CASE REPORTS AND SMALL CASE SERIES

Report of Cases. Case 1. A 76-year- surgery. She also noted a burning sen- Corneal Melting old woman was referred for evalu- sation on installation of the diclo- Associated With Use ation of a in her left eye. fenac drops. She called the sur- of Topical Nonsteroidal She had undergone uncomplicated geon’s staff and was told to refrigerate Anti-inflammatory Drugs surgery 3 months previ- the drops to minimize the burning. ously. By history, 2 weeks prior to Examination disclosed visual acuity After Ocular Surgery her visit, she had developed a pain- to be 20/40 OD and 20/100 OS. A ful and was prescribed di- 2ϫ4-mm epithelial defect with 50% Nonsteroidal anti-inflammatory drugs clofenac sodium (Falcon Ophthal- tissue loss was noted in the inferior (NSAIDs) are used widely for sys- mics, Inc, Fort Worth, Tex), 4 times . There were rare cells in the temic control of acute or chronic pain daily, and artificial tears, as needed, anterior chamber and mild stromal and inflammation. Topical NSAIDs by a local ophthalmologist. On ex- infiltration. The ulcer appeared neu- have been used to effectively allevi- amination, visual acuity was 20/25 rotrophic. Diclofenac use was dis- ate ocular inflammation after cata- OD and 20/50 OS. A 4ϫ4-mm epi- continued and she was treated with ract removal and argon laser trabecu- thelial defect and corneal infiltrate ciprofloxacin hydrochloride drops loplasty and to treat cystoid macular associated with 80% tissue loss was every hour and bacitracin ointment edema. They have also been used for noted in the inferior temporal cor- every 2 hours to cover possible in- pain control after radial keratotomy nea. She had fibrin, 4+ cells, and a fection and promote epithelial heal- and excimer laser photorefractive in the anterior chamber. ing. The ulcer resolved over 2 weeks keratectomy. Additional indications Corneal cultures were performed, with mild residual stromal thinning include allergic and the and she was treated with topical for- and superficial scarring. The visual prevention of during cataract tified cefazolin (50 mg/mL) and to- acuity was 20/40 OS. Basal Schirmer surgery. Despite the increased topi- bramycin sulfate (15 mg/mL) every tear secretion test results were 12 cal use of this class of drug after ocu- hour alternating around the clock. mm OD and 8 mm OS, and the cor- lar surgery, corneal complications due Diclofenac therapy was discon- neal sensitivity measured by Cochet- to NSAID use have been uncom- tinued. Cultures were positive for Bonnet esthesiometry was normal (55 mon. Reported complications in- group B streptococcus. Despite treat- mm OD and 50 mm OS). clude superficial punctate ,1 ment, microbial keratitis was com- Case 3. A 77-year-old white subepithelial infiltrates,2 stromal in- plicated by corneal perforation and man was referred to the Cornea Ser- filtrates,3 immune rings,3 and persis- required cyanoacrylate tissue adhe- vice for evaluation of a peripheral tent epithelial defects.4 In August sive 8 days later. Six weeks after di- corneal perforation in his left eye. He 1999, severe complications associ- clofenac therapy was discontinued, had undergone uncomplicated cata- ated with topical NSAID use, includ- the corneal sensitivity measured by ract surgery 21⁄2 weeks prior to his ing corneal melting, were reported Cochet-Bonnet esthesiometry was visit and had normal follow-up ex- by members of the American Society normal (60 mm OD and 55 mm OS). amination results 1 week previ- of Cataract and Refractive Surgery The basal Schirmer tear secretion test ously. He had been taking topical to- (ASCRS) responding to a survey and result was 2 mm OD and 5 mm OS. bramycin-dexamethasone drops and distributed in letters from ASCRS to Her visual acuity was 20/400 OS, and diclofenac drops (Voltaren) 4 times members and nonmembers. We re- the tissue adhesive and bandage soft daily since surgery. On examina- port 5 cases of corneal melting asso- contact were in place. Re- tion visual acuity was hand mo- ciated with the use of topical NSAIDs peated basal Schirmer tear secre- tions in the left eye. Slitlamp exami- after ocular surgery referred to our tion test results 3 months later were nation revealed a perforated corneal service over a past 4-month period 10 mm OD and 15 mm OS. ulcer measuring 3.2ϫ2.0 mm near (Table). Four of the cases pro- Case 2. A 66-year-old woman the 11-o’clock position. The ante- gressed to corneal perforation. Three was referred for evaluation of a cor- rior chamber was flat. The Seidel test eyes required tissue glue, 2 required neal ulcer in her left eye. She had un- result was trace positive because a a patch graft, and 1 required a pen- dergone uncomplicated cataract sur- plug of was incarcerated in the etrating keratoplasty. Of the 2 eyes for gery 4 weeks previously, and was perforation. Corneal sensitivity was which cultures were obtained, 1 was taking apraclonidine hydrochloride severely diminished on the left eye. positive for bacteria. We conclude that and diclofenac (Voltaren; Ciba Vi- It measured 1 mm in the left eye by topical NSAID use after ocular sur- sion Ophthalmic, Atlanta, Ga) 4 times Cochet-Bonnet esthesiometer com- gery in healthy patients should be daily. She had a history of foreign pared with 60 mm in the right eye. used with caution due to the poten- body sensation, red eye, and photo- The patient was treated with tissue tial of corneal melting. phobia beginning a few days after the adhesive, a bandage soft ,

