One of our wonderful tech’s has been looking into better ways to treat Demodex mites which he sees everyday on patient’s eyelashes under the microscope. He saw a presentation at ASCRS (the international cornea & cataract meeting) on the use of 1% Malathion Drops or Shampoo and 4% Pilogel for unwanted critters in hair areas.
He has done research on 1% Malathion Drops or Shampoo and 4% Pilogel and Neem Oil.
He has even offered to try using all of the above on his own eyes to be sure it is not painful or toxic.
So far I could not find any published studies to say these options kill Demodex effectively. 1% Malathion Drops or Shampoo and 4% Pilogel does appear to help with pubic lice or pediculosis which we do occasionally see in eyelashes. But I have never recommended this for Demodex as diluted tea tree oil usually works fine. Avenova works also with less burning but I find TTO is stronger & works more effectively.
Still we have patients who keep getting demodex which we believe blocks the orifice of the meibomian gland and leads to meibomian gland atrophy: are these other chemicals an option for the eye?
The only studies I could find on Neem Oil and the eye. The only potential serious side effect that can occur with Neem Oil, that I could find is toxic optic neuropathy if Neem Oil is ingested.
For now, we will wait to see if our Tech will really try these options on his eye first.
SLC
Indian J Ophthalmol. 2014 Mar; 62(3): 337–339.
PMCID: PMC4061674
PMID: 24722271
A rare case of toxic optic neuropathy secondary to consumption of neem oil
Copyright : © Indian Journal of Ophthalmology
This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Neem oil (also known as Margosa oil) is a deep yellow oil with an unpleasant taste and smell. It is an extract of the seed of the Neem tree (Azadirachta indica A. Juss) a native tree of India but now widely distributed throughout Indo-Malaysia.[1]
Consumption is usually accidental, rarely suicidal or may be due to nasal instillation for common cold in children as practiced in southern parts of India. Even small doses of neem oil are known to cause severe metabolic acidosis along with seizures which can be refractory with known late neurological sequelae.[2] The diagnosis is based on patient history and neuro-ophthalmological findings.[3]
We report a rare case of toxic optic neuropathy secondary to neem oil consumption associated with neurological manifestations.
Case Report
A 35-year-old female patient presented with bilateral visual loss of two days duration (on 16.12.2009) with history of consumption of about 150 ml neem oil five days back (12.12.2009) in an attempted suicide, for which she was taken to the nearby government hospital. She was admitted and treated with induced vomiting after about 2-3 hours of consumption. Patient was asymptomatic for about 48 h in the hospital. Later patient noticed sudden bilateral visual loss and was referred to us for further ophthalmic evaluation.
Ophthalmic examination revealed no perception of light in both eyes. Anterior segment examination revealed bilateral 6-mm, dilated and sluggishly reactive pupils. Rest of her anterior segment examination was normal. Her fundus examination showed bilateral, hyperemic and edematous discs with extension of edema along the superior and inferior temporal arcuate fibers for about 2-3 disc diopters from the disc margins. The veins around the disc were mildly dilated and tortuous [Fig. [Fig.11 and and2].2]. The rest of the vitreous, fundus examination revealed no abnormal findings. Neurological examination showed exaggerated deep tendon reflexes and an extensor bilateral plantar reflex.
Right Eye Fundus picture showing disc edema, venous tortuosity with extension of edema along the superior and inferior arcades for about 2-3 disc diopters from the disc margins
Left Eye Fundus picture showing disc edema, venous tortuosity with extension of edema along the superior and inferior temporal arcades for about 2-3 disc diopters from the disc margins
Complete hemogram was within normal limits, Venereal Disease Research Laboratory (VDRL ), HIV1 and 2 were non-reactive. A magnetic resonance imaging (MRI) scan showed bilateral putaminal regions with altered signal, hypointensities in T1-weighted images, hyperintensities on T2-weighted images and hyperintense on Fluid Attenuation Inversion Recovery (FLAIR) images suggestive of cytotoxic edema due to tissue hypoxia [Fig. [Fig.33 and and44].
Bilateral putaminal regions showed altered signal hypointensities in T1W images
Hyperintensities on T2W images
Medical therapy was initiated which included methyl prednisolone 1 g intravenously (IV) for three days followed by oral prednisolone 50 mg /day for 11 days along with 1000 μg vitamin B12 (injection methyl cobalamin – 1000 μg intramuscularly) every five days for eight weeks.
Patient did not show any visual improvement after one week of treatment but pupillary reactions improved. During her subsequent follow-up after about 15 days her vision in both eyes improved to counting fingers 1/2 meters and at one month follow-up vision was 20/200 in both eyes and pupillary reactions were normal in both eyes. Her fundus examination showed reduced disc edema [Fig. [Fig.55 and and66]
Right Eye Fundus picture showing reduced disc edema
Left Eye Fundus picture showing reduced disc edema
At two months follow-up her vision remained 20/200 in both eyes and injection methyl cobalamin 1000 μg intramuscular was continued.
Discussion
Neem oil, also known as Margosa oil is obtained from the neem plant (Azadirachta indica A. Juss). Neem oil is extracted from oil seed kernels. It contains neutral oils such as palmitic and stearic acids. The active ingredients are terpenoids such as azadirachtin, nimbin, picrin and sialin. It also contains aflatoxin, but in very low concentrations. Azadirachtin is attributed with the pesticide action of neem oil. It is used as an insecticide for arthropod pests.[1]
Neem oil is used as a traditional medicine in India for various diseases like headache, gastrointestinal disorders, as a male contraceptive, menstrual disorders, asthma etc.
Neem oil poisoning causes vomiting which occurs within minutes to hours following ingestion of the oil. Drowsiness and tachypnea with acidotic respiration followed by recurrent generalized seizures are the other clinical features. The seizures are usually associated with loss of consciousness and coma.[4]
In our case, patient had bilateral toxic optic neuropathy. Patient had consumed 150 ml of neem oil which had the following contents: Neem oil kernel extract in solvent methanol containing 0.15%, Azadirachtin – 60%, Emulsifier-5%, treated Neem oil – 35%.
No specific antidote is available. Gastric lavage is not recommended. Treatment is primarily symptomatic.[5] She had bilateral toxic optic neuropathy with exaggerated deep tendon reflexes and extensor plantar reflex. MRI scan findings were suggestive of acute toxic encephalopathy and it can be considered as a possible etiology for bilateral toxic optic neuropathy.[6] We treated her with injection IV methyl prednisolone 1 g per kg body weight for three days based on case reports on methanol poisoning.[7]
References
1. Rahaman A, Talukder FA. Bio efficacy of some plant derivatives that protect grain against the pulse beetle.Callosobruchus maculates. J Chem Ecol. 1993;19:246–7. [PMC free article] [PubMed]
2. Dhongade RK, Kavade SG, Damle RS. Neem Oil Poisoning. Indian Pediatr. 2008;45:55–7. [PubMed]
3. Halavaara J, Valanne L, Setala K. Neuroimaging supports the clinical diagnosis of methanol poisoning. Neuroradiology. 2002;44:924–8. [PubMed]
4. Sinniah D, Baskaran G. Margosa oil poisoning as a cause of Reye’s Syndrome. Lancet. 1981;1:487–9.[PubMed]
5. Lai SIM, Lim KW, Ching HK. Margosa Oil Poisoning as a cause of toxic encephalopathy. Singapore Med J. 1990;31:463–5. [PubMed]
6. Dietemann JL, Botelho C, Nogueira T, Vargas MI, Audibert C, Abu Eid M, et al. Imaging in acute toxic encephalopathy. J Neuro radiol. 2004;31:313–26. [PubMed]
7. Sodhi PK, Goyal JL, Mehta DK. Methanol-induced optic neuropathy: Treatment with intravenous high dose steroids. Int J clin pract. 2001;55:599–602. [PubMed]
There are some websites that say Neem Oil helps with Conjunctivitis but I have not seen any publications to say it works or is safe for meibomian glands or for the eyes.
On this site, a patient said Neem Oil made her worse: case of 1.