Supplementary Material for: Exposure to Caper Spurge (Euphorbia lathyris) Sap: A Case of Ocular and Periorbital Toxicity

Introduction
We aim to describe a case of bilateral keratoconjunctivitis after exposure to the toxic sap of Euphorbia lathyris.

Case Report
A 76 year old gentleman presented after exposure to Euphorbia lathyris whilst he was gardening. He had 6/12 visual acuity in his right eye, and 6/4 in his left. Examination revealed marked periocular dermatitis, conjunctival injection and corneal oedema in the right eye with diffuse punctate epithelial staining. He was treated with ocular irrigation, topical steroids, antibiotics, cycloplegics and lubricants. Over 48 hours, his left eye started to become symptomatic. He developed bilateral corneal epithelial defects and anterior chamber inflammation. His visual acuity worsened to 6/36 right and 6/24 left. At his 3-week follow up, there was marked improvement with resolution of the toxic keratoconjunctivitis in both eyes.

Conclusion
Toxic sap from Euphorbia lathyris can cause severe keratoconjunctivitis. Irrigation of both eyes despite unilateral symptoms and early follow up should be considered as signs of toxicity may only become evident after 24-48 hours.