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 Summary of Cases*

Patient No.

12 3 4 5 Age, y 76 66 77 71 79 Sex Female Female Male Male Male Eye Left Left Left Left Left Date of surgery 3/6/1999 6/16/1999 7/22/1999 4/29/1999 7/16/1999 Date started 5/31/1999 6/16/1999 7/22/1999 4/30/1999 8/6/1999 diclofenac therapy Days of diclofenac therapy 10 29 18 11 17 NSAIDs used† Diclofenac QID Diclofenac QID Diclofenac QID Diclofenac QID Diclofenac QID (generic) (brand name) (brand name) (generic) (generic) Other topical medications Tears Apraclonidine Tobramycin- 1% Prednisolone Latanoprost, 0.2% used hydrochloride dexamethasone acetate brimonidine tartrate, dorzolamide hydrochloride, timolol maleate Medical history Angina, Hypothyroid Arrhythmia Hypertension, Hypothyroid hiatal hernia, gastritis, hypertension, coronary artery hyperlipidemia disease, type 2 diabetes Schirmer test results, OD/OS 2 mm/5 mm 12 mm/8 mm 5 mm/9 mm 12 mm/30 mm 9 mm/8 mm Pain None None None Mild Mild Esthesiometry, OD/OS Before surgery NA NA 60 mm/1 mm NA 50 mm/35 mm After surgery 60 mm/55 mm 55 mm/50 mm 60 mm/35 mm 60 mm/55 mm 60 mm/45 mm Iris color Gray-blue Blue Hazel Brownish green Brown Location on cornea Inferior-temporal Inferior Superior-nasal Superior Inferior-central Initial % tissue loss 80 50 100 90 99 Progression to perforation Yes No Yes Yes Yes Culture Group B Not performed Not performed No growth Not performed streptococcus Treatment Tissue adhesive Antibiotics, Tissue adhesive, Patch graft Tissue adhesive, lubrication patch graft penetrating keratoplasty

*QID indicates 4 times daily; NSAIDs, nonsteroidal anti-inflammatory drugs; and NA, not applicable. †Generic diclofenac, Falcon Ophthalmics, Inc, Fort Worth, Tex; and brand-name diclofenac (Voltaren), Ciba Vision Ophthalmic, Atlanta, Ga.

topical ofloxacin, and intravenous discomfort and a 1-day history of de- and 30 mm OS, and the corneal sen- cefazolin (1 g every 8 hours). One creased vision in his left eye. Exami- sitivity measured by Cochet-Bonnet week later, his vision improved to nation showed a 4.5ϫ12.0-mm epi- esthesiometry was normal (60 finger counting. The tissue adhe- thelial defect and diffuse infiltrate in mm OD and 55 mm OS). sive was in place, and the anterior the area of his cataract wound supe- Case 5. A 79-year-old white man chamber was deep. However, 2 riorly at the limbus with 90% tissue was referred to the Cornea Service for weeks after the placement of tissue loss. His visual acuity was 20/400. evaluation of a descemetocele in the adhesive, he underwent a corneal The anterior chamber was deep with left eye. He had undergone argon la- patch graft for a recurrent leak and fibrin and 4+ cells (Figure 1, A). ser trabeculoplasty in his left eye 5 a flat anterior chamber. Two weeks Cultures were performed, and he was weeks previously for chronic open- after the corneal patch graft, basal admitted to the hospital and given angle . His visual acuities Schirmer tear secretion test results fortified tobramycin (15 mg/mL) and were 20/30 OD and 20/40 OS. Post- were 5 mm OD and 9 mm OS. The cefazolin (50 mg/mL) every hour al- operatively he was instructed to use corneal sensitivities measured by Co- ternating around the clock, and aque- 1% prednisolone acetate 4 times daily chet-Bonnet esthesiometry were 60 ous suppressants. The next day he for 3 days. Results of a follow-up ex- mm OD and 35 mm OS. progressed to corneal perforation amination 1 week after argon laser Case 4. A 71-year-old white man with iris prolapse. A corneoscleral trabeculoplasty were unremark- was referred for evaluation of sclero- patch graft was performed. Cultures able. Three weeks after laser sur- keratitis in his left eye. He had un- were negative and no organisms were gery he returned with a red eye and dergone cataract surgery 10 days pre- identified in the corneal button (Fig- was noted to have anterior chamber viously and was receiving diclofenac ure 1, B). Three months after patch inflammation. Diclofenac (Falcon (Falcon Ophthalmics, Inc) 4 times penetrating keratoplasty, his visual Ophthalmics, Inc), 4 times daily, was daily, and 1% prednisolone acetate 6 acuity was 20/200 OS (Figure 1, C). added to his regimen of glaucoma times per day since surgery. He had At that time basal Schirmer tear se- medications (brimonidine tartrate, a 3-day history of mild hyperemia and cretion test results were 12 mm OD dorzolamide hydrochloride, timo-

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 Figure 1. Case 4. A, Slitlamp examination shows a 4.5ϫ12.0-mm defect A superiorly at the limbus with diffuse infiltrate and 90% tissue loss. B, Arrow in photomicrographs denotes loss of epithelium, Bowman layer, and anterior stroma in area of bland ulceration (hematoxylin-eosin, original magnification ϫ25). Inset shows paucity of inflammatory cells in ulcer bed (hematoxylin-eosin, original magnification ϫ100). C, Three months after patch penetrating keratoplasty, there is a clear graft and deep anterior chamber.

A

B

B

C

Figure 2. Case 5. A, Photograph 5 weeks after argon laser trabeculoplasty shows a 2.5ϫ2.0-mm epithelial defect with 99% tissue loss and descemetocele inferocentrally. B, The descemetocele was Seidel positive.

