Ocular toxicity by seeds of Annona squamosa (custard apple)

Custard apple seeds have been used in native medicine from time immemorial for the management of head lice and skin exfoliation. We report six consecutive patients who developed toxic keratoconjunctivitis within 6–12 h of ocular exposure to custard apple seeds. The use of topical steroid worsens the toxicity and predisposes to the development of microbial keratitis in such cases. Patients showed a good response to primary treatment with topical fortified antibiotics and lubricants. This case series highlights the need to educate the patients regarding the potential toxic effects of the custard seeds and the treating physicians about possible deleterious effects on using topical steroid.