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Middle East African Journal of Ophthalmology Middle East African Journal of Ophthalmology
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Year : 2021  |  Volume : 28  |  Issue : 2  |  Page : 131-136  

Ocular complications resulting from the use of traditional herbal medicine in central Saudi Arabia: A review

Department of Emergency, King Khaled Eye Specialist Hospital, Riyadh, Kingdom of Saudi Arabia

Date of Submission07-Apr-2021
Date of Acceptance08-Aug-2021
Date of Web Publication25-Sep-2021

Correspondence Address:
Dr. Huda Al-Ghadeer
Department of Emergency, King Khalid Eye Specialist Hospital, Aruba Road, POB. 7191, Riyadh 11462
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/meajo.meajo_120_21

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The present paper reviewed the ocular complications resulting from the use of traditional eye medicine in Central Saudi Arabia. We performed a literature search of the PubMed database using the keywords “traditional medicine,” “herbal medicine,” “ocular injuries,” and “visual impairments,” covering all years available for peer-reviewed full-text articles, letters, and review chapters of books. An additional search was performed in Google Scholar. All published materials were in English. Several ocular symptoms and disorders, including conjunctival cicatrization, symblepharon formation, obliteration of the fornices and the canaliculi, keratinization of the cornea, dryness, central corneal thinning, and corneal epithelial defect, have been associated with the use of traditional herbal medicine. In addition, the use of traditional eye medicine may result in corneal edema, opacity, ulceration, and perforation. Early recognition of ocular injuries could avoid or at least delay long-term sequelae. Ophthalmologists should be aware of the side effects of traditional remedies. Furthermore, public education, early detection of symptoms, and timely intervention may prevent permanent damage to the eyes.

Keywords: Herbal, ocular, Saudi Arabia, traditional medicine, visual impairments

How to cite this article:
Al-Ghadeer H, Al-Amry M. Ocular complications resulting from the use of traditional herbal medicine in central Saudi Arabia: A review. Middle East Afr J Ophthalmol 2021;28:131-6

How to cite this URL:
Al-Ghadeer H, Al-Amry M. Ocular complications resulting from the use of traditional herbal medicine in central Saudi Arabia: A review. Middle East Afr J Ophthalmol [serial online] 2021 [cited 2022 Jun 28];28:131-6. Available from: http://www.meajo.org/text.asp?2021/28/2/131/326662

   Introduction Top

Traditional medicine has been in practice in several countries since ancient times. The prevalence of preventable blindness in developing countries may be 20 times higher than that in developed countries. This is especially pertinent in the underdeveloped parts of Africa and Asia, where a majority of blind people reside. Several causes of visual impairment exist in countries, such as Saudi Arabia; many of these are preventable through public education and provision of modern healthcare. Unfortunately, traditional medicine is still actively practiced in the rural areas of Saudi Arabia. For example, the topical use of traditional remedies is a common practice in central and southern parts of Saudi Arabia.[1] Traditional medicine refers to health practices, approaches, knowledge, and beliefs based on plant, animal, and mineral sources, spiritual therapies, and manual techniques to treat, diagnose, and prevent illnesses, as well as maintain the overall well-being.[2] The common belief is that herbal and traditional medicines are devoid of adverse effects, and this notion has led to the frequent use of traditional eye medication. These traditional eye medicines are usually prescribed by traditional medicine practitioners, who may be novice in this field. Harmful eye medications include ocular instillation of herbal extracts, breast milk, grounded cowries, bird, and lizard feces.[3],[4] These harmful practices usually result in ocular morbidity owing to their direct contact with the eyes. According to a survey by the World Health Organization, approximately 70%–80% of world population relies on nonconventional medicines mainly based on herbal sources.[5] Herbal ocular “medicines” are responsible for an estimated 8%–10% of corneal blindness in Africa.[6] Reports from Nigeria[7],[8] and other parts of Africa have documented the deleterious effects of traditional eye medicines.[9],[10] The adverse effects include worsening of the original illness and predisposition to infections that may completely damage the eye in some cases. The present paper provides an overview of ocular complications and ocular injuries, resulting from the use of traditional herbal medicine in Central Saudi Arabia to avoid long-term sequelae.

   Kermes Top

Kermes refers to the red dye obtained from the female scaled insect of Kermes ilicis. It has been used for centuries for different purposes including as a traditional medicine.[11],[12],[13] However, the ocular use of the dye and its associated acute toxicity have been rarely reported. Toxic effects of Kermes may cause chemical or thermal injury to the conjunctiva.[12] Initial manifestations may be conjunctivitis with irritation, burning, and tearing and may be identical to those of ocular cicatricial pemphigoid (OCP). The dye is acidic in nature and its repeated use may induce a chronic acid burn of the cornea, which may lead to conjunctival cicatrization, symblepharon formation, and keratinization.[12],[13] Kermes is one of the oldest dyes used either as a traditional medicine or for cosmetic purposes, such as dyeing hair.[11] A spectrum of ocular complications following topical administration of various formulations of Kermes dye has been reported in the past.[11] Al-Ghadeer[1] reported a case of acute ocular complication in a 55-year-old man who presented with complaints of decreased vision, severe pain, tearing, and photophobia of his left eye after he was administered drops of Kermes by a man practicing traditional medicine. Ophthalmic examination revealed best-corrected visual acuity of 20/30 in the right eye (OD) and 20/200 in the left eye (OS). Examination of the OS revealed swelling and black pigmentation over the upper eyelid. Conjunctival chemosis, along with well-demarcated black elevated areas, was observed inferonasally [Figure 1]. Furthermore, early cicatrization involving the fornix of the conjunctiva and symblepharon formation was present. Administration of topical fluorescein hydrochloride revealed a large epithelial defect involving the whole cornea [Figure 1]. There was no evidence of perilimbal ischemia. Intraocular pressure was normal in both eyes. The left eye was immediately irrigated with normal saline for 30 min. The patient was instructed to frequently lubricate the left eye with preservative-free artificial tears, in addition to the administration of topical ofloxacin (0.3%) drops 4 times a day for 1 week and topical prednisolone acetate (1%) 4 times a day for the 1st week, which was then tapered. In addition, topical cyclopentolate (1%) drops twice a day was prescribed for the first 2 weeks. Over the following several days, the patient's best-corrected visual acuity improved to 20/60. Swelling of the eyelid and skin discoloration completely resolved. The corneal epithelial defect healed completely without scarring. Chemical analysis of some particulate materials obtained from the lower fornix revealed the main ingredient to be kermesic acid (C18H12O9), consistent with the composition of kermes. In addition, elements such as barium, iron, manganese, potassium, and copper were found using gas chromatography/mass spectrometry. In a previous study, Tabbara[13] reported that the long-term use of topical kermes resulted in cicatricial pseudopemphigoid in 36 patients from Saudi Arabia. The majority of the patients were females between 42 and 76 years of age.[13] All the patients had used topical kermes prepared at home by dissolving the dye in water and used the solution between 2 and 8 times daily for an average of 6 years.[13] Clinically, these patients showed evidence of conjunctival cicatrization, obliteration of the fornices, conjunctival epidermalization, keratinization of the cornea, dry eye syndrome, symblepharon formation, and obliteration of the canaliculi. Biopsy specimens obtained during the cataract surgery revealed squamous metaplasia with keratinization and fibrosis.[13] In addition, there was a significant loss of conjunctival goblet cells with extensive fibrosis of the substantia propria.[13] Chemical analysis revealed barium, manganese, potassium, and copper with pH of 4.95 in deionized water to be the main components.[13] In contrast, a study reported that kermes has antiseptic properties and inhibited the growth of  Escherichia More Details coli and Staphylococcus aureus at a concentration of 3.2 mg/mL.[13]
Figure 1: Complete corneal abrasion using topical fluorescein hydrochloride. Note the black elevated lesion (arrow) secondary to the use of kermes

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   Lepidium sativum (rashad) Top

Garden cress (Lepidium sativum) is a well-known garden weed. It is called rashad or thevfaa in Arabic. It has a peppery nature with tangy flavor, and its seeds, called haloon, are used as a medicine or as a flavoring agent in foods.[14] Furthermore, it is used as topical ocular medicine. It may result in severe cicatricial injury mainly to the conjunctiva, symblepharon, and pseudopterygium, which is clinically difficult to differentiate from other cicatricial diseases such as OCP, pseudo-OCP, and medicamentosa.[14],[15] A 47-year-old man reported severe ocular pain and redness bilaterally after he self-placed the seeds of rashad into his eyes. On examination, there were conjunctival epithelial defect and symblepharon [Figure 2]. He required topical as well as oral steroid treatment and he regained his 20/25 vision with no further sequelae after 3 months of follow-up.[14] The patient was first prescribed topical fluorometholone drops (0.1%) every 6 h, tears replacement drops, and ointments. He was followed up after 2 days in the emergency room with little improvement. One week later, the conjunctival epithelial defect increased in OD with extension of the pseudopterygium-like corneal vascularization of OU. The patient's medication was revised, and he was placed on prednisolone acetate drops (Pred Forte) (1%) every 3 h, cyclosporine drops (1%) 4 times a day, and every 1-h tears replacement drop and gel 4 times per day. One month later, he still had some vision problem and was started on oral prednisolone 20 mg/day that was tapered over the next 4 weeks.[14] The conjunctiva biopsy was negative for immunoglobulins and complement protein C3; however, severe inflammatory cell infiltration with some loss of goblet cells was observed in chemical burn.[14] In OCP, the histochemical tests aid in the diagnosis. It consists of accumulation of C3 and IgA, IgM, and IgG in the conjunctival basement membrane, which was negative in this case on conjunctiva biopsy.[14]
Figure 2: Symblepharon formation caused by Lepidium sativum (rashad)

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   Alum Top

Alum refers to a group of hydrated double salts, usually consisting of aluminum sulfate, water, and the sulfate of another element. A whole series of hydrated double salts results from the hydration of the sulfate of a singly charged cation (e.g. K+) and the sulfate of any one of a number of triply charged cations (e.g. Al3+).[16] A commonly known alum is potassium aluminum sulfate, also known as potassium alum or potash alum with a chemical formula of K2(SO4)·Al2(SO4) 3·24H2O or KAl(SO4) 2·12H2O.[3] Most alums are colorless, odorless, and exist as a white crystalline powder.[16]

Self-administration of alum substance resulted in severe vision loss in a 56-year-old female with severe corneal thinning, a scar, and decreased vision.[17] Topically administered alum resulted in severe ocular injury. She reported painless decrease in the vision following self-application of alum substances to her left eye for eye redness and discomfort. Ophthalmic examination indicated a best-corrected visual acuity of 20/20 in the right eye (OD) and counting fingers at 1 m in the left eye (OS). Slit-lamp examination of the left eye indicated a quiet conjunctiva and a central corneal scar with no corneal epithelial defect. There was corneal thinning without descemetocele, nuclear sclerosis, and a hazy view of the fundus [Figure 3]a and [Figure 3]b. Scanning electron microscopy of active compounds in the alum revealed the presence of aluminum and sulfur. Alum is generally soluble in hot water and is used in various industrial and manufacturing processes. For instance, it is used as a flocculating agent in water-purification plants and as a binder for dyeing fabrics, such as cotton, to ensure the dye remains insoluble. Alums are also used in pickles, in baking powder, as fire extinguishers, and as astringents in medicine.[16] Injury from alum may stimulate the production and activity of matrix-degrading enzymes such as collagenases and matrix metalloproteinases, which can cause stromal melting.[17]
Figure 3: (a and b) Slit lamp images showing central corneal thinning surrounded by a scar

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   Calotropis procera (ushaar) Top

