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Year : 2022  |  Volume : 34  |  Issue : 1  |  Page : 62-64

Custard apple-induced toxic keratopathy

Department of Ophthalmology, Giridhar Eye Institute, Kochi, Kerala, India

Date of Submission10-Jan-2021
Date of Decision12-Jan-2021
Date of Acceptance02-Feb-2021
Date of Web Publication21-Apr-2022

Correspondence Address:
Dr. R Sruthi
Giridhar Eye Institute, Kochi - 682 020, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/kjo.kjo_5_21

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Custard apple seeds are a natural remedy for head lice. We report a case series of three patients with ocular exposure to custard apple seeds. All three developed toxic keratopathy which was treated with topical antibiotics and soft steroids and they responded well to the treatment. This report is intended to increase the awareness in this regard.

Keywords: Annona squamosa, custard apple, toxic keratopathy

How to cite this article:
Sruthi R, Kalaimathi G S, Pillai VS. Custard apple-induced toxic keratopathy. Kerala J Ophthalmol 2022;34:62-4

How to cite this URL:
Sruthi R, Kalaimathi G S, Pillai VS. Custard apple-induced toxic keratopathy. Kerala J Ophthalmol [serial online] 2022 [cited 2022 Dec 8];34:62-4. Available from: http://www.kjophthal.com/text.asp?2022/34/1/62/343665

  Introduction Top

Custard apple (Annona squamosa) commonly known as “sitaphal” belongs to the family Annonaceae which is a large family comprising about 135 genera and more than 2500 species distributed mainly in tropical and subtropical regions.[1] In folklore medicine, various parts of A. squamosa are used for the treatment of many diseases. The extract from the leaves is used as antidiabetic, anti-ulcer, antidepressant, anti-inflammatory, and antimicrobial. The seed powder is used to kill head lice and fleas as well as for skin exfoliation. A. squamosa plant extract contains steroids, terpenoids, glycoside, alkaloid, flavonoid saponin, phenolic compounds, and acetogenins.[2] Hence, when this comes in contact with the eyes, it causes severe inflammation and toxic keratopathy.

Even though some cases have been reported before, general public and even doctors are not well aware of the hazardous effects of this natural remedy. We report three cases with toxic keratopathy due to accidental eye contact with custard apple seed powder applied over the scalp to increase the awareness about the toxic effects of this plant.

  Case Reoprt Top

Three patients from the same family (mother and two daughters) presented to us with a history of applying custard apple seed powder over the scalp as a treatment for head lice. On the next day, patients started experiencing symptoms and they presented to us on the 3rd day.

Case 1

A 35-year-old female patient presented with photophobia, difficulty in opening the eye, and pain in the left eye. On examination, she had unaided visual acuity of 6/9 in the right eye improving to 6/6 with pin hole and 6/18 p in the left eye not improving with pinhole. After applying topical proparacaine drops, the patient opened her eyes. There was mild upper and lower lidedema, severe conjunctival congestion, and central epithelial defect measuring 4 mm × 4 mm, and her anterior chamber was quiet. She was treated with topical moxifloxacin 0.5% eye drops 4 times/day, hydroxyl propyl methyl cellulose drops and gel 2%, and loteprednol 0.5% eye drops 4 times/day. On the next day, she complained of pain in the left eye and there was an epithelial defect of 7 mm × 6 mm size with loose epithelium above that, central Descemet membrane folds [Figure 1]a and [Figure 1]b, and + 0.5 cells in the anterior chamber. The loose epithelium was debrided and she was advised to continue the same medications. The size of the epithelial defect decreased by the 3rd day and the defect completely healed by day 5. The anterior chamber became quiet by then.
Figure 1: (a) Anterior segment photo of Case 1 on day 2: Large epithelial defect with Descemet membrane folds (after scraping the loose epithelium). (b) Anterior segment photo (with slit) of the case 1 on day 2: Epithelial defect with Descemet membrane folds

