We read with interest the article entitled “Ophthalmic Exposure to Crotalid Venom,” which presented the first reported case involving the use of intravenous (i.v.) antivenom (CroFab®; BTG International Inc., West Conshohocken, PA) in the management of pit viper ocular accidental contact irritation (
1). Virtually all published experience with snake venom ophthalmia relates to spitting cobras (family Elapidae), where both fangs and venom have evolved to specifically target the eye, yet there is no evidence that this results in systemic envenoming, the prime indication for antivenom therapy. In spitting cobra-induced ocular envenoming, antivenom has been used only topically, but the most current published expert advice does not recommend this treatment (
- Johnson R.
Ophthalmic exposure to crotalid venom.
J Emerg Med. 2009; 36: 37-38
- Warrell D.A.
Management of cobra spit ophthalmia.
in: Warrell D.A. Guidelines for the clinical management of snake bite in the South-East Asia Region. 49. World Health Organization, Regional Office for South-East Asia, New Delhi, India2005
3). With this background, the use of i.v. antivenom in the Johnson case is puzzling and difficult to support.
- Warrell D.A.
Clinical toxicology of snakebite in Asia.
in: Meier J. White J. Handbook of clinical toxicology of animal venoms and poisons. Informa HealthCare, Boca Raton, FL1995: 579-618
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- Ophthalmic exposure to crotalid venom.J Emerg Med. 2009; 36: 37-38
- Management of cobra spit ophthalmia.in: Warrell D.A. Guidelines for the clinical management of snake bite in the South-East Asia Region. 49. World Health Organization, Regional Office for South-East Asia, New Delhi, India2005
- Clinical toxicology of snakebite in Asia.in: Meier J. White J. Handbook of clinical toxicology of animal venoms and poisons. Informa HealthCare, Boca Raton, FL1995: 579-618
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- Efficacy, safety, and use of snake antivenoms in the United States.Ann Emerg Med. 2001; 37: 181-188
- Acute hypersensitivity reactions associated with administration of crotalidae polyvalent immune Fab antivenom.Ann Emerg Med. 2008; 51: 407-411
- Snake venom ophthalmia and blindness caused by the spitting cobra (Naja nigricollis) in Nigeria.Am J Trop Med Hyg. 1976; 25: 525-529
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Published online: December 14, 2009
© 2010 Published by Elsevier Inc. All rights reserved.
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- Ophthalmic Exposure to Crotalid VenomJournal of Emergency MedicineVol. 36Issue 1
- Response to Drs. Chu, White, and WeinsteinJournal of Emergency MedicineVol. 39Issue 5
- PreviewI appreciate Drs. Chu, White, and Weinstein's interest in my article, “Ophthalmic Exposure to Crotalid Venom” (1). Their comments are not only complete but also give a brief overview of the treatment of crotalid envenomation and describe what is thought to be the standard of care for crotalid ocular envenomations.