lol maleate, and latanoprost). Five sive had dislodged. Both the epithe- ketorolac and diclofenac instilled weeks after argon laser trabeculo- lial defect and the descemetocele had over 20 minutes have been shown plasty, the patient presented with hy- enlarged. The ulceration was weakly to significantly decrease normal cor- peremia, pain, , and de- Seidel positive (Figure 2, B). He un- neal sensation.5,6 Although de- creased vision in the left eye. His derwent therapeutic penetrating kera- creased corneal sensation was con- visual acuity in the left eye was fin- toplasty the next day. Two weeks firmed in only 2 of our patients at ger counting. A 2.5ϫ2.0-mm epi- later basal Schirmer tear secretion test time of presentation and was not thelial defect with 99% tissue loss and results were 9 mm OD and 8 mm OS, tested in the other 3, hypesthesia a descemetocele were noted infero- and corneal sensitivities measured by may be why our patients reported centrally. There was fibrin and 4+ Cochet-Bonnet esthesiometry were little pain and delayed seeking medi- flare in the anterior chamber. The ul- 60 mm OD and 45 mm OS. cal attention. All our patients used cer appeared sterile (Figure 2, A). diclofenac. Seitz et al7 reported that Corneal sensitivities measured by Co- Comment. Diclofenac is an anti- repeated instillation of diclofenac chet-Bonnet esthesiometry were 50 inflammatory drug that inhibits had more pronounced and longer mm OD and 35 mm OS. Basal cyclo-oxygenase activity and de- lasting effects on corneal sensitiv- Schirmer tear secretion test results creases the synthesis of prostaglan- ity than ketorolac. This finding may were 5 mm OD and 15 mm OS. Tis- dins. Prostaglandins contribute to have predisposed our patients to the sue adhesive and a bandage soft con- postoperative inflammation and severe complication of corneal melt- tact lens were applied over the melt. pain. Topical diclofenac has also ing. In all our patients corneal sen- One week later the contact lens had been used to minimize postsurgi- sitivity was in the normal range af- torn and moved and the tissue adhe- cal pain. Four drops of the NSAIDs ter the NSAIDs were discontinued.