Calotropis procera (ushaar) is a xerophytic shrub that belongs to the family Asclepiadaceae. The plant is widely distributed in the tropical areas of Asia, Africa, and Northwest South America.[18] It is a medium-branched plant and grows to a height of 4–5 m. The shrub has white or pink flowers,[19] produces milky white latex throughout its life [Figure 4]a, and is known to exert a variety of effects in several animal models.[20] Its oral administration results in potent anti-inflammatory and analgesic effects, as well as weak antipyretic effects, whereas its topical administration produces an intense inflammatory response in animal models.[18],[21] These antagonistic biological activities observed in experimental animals (inflammatory and anti-inflammatory) depend on the extraction medium and the route of administration of the latex.[18] Ocular injury caused by this plant can be mechanical; however, it more commonly results from toxic exposure to the latex. Accidental exposure has been reported to cause inflammation of the skin and eyes.[22],[23] Further, the plant produces a copious amount of latex, having both inflammatory and anti-inflammatory pharmacological properties.[24] Local application produces an intense inflammatory response and causes significant ocular morbidity. Corneal toxicity following self-application of latex from C. procera was reported in a 74-year-old man, who presented with painless decreased vision in the affected eye with diffuse corneal edema and reduced endothelial cell count on specular microscopy.[24] Slit-lamp examination of the OS revealed diffuse corneal edema with significant Descemet's folds and small pigmented keratic precipitates [Figure 4]b. Specular microscopy (SP-3000 P) revealed 2224 endothelial cells/mm2 in the OD and 593 cells/mm2 in the OS, with abnormal morphology. Six months later, the cornea remained clear with best-corrected visual acuity of 20/60 in the OS. Slit-lamp examination revealed a clear cornea with no residual edema [Figure 4]c.[24] The milky white latex of C. procera has irritant and proinflammatory properties.[18] Exposure to the latex irritates the mucous membrane and produces contact dermatitis and intense inflammation when injected locally into animal models.[23],[25] The latex is known to contain several alkaloids, e.g., calotropin, catotoxin, calcilin, and gigantin that are considered poisonous.[18] Shivkar and Kumar,[23] in their study using a rat paw model, found that injection of dried latex produced an intense inflammatory response involving edema formation and cellular infiltration. They demonstrated that this response was caused by histamine present in the latex, as well as the release of histamine from mast cells. Further, they reported that latex induced the synthesis of prostaglandins via activating cyclooxygenase-2.[25] Both histamine and prostaglandins are key mediators in an inflammatory response. Based on these findings, we believe that stromal keratitis is caused by inflammation induced by exposure to latex because of its strong proinflammatory properties. The resolution of keratitis with local corticosteroids use is based on this mechanism. Another possible mechanism could be reduced endothelial count due to the direct toxic effect of the latex, as suggested by Al-Mezaine et al.,[21] who were the first to describe keratitis caused by ushaar in English literature. Simple health education such as hand washing, protective eyewear, and avoid rubbing eyes while plucking Calotropis flowers can prevent serious eye injuries.
Figure 4: (a) Milky latex from the cut leaf of Calotropis procera. (b) Slit lamp biomicroscopy of the left eye, diffuse corneal edema with Descemet's folds. (c) Complete disappearance of corneal edema after treatment

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   Aloe vera (alsabar) Top

Aloe vera is one of the common herbs used to treat eye diseases. Its fresh sap is dripped directly into the eyes and is used for improving the sight or treating watery eye or eye infections. Moreover, other herbs such as Helf (Imperata cylindrica) and Hanzal (Citrullus colocynthis) are used to treat eye diseases. A study conducted in Nigeria showed that some herbal extracts could be applied locally to the lids or the conjunctival sac.[26] Most of these herbal extracts, especially those with high pH or those containing particulate foreign matter, may cause blindness. Alkaline substances may penetrate and opacify the cornea and may damage the corneal epithelium producing ulceration and even perforation. Microbial contamination of herbal solutions may result in suppurative keratitis, followed by endophthalmitis.[26]

   Honey Top

Honey is a common household product with several medicinal uses as described in traditional medicine. It has several beneficial properties such as antimicrobial, antioxidant, and wound-healing properties.[27],[28],[29],[30] It is used worldwide to treat several ophthalmological conditions such as blepharitis, keratitis, conjunctivitis, corneal injuries, and chemical and thermal burns to the eyes.[27] Application of honey in infective conjunctivitis reduces redness, swelling, pus discharge, and the time for bacterial eradication.[31],[32] It has antiangiogenic and anti-inflammatory effects when applied topically in corneal inflammatory and infectious conditions.[33] Moreover, its topical application has been shown to treat corneal abrasions and endotoxin-induced keratitis in an animal model.[33] It is reported that honey is effective in bullous keratopathy[34] and corneal epithelial wound healing.[35] It also has beneficial effects in patients with dry eyes.[36] Its antibacterial activity is attributed to its ability to draw moisture out of the environment causing bacterial dehydration. This effect is mediated by the low pH of honey that inhibits the growth of most microorganisms.[37] It was reported that honey exerts inhibitory effects on approximately 60 bacterial species including aerobes and anaerobes, as well as Gram-positive and Gram-negative bacteria.[27] Honey also has cleansing effect on wounds as it reduces inflammation and stimulates tissue regeneration.[27] Despite its myriad useful effects, honey is considered a potential reservoir for microbes. In addition, it easily gets contaminated during its production by bees and microorganisms, through equipment, containers, wind, and dust.[38] The contaminant microorganisms in natural honey can potentially be unsafe if the natural unprocessed honey is used for therapeutic purposes. For example, a case of Acanthamoeba keratitis was reported after the administration of topical honey by a traditional medicine therapist in a 32-year-old male who complained of red eye and blurred vision.[39] The pain and other symptoms became more severe after the 1st week, with appearance of radial perineuritis at the cornea,[39] following self-instillations of a drop of natural honey to his left eye. Confocal microscopy cornea imaging demonstrated cysts and trophozoites of Acanthamoeba in the corneal stroma.[39] Shenoy et al.[40] reported a 35-year-old lady presented with redness and decreased vision in her right eye for the past 15 days. She was initially treated at a local health center for a corneal abrasion in her right eye, after being hit by the tail of a horse while cleaning the stable. She applied honey 3 times every day to her painful right eye as advised by a local traditional healer. A week later, the pain in her eye decreased; however, her vision in the right eye deteriorated and redness increased. The best-corrected vision in the right eye was counting fingers at 2 m, and left eye was 0.5 with + 2.0 D sph. The right eye showed ciliary congestion. A central corneal ulcer measuring (2 mm × 3 mm) in size with a hypopyon was noted. Culture of the scrapings from the ulcer revealed a dermatophyte on Sabouraud agar, which was identified as Trichophyton mentagrophytes. There was no evidence of superficial mycoses affecting the skin, nails, or any other area of her body. The ulcer was treated with topical antifungal drops (fluconazole [0.3%]; Zocon) every hour and cycloplegic (cyclopentolate hydrochloride [1%]; Mydrilate) three times daily. Ten days following the treatment, the patient underwent therapeutic keratoplasty for a nonhealing corneal ulcer with impending perforation. [Table 1] summarizes the ocular complications induced by traditional medicine use in Central Saudi Arabia.
Table 1: Ocular complications induced by the use of traditional medicine in Central Saudi Arabia

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   Conclusion Top

Traditional medicine and healing practices appear to cause more harm than benefit to the patient. This review describes most common traditional eye medications with potential to cause ocular morbidity in our community. Healthcare workers, including ophthalmologists, should be well aware of the harmful effects of traditional eye medicines. Therefore, clinicians must remain cautious in recognizing adverse reactions. Moreover, awareness programs and education of the public on sight-threatening dangers of the use of traditional eye medication cannot be over-emphasized and are strongly recommended. More studies are required on different traditional eye medications as these are still widely used in some areas of Saudi Arabia. Intensive health education is needed to encourage the use of eye care services, particularly in rural areas to reduce the unregulated use of traditional eye therapies that could result in hazardous effects such as long-term sequelae and even blindness.

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   References Top

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