Copyright 2000 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2000
Intense local cell reactions to silicone implants, gels, and oils have been described in various human tissues. Several articles have described histopathologically reactions to long-standing silicone oil in the human eye and the migration of silicone vacuoles into various ocular tissues.1,2 However, to our knowledge, only 1 previous article described an intraocular giant cell reaction,3 and none have described a granulomatous reaction to intraocular silicone. We report a case in which an extensive granulomatous reaction to intraocular silicone oil was associated with enhanced serum IgG binding to silicones.
A 50-year-old man with a history of cirrhosis secondary to alcoholic liver disease but an otherwise unremarkable medical and ophthalmic history was referred for the treatment of floaters and decreased vision in his right eye. The patient's visual acuity on initial examination was 20/200 OD, and findings from funduscopic examination revealed a small, yellow, parafoveal retinal lesion with a satellite lesion adjacent to the optic nerve. In addition, leukocytic sheathing of the vessels was noted along the superotemporal arcade with prominent vitreous cell and flare. Serum Toxoplasma gondii IgG titers were positive at a level of 1:32, and the patient started receiving triple drug therapy (sulfadiazine, clindamycin, and leucovorin calcium) along with oral prednisone.
During the course of his treatment, a stainless steel transjugular intrahepatic portosystemic shunt was implanted for ascites and worsening liver failure. Although his visual acuity initially improved to 20/40 OD, the patient was seen 1 month later for increased floaters. Findings from funduscopic examination revealed 2 peripheral retinal tears at the 10- and 12-o'clock positions, which were treated by laser photocoagulation. Three months later, a vitrectomy was performed for progression of vitreitis and worsening of visual acuity to light perception only. Results of intraoperative fundus examination revealed spreading of the toxoplasma lesion into the macula. Six weeks later, the patient experienced sudden loss of vision secondary to an extensive retinal detachment. He underwent a repeated vitrectomy with intravitreal injection of liquid silicone (1000 centistoke, medical grade) but was subsequently lost to follow-up. He was seen 3 months later with a dense cataract, pupillary block glaucoma, and corneal perforation. The patient refused any further therapeutic intervention and underwent an evisceration.
On gross examination, the globe contents were firm and rust colored. Findings from microscopic examination revealed fragments of disorganized atrophic retina. There was massive fibrovascular proliferation in the vitreous cavity and subretinal space, which contained a moderate chronic inflammatory infiltrate and occasional eosinophils. Within this mass were numerous large and small vacuoles consistent with silicone (Figure 1), many of which were surrounded by epithelioid histiocytes and foreign body giant cells (Figure 2). Giant cells were not found elsewhere in the eye. In areas remote from the silicone vacuoles, there was necrosis and a solitary granuloma with a necrotic center. Rare T gondii cysts were present but were not associated with either the foreign body giant cells or the granuloma. The serum level of IgG binding to silicone, as determined by a microplate modification of a previously described enzyme-linked immunosorbent assay technique,4 was 15.8 + 0.58 arbitrary units, 4 SDs above the mean for adult sera in the reference range (3.2 + 2.1 arbitrary units).
Silicone vacuoles located in an area of dense vitreous fibrovascular proliferation with chronic inflammatory cells and occasional eosinophils (hematoxylin-eosin, original magnification ×40).
Several multinucleated giant cells around silicone vacuoles (hematoxylin-eosin, original magnification ×200).
Enhanced binding of serum IgG to silicones has been observed in patients who develop intense local inflammatory reactions to implanted silicone materials such as ventriculoperitoneal shunts.4 Intravitreal injection of liquid silicone is an effective therapy for complex retinal detachments. A recent prospective study revealed that the complication rate and frequency of enhanced serum IgG binding to intraocular and extraocular silicone devices, even after extended periods of exposure, was a rare event and should not alter their clinical use.5 The authors of that study noted that the only patient who developed significantly elevated levels of silicone-specific IgG and also had complications to silicone devices used in retinal surgery may have had predisposing rheumatologic risk factors.5 Additionally, aberrant immunological function, including elevated IgG and IgA production, has been correlated with decreased suppressor T-cell activity in patients with cirrhosis of the liver.6 Whether such abnormalities of immunoregulation dynamics in our patient with cirrhosis secondary to alcoholic liver disease were predisposing factors for the granulomatous reaction to silicone and elevated levels of silicone-specific IgG is speculative. Therefore, although intraocular silicone oil is usually well tolerated, its use in individuals with immunological risk factors may require some caution.
Corresponding author: Saad Shaikh, MD, Department of Ophthalmology, Stanford, Stanford University School of Medicine, CA 94305 (e-mail: email@example.com). Reprints: Peter R. Egbert, MD, Department of Ophthalmology, Stanford University School of Medicine, Stanford, CA 94305.
Shaikh S, Egbert PR, Goldblum RS, Wieland MR. Granulomatous Local Cell Reaction to Intravitreal Silicone. Arch Ophthalmol. 2000;118(8):1129-1132. doi: