal epithelial defect in the left eye, measuring 3mm x 3mm with an inferior ring defect with overlying epithelial defect and underlying necrosis.

Figure 2.

Slit lamp photographs 11 days after exposure to Epipremnum aureum sap. a. Worsening corneal epithelial defect in the right eye measuring 8 mm x 6.5 mm with fluorescein dye staining. b. Diffuse conjunctival hyperemia, necrotic stromal involvement in a semiannular configuration and peripheral corneal neovascularization. c. Worsened corneal epithelial defect in the left eye measuring 9 mm x 10 mm with fluorescein dye staining. d. Diffuse conjunctival hyperemia of the left eye with an annular appearing necrotic stromal involvement and peripheral corneal neovascularization.

Figure 3.

a. Slit lamp photographs 21 days after exposure to Epipremnum aureum sap with persistent epithelial defects. a. Persistent corneal epithelial defect in the right eye, measuring 8 mm x 6.5 mm with fluorescein staining, despite treatment with topical antibiotics (polymyxin b sulfate and trimethoprim), doxycycline, oral acyclovir and oral vitamin C. Deep stromal involvement and peripheral corneal neovascularization are also seen. b. Large persistent corneal epithelial defect in the left eye involving almost the entire cornea, measuring 9 mm x 11 mm. Deep stromal involvement and peripheral corneal neovascularization are also seen.

Figure 4.

Slit lamp photographs approximately 2 months after exposure to Epipremnum aureum sap. a. Fluorescein staining highlighting improved epithelial defect in the right eye, measuring 4.5 mm x 4 mm. b. Central and inferior paracentral corneal scarring is also improved with the pupil now partially visible. c. Fluorescein staining highlighting improved epithelial defect in the left eye, measuring 5 mm x 4 mm following placement of amniotic membrane d. Large diffuse central corneal scarring blocks view of pupil in the left eye.

Figure 5.

Slit lamp photographs 7 months after Epipremnum aureum sap exposure. a. Inferior and paracentral corneal scarring is noted in the right eye. b. Diffuse, dense corneal scarring of the left eye involving the visual axis.

Figure 6.

Epipremnum aureum in patient’s neighborhood