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 Topical NSAIDs are used fre- a preponderance of cases occurred quently. NSAIDs, especially diclo- with generic diclofenac. A Case of Suspected fenac, are used for the treatment of Patients receiving topical diclo- Alphagan-Induced cystoid for up to 3 fenac after ocular surgery, especially Psychosis months. Topical indomethacin has cataract surgery, should be moni- been used for inflamed pterygia tored closely. The frequency of ad- Brimonidine tartrate is an ␣-agonist and pinguecula.8 Ketorolac (Acu- ministration and duration of treat- that currently is used to treat glau- lar; Allergan, Irvine, Calif) is effec- ment should be minimized, and as- coma by decreasing aqueous produc- tive in relieving ocular itching needed use should be discouraged. A tion and by possibly increasing uveal caused by seasonal allergic con- history of ocular surface disease as- scleral outflow. It is a lipid-soluble junctivitis. Surprisingly, despite sociated with an increased risk of cor- agent that can cross the blood-brain the frequent use of topical NSAIDs, neal melting is a relative contraindi- barrier and can have, in theory, some there have been few reports of cor- cation for topical NSAID use, but psychoactive properties. It has been neal complications. patients without any such history may reported that dizziness and depres- In addition to reducing pain, also develop severe complications. sion could occur owing to the afore- NSAIDs have been shown to affect mentioned properties.1 I report a case corneal epithelial healing. Topical Julianne C. Lin, MD involving acute psychosis and de- diclofenac retards epithelial heal- Christopher J. Rapuano, MD lirium in a patient receiving bri- ing to a significantly greater extent Peter R. Laibson, MD monidine (Alphagan; Allergan Inc, than dexamethasone.9 Topical di- Ralph C. Eagle, Jr, MD Irvine, Calif), which resolved imme- clofenac has been associated with Elisabeth J. Cohen, MD diately after cessation of the agent. persistent epithelial defects in pa- Philadelphia, Pa tients after undergoing penetrating Report of a Case. A 68-year-old man 4 keratoplasty. In addition to the pa- The authors have no proprietary in- with mild open-angle glaucoma re- tients described in this report, we terest in the development or market- ceived brimonidine after ␤-block- have treated 2 other patients who de- ing of the drugs mentioned. The au- ers failed to lower his intraocular veloped acute corneal surface break- thors have no financial interest in any pressure. The patient received bri- down when given topical NSAIDs for of the products mentioned herein. monidine for about 3 months be- cystoid macular edema. One had se- Corresponding author: Elisa- fore the family began to notice vere ocular surface disease due to dry beth Cohen, MD, Cornea Service, Wills dramatic behavioral changes. In ret- eyes associated with graft-vs-host Eye Hospital, 900 Walnut St, Phila- rospect, the patient’s wife reported disease and the other had neuro- delphia, PA 19107 (e-mail: ejcohen that he began having subtle lapses trophic keratitis following a cere- @hslc.org). in memory almost on initiation of bral vascular accident. The first pa- treatment. Following this, the pa- tient was treated with topical 1. Gills JP. Voltaren associated with medication tient started complaining of being ketorolac and the second with di- keratitis [letter]. J Cataract Refract Surg. 1994; constantly tired and began exhibit- 20:110. clofenac. 2. Sher NA, Krueger RR, Teal P, Jans RG, Ed- ing signs of depression. Shortly Three of our patients had cor- mison D. Role of topical corticosteroids and thereafter, he began a downward neal melts that were located inferi- nonsteroidal antiinflammatory drugs in the eti- course during which time he be- ology of stromal infiltrates after excimer pho- orly consistent with neurotrophic ul- torefractive keratectomy. J Refract Corneal Surg. came more and more delusional. cers. These patients had a normal lid 1994;10:587-588. Anxiety overcame him, and he wor- 3. Probst LE V, Machat JJ. Corneal subepithelial in- position and lid closure and no evi- filtrates following photorefractive keratectomy ried about myriad irrational con- dence of exposure. The melt in the [letter]. J Cataract Refract Surg. 1996;22:281. cerns, ranging from imminent blind- other 2 patients was located supe- 4. Shimazaki J, Saito H, Yang HY, Toda I, Fu- ness, death, financial ruin, and even jishima H, Tsubota K. Persistent epithelial riorly at the limbus near the phaco- defect following penetrating keratoplasty: an ad- concerns about people spying on emulsification entrance wound. The verse effect of diclofenac eyedrops. Cornea. 1995; him. His wife became concerned that corneal and scleral melting in our pa- 14:623-627. the medication may have been con- 5. Sun R, Gimbel HV. Effects of topical ketorolac tients resembled that seen in pa- and diclofenac on normal corneal sensation. J Re- tributing to his behavioral change tients who have an underlying col- fract Surg. 1997;13:158-161. and read the package insert.1 When 6. Szerenyi K, Sorken K, Garbus JJ, Lee ML, lagen vascular disease. None of our McDonnell PJ. Decrease in normal human cor- there was no mention of this type of patients was known to have colla- neal sensitivity with topical diclofenac sodium. behavioral change, they sought a sec- gen vascular disease. One patient had Am J Ophthalmol. 1994;118:312-315. ond opinion and came to my office. 7. Seitz B, Sorken K, LaBree LD, Garbus JJ, borderline diabetes. McDonnell PJ. Corneal sensitivity and burning On examination, the patient was un- In our small series of 5 cases, sensation, comparing topical ketorolac and diclo- kempt and quite confused, only rec- both generic and brand-name di- fenac. Arch Ophthalmol. 1996;114:921-922. ognizing his name. His visual acu- 8. Frucht-Perry J, Solomon A, Siganos AS, Shvart- clofenac were used. Two patients zenberg T, Richard C, Trinquand C. Treatment ity was 20/20 OU, and intraocular used brand-name Voltaren and the of inflamed and pinguecula with topi- pressure was 16 mm Hg OD and 14 cal indomethacin 0.1% solution. Cornea. 1997; other 3 patients used generic diclo- 16:42-47. mm Hg OS. The cup-disc ratio was fenac (Falcon Ophthalmics, ge- 9. Tomas-Barberan S, Fagerholm P. Influence of 0.65 OU. When the son described neric company of Alcon). This dis- topical treatment on epithelial wound healing and the behavioral changes in his fa- pain in the early postoperative period follow- tribution contrasts with a recent ing photorefractive keratectomy. Acta Ophthal- ther, I instructed the patient to dis- letter from the ASCRS indicating that mol Scand. 1999;77:135-138. continue brimonidine and to start

