George Riding
Introduction
During my time working in northeast Victoria in the run up to Christmas, colleagues and patients alike would warn me of the infamous ‘Christmas Eye’. Christmas Eye, a seasonal toxic epithelial keratopathy, earns its festive name from its peak incidence between mid-November and mid-January, and presents with intense folkloric monocular pain resembling a grinch-like plague descending on the local area during festive season.
Christmas Eye is also known as “Harvester’s keratitis” due to the strong occupational association with summer harvesting activities, and ‘Albury-Wodonga syndrome’ due to the geographical region to which its incidence is limited, from Canberra to the Albury-Wodonga region of north-east Victoria and south-west New South Wales (1, 2). This combination makes Christmas Eye a festive nightmare for agricultural workers in this region, with pain often impeding the ability to work.
Aetiology
‘A seasonal corneal ulcer’ was first reported in 1974 by Walker (1),who described a series of local ‘Christmas Eye’ cases encountered in his practice. Walker proposed that this was secondary to the local 0.5-0.7mm Orthoperus beetle, which was identified in the eye of one patient, although the evidence was initially indeterminate as direct application of beetle extracts did not reproduce corneal insults in animal studies (1).Years later, the consensus view is that Christmas Eye is secondary to the release of a pederin-like vesicant amide, a blistering agent which inhibits protein synthesis and causes epithelial cell death, likely stored in the haemolymph of the Orthoperus beetle (3, 4). This vesicant is hypothesised to be released when Orthoperus is crushed during eye rubbing or rapid eye movement sleep, with a delayed auto-catalytic reaction on the corneal epithelium resulting in the formation of a painful epithelial defect (1, 3, 5).
Presentation
Despite uncertainty regarding the aetiology, the unrelenting, agonising pain unique to Christmas Eye has long afforded a syndromic diagnosis by local eye healthcare professionals (5). The pathognomic ‘clutch sign’, where patients present in “abject misery” holding their eye, is instantly recognisable (2, 5). The Orthoperus beetle swarms in the dry Australian summer evenings,and patients classically present waking in the night with unrelenting monocular pain, photophobia and foreign body sensation, following outdoor activities the previous evening such as gardening or agricultural work (1, 5).
On examination, multiple punctate epithelial erosions may be seen, although they often coalesce to form a large shallow epithelial defect confined to the corneal epithelium, and fluorescein-staining may reveal a characteristic ‘green-splash’ covering up to 90% of the cornea (1, 2, 5, 6).Visual acuity can transiently decrease, accompanying conjunctival injection and chemosis, eyelid and periorbital oedema, and mild anterior chamber reaction, although regional lymphadenopathy is typically absent (1, 2, 5, 6).Despite the folkloric presentation, clinicians must be wary of atypical presentations, as a minority of patients may present with mild pain (6).
Management
The pain is often refractory to analgesia, with hospital admission for analgesia sometimes required (5). The cornerstone of management is symptom control and monitoring epithelial healing, as pain persists until the cornea re-epithelialises, which can take between 2-5 days (2, 5).Local healthcare professionals have developed methods to manage the short-term debilitating pain, with bandage contact lenses particularly effective (2). Topical chloramphenicol is often prescribed, although the role of topical NSAIDs is disputed: some report good pain relief, although there are concerns regarding adverse effects in at-risk corneas (2, 5, 7).
Prognosis
Pain usually improves within 3-4 days, and complete resolution of symptoms occurs within 2 weeks in most patients (1). Most patients have complete resolution of the epithelial defect and visual acuity returns to normal, although a locally eminent optometrist who has managed hundreds of Christmas Eye cases has recently reported a small cluster of patients with unexpected sequelae: subepithelial haze for 12-months, stromal thinning with slow recovery, and an episode of dense corneal scar (2). The role of topical NSAIDs has been questioned, and regular use withdrawn by some clinicians (2).
Summary
Christmas Eye is an acute toxic epithelial keratopathy endemic to the Albury-Wodonga and Canberra areas of southeast Australia. UK residents may encounter this when working in Emergency Departments in Australia, and Christmas Eye must be considered in patients presenting with severe monocular pain around Christmas time. Management is mainly supportive and most patients achieve full visual recovery.
References
- Walker TD. A seasonal corneal ulcer. Aust N Z J Ophthalmol. 1974;2(2):64–7.
- Holloway R. Christmas Eye. Pharma. 2019 Dec;18–22. Available from: https://www.optometry.org.au/wp-content/uploads/Publications/Pharma/Issues/PHARMA-December-2019-FULL-PDF.pdf
- Farrow R. Insects of South-Eastern Australia: An Ecological and Behavioural Guide. Clayton South (AU): CSIRO Publishing; 2016.
- Frank JH, Kanamitsu K. Paederus sensu lato (Coleoptera: Staphylinidae): Natural history and medical importance. J Med Entomol. 1987;24(2):155–91.
- Howsam G. The Albury-Wodonga syndrome: A tale of two cities. Aust N Z J Ophthalmol. 1995;23(2):135–7.
- Raj PR, Varatharajullu P, Adler PA. Atypical Christmas Eye Disease: A case report and literature review. Open Ophthalmol J. 2021;15:264–9.
- Rigas B, Huang W, Honkanen R. NSAID-induced corneal melt: Clinical importance, pathogenesis, and risk mitigation. Surv Ophthalmol. 2020;65(1):1–11.