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Case 2

A 7-year-old female child presented with photophobia, difficulty in opening the eyes, and pain in both eyes. On examination, after applying topical proparacaine eye drops, vision with glasses in both eyes was 6/18. There was upper and lower lid edema, severe conjunctival congestion, and central epithelial defect measuring 5 mm × 4 mm in both eyes and the anterior chambers were quiet. She was given topical fluorometholone and tobramycin combination eye drops 4 times/day, carboxymethyl cellulose sodium eye drops 2 hourly, and hydroxyl propyl methyl cellulose eye ointment. On the next day, she improved symptomatically and the epithelial defect in the right eye decreased in size [Figure 2]a and [Figure 2]b and the defect in the left eye resolved completely. The epithelium in the right eye was completely regenerated by day 3.
Figure 2: (a) Anterior segment image of case 2 on day 2: Central epithelial defect. (b) Anterior segment image (with slit) of case 2 on day 2: Central epithelial defect

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Case 3

A 4-year-old female child presented with the same symptoms as mentioned above. On examination, she had upper and lower lidedema in both eyes, conjunctival congestion in both eyes, and small central epithelial defect of size 2 mm × 2 mm and punctate epithelial erosions in both eyes. She was also given topical fluorometholone and tobramycin combination eye drops 4 times/day and carboxy methyl cellulose eye drops 2 hourly. On the next day, her epithelial defect healed completely and only punctuate epithelial erosions were remaining. Cornea became clear by day 3 in both eyes.

  Discussion Top

There have been only a few reports of toxic keratopathy induced by custard apple seeds to our knowledge. In 2016, Nagaraja et al.[3] reported a case series of six patients with custard apple-induced keratopathy. They suggested avoidance of topical steroids as there was an increased chance of infective keratitis. Pratheeba Devi et al.[4] in 2017 published two cases of custard apple-induced keratopathy which were treated with epithelial debridement, topical antibiotics, and patching. The largest published series is by Gandhi et al.[5] in which they reported nineteen similar cases.

In an experiment published by Sookvanichsilp N et al.,[6] the extracts of active compounds of leaves and seeds from A. squamosa in four organic solvents, i.e., petroleum ether, ether, chloroform, and ethanol, were tested for toxicity to the eyes, ear, and skin of rabbits. The results revealed that some extracts caused conjunctival redness, chemosis, rugged cornea, skin erythema, and edema.

Similarly, in human eyes, the toxin mainly affects the cornea and the conjunctiva and causes conjunctival congestion, epithelial erosions, and loose epithelium which leads to an epithelial defect. We used soft steroids along with topical antibiotics in all three cases and the epithelium completely healed by day 5. Soft steroids reduced the inflammation due to toxicity, lubricants helped in healing, and comfort and the antibiotics prevented infection. We removed the loose epithelium in one patient. There was no evidence of infective keratitis in any of the cases. The aggressive treatment and frequent follow-ups are the key factors in regaining the integrity of the ocular surface.

  Conclusion Top

The ocular exposure of custard apple seeds is highly toxic to the ocular surface. Careful management and follow-ups will prevent infective keratitis as well as help in regeneration of the epithelium and reduction of the inflammation. Patients need to be educated about the ill effects of this traditional remedy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Al-Ghazzawi AM. Anti-cancer activity of new benzyl isoquinoline alkaloid from Saudi plant Annona squamosal. BMC Chem 2019;13:13.  Back to cited text no. 1
Saha R. Pharmacognosy and pharmacology of Annona squamosa: A review. Int J Pharm Life Sci 2011;2:1183-9.  Back to cited text no. 2
Nagaraja H, Kugar T, Shivanna Y, Agrawal A, Shetty R. Ocular toxicity by seeds of Annona squamosa (custard apple). Indian J Ophthalmol 2016;64:611-3.  Back to cited text no. 3
[PUBMED]  [Full text]  
Nivean PD, Malarkodi S, Nishanth M, Nivean M. Custard apple seed induced keratitis: A harmful traditional practice in South India. GMS ophthalmology cases. 2017;7:Doc 23.  Back to cited text no. 4
Gandhi P, Radhakrishnan N, Khaitan I, Srinivasan M, Prajna VN. Toxic keratitis after application of custard apple seed for head lice infestation. Cornea 2019;38:948-50.  Back to cited text no. 5
Sookvanichsilp N, Gritsanapan W, Somanabandhu AO, Lekcharoen K, Tiankrop P. Toxicity testing of organic solvent extracts from Annona squamosa: Effects on rabbit eyes and ear skin. Phytother Res 1994;8:365-8.  Back to cited text no. 6


  [Figure 1], [Figure 2]


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