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 0.005% latanaprost. After leaving the clinic, the son saw that the father had a loaded gun, stating that the po- lice were out to get him. With this dis- covery, the son took his father to a psychiatric hospital. At the hospital, the admitting psychiatrist tele- phoned me and stated that the pa- tient told him that I had instructed him to discontinue latanaprost and initiate brimonidine therapy. When I told the psychiatrist that it was the other way around, the patient told him that I was lying, trying to withhold care, and that he would go blind without the brimonidine. The psychiatrist indeed stopped bri- monidine administration and gave the patient an anxiolytic. Within 48 hours Figure 1. Silicone vacuoles located in an area of dense vitreous fibrovascular proliferation with chronic of discontinuing brimonidine treat- inflammatory cells and occasional eosinophils (hematoxylin-eosin, original magnification ϫ40). ment, the patient returned to base- line, and his paranoid ideation also the and the migration of ity initially improved to 20/40 OD, dissipated. silicone vacuoles into various ocu- the patient was seen 1 month later for lar tissues.1,2 However, to our knowl- increased . Findings from fun- Comment. I report a case of bri- edge, only 1 previous article de- duscopic examination revealed 2 pe- monidine causing acute psychosis, scribed an intraocular giant cell ripheral retinal tears at the 10- and paranoid delusions, and auditory reaction,3 and none have described 12-o’clock positions, which were hallucinations in a patient without a granulomatous reaction to intra- treated by laser photocoagulation. a notable medical or psychiatric ocular silicone. We report a case in Three months later, a vitrectomy was history. The psychiatric symptoms which an extensive granulomatous performed for progression of vitre- reversed within 48 hours on cessa- reaction to intraocular silicone oil itis and worsening of visual acuity to tion of brimonidine. On contact with was associated with enhanced se- light perception only. Results of in- Allergan Inc, no known cases of psy- rum IgG binding to silicones. traoperative fundus examination re- chosis were ever reported. Thus, vealed spreading of the toxoplasma when prescribing brimonidine, care- Report of a Case. A 50-year-old man lesion into the macula. Six weeks ful monitoring of patient behavior with a history of cirrhosis second- later, the patient experienced sud- is necessary, and the patient’s fam- ary to alcoholic liver disease but an den loss of vision secondary to an ex- ily should be made aware of poten- otherwise unremarkable medical and tensive . He un- tial behavioral changes that can be ophthalmic history was referred for derwent a repeated vitrectomy with associated with the drug. In addi- the treatment of floaters and de- intravitreal injection of liquid sili- tion, one may wonder whether bri- creased vision in his right eye. The cone (1000 centistoke, medical monidine should be considered a patient’s visual acuity on initial grade) but was subsequently lost to relative contraindication in any pa- examination was 20/200 OD, and follow-up. He was seen 3 months tient with a history of depression. findings from funduscopic exami- later with a dense cataract, pupillary nation revealed a small, yellow, para- block glaucoma, and corneal perfo- David D. Kim, MD foveal retinal lesion with a satellite ration. The patient refused any fur- Green Bay, Wis lesion adjacent to the . In ther therapeutic intervention and addition, leukocytic sheathing of the underwent an evisceration. 1. Alphagan [package insert]. Irvine, Calif: Aller- gan Inc; 1999. vessels was noted along the supero- On gross examination, the temporal arcade with prominent vit- contents were firm and rust reous cell and flare. Serum Toxo- colored. Findings from micro- plasma gondii IgG titers were positive scopic examination revealed frag- Granulomatous Local at a level of 1:32, and the patient ments of disorganized atrophic Cell Reaction to started receiving triple drug therapy . There was massive fibrovas- Intravitreal Silicone (sulfadiazine, clindamycin, and leu- cular proliferation in the vitreous covorin calcium) along with oral cavity and subretinal space, which Intense local cell reactions to sili- prednisone. contained a moderate chronic in- cone implants, gels, and oils have During the course of his treat- flammatory infiltrate and occa- been described in various human ment, a stainless steel transjugular in- sional eosinophils. Within this mass tissues. Several articles have de- trahepatic portosystemic shunt was were numerous large and small scribed histopathologically reac- implanted for ascites and worsening vacuoles consistent with silicone tions to long-standing silicone oil in liver failure. Although his visual acu- (Figure 1), many of which were

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 sis secondary to alcoholic liver disease were predisposing factors for the granulomatous reaction to sili- cone and elevated levels of silicone- specific IgG is speculative. There- fore, although intraocular silicone oil is usually well tolerated, its use in individuals with immunological risk factors may require some caution.

Saad Shaikh, MD Peter R. Egbert, MD Randall S. Goldblum, MD Mark R. Wieland, MD Stanford, Calif

Corresponding author: Saad Shaikh, Figure 2. Several multinucleated giant cells around silicone vacuoles (hematoxylin-eosin, original MD, Department of , magnification ϫ200). Stanford, Stanford University School of Medicine, CA 94305 (e-mail: saads surrounded by epithelioid histio- travitreal injection of liquid sili- @earthlink.net). cytes and foreign body giant cells cone is an effective therapy for com- Reprints: Peter R. Egbert, MD, (Figure 2). Giant cells were not plex retinal detachments. A recent Department of Ophthalmology, Stan- found elsewhere in the eye. In ar- prospective study revealed that the ford University School of Medicine, eas remote from the silicone vacu- complication rate and frequency of Stanford, CA 94305.

oles, there was necrosis and a soli- enhanced serum IgG binding to 1. Eckardt C, Nicolai U, Czank M, Schmidt D. Ocu- tary granuloma with a necrotic intraocular and extraocular silicone lar tissue after intravitreous silicone oil injec- center. Rare T gondii cysts were devices, even after extended peri- tion: histologic and electron microscopy stud- ies [in German]. Ophthalmologe. 1993;90:250- present but were not associated with ods of exposure, was a rare event 257. either the foreign body giant cells or and should not alter their clinical 2. Knorr HL, Seltsam A, Holbach L, Naumann GO. the granuloma. The serum level of use.5 The authors of that study Intraocular silicone oil tamponade: a clinico- pathologic study of 36 enucleated eyes. Ophthal- IgG binding to silicone, as deter- noted that the only patient who mologe. 1996;93:130-138. mined by a microplate modifica- developed significantly elevated 3. Parmley VC, Barishak YR, Howes EL Jr, Craw- ford JB. Foreign-body giant cell reaction to liq- tion of a previously described en- levels of silicone-specific IgG and uid silicone. Am J Ophthalmol. 1986;101:680- zyme-linked immunosorbent assay also had complications to silicone 683. technique,4 was 15.8±0.58 arbi- devices used in retinal surgery may 4. Goldblum RM, Pelley RP, O’Donell AA, Pyron D, Heggers JP. Antibodies to silicone elastom- trary units, 4 SDs above the mean for have had predisposing rheumato- ers and reactions to ventriculoperitoneal shunts. adult sera in the reference range logic risk factors.5 Additionally, Lancet. 1992;340:510-513. (3.2±2.1 arbitrary units). aberrant immunological function, 5. Shaikh S, Morse LS, Goldblum RM, Benner JD, Burnett H, Caspar J. The effect of silicone including elevated IgG and IgA ocular surgical devices on serum IgG binding Comment. Enhanced binding of se- production, has been correlated to silicones. Am J Ophthalmol. 1998;126:798- 804. rum IgG to silicones has been ob- with decreased suppressor T-cell 6. Rong PB, Kalsi J, Hodgson HJ. Hyperglobulin- served in patients who develop in- activity in patients with cirrhosis of aemia in chronic liver disease: relationships be- tense local inflammatory reactions the liver.6 Whether such abnor- tween in vitro immunoglobulin synthesis, short lived suppressor cell activity and serum immu- to implanted silicone materials such malities of immunoregulation dy- noglobulin levels. Clin Exp Immunol. 1984;55: as ventriculoperitoneal shunts.4 In- namics in our patient with cirrho- 546-552.

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