Foreign-Body Giant-Cell Reaction to the Hydroxyapatite Orbital Implant
Porous, coral-derived hydroxyapatite, a bone graft substitute, has recently
been used as an orbital implant after enucleation. The implant is enveloped with a scleral shell to allow attachment of the extraocular muscles and greater movement in the orbit.1,2 After implantation, the hydroxyapatite is infiltrated with fibrovascular tissue, which
minimizes extrusion and infection.1,2 This technique is gaining popularity because of the improved appearance of the patient and increased mobility of the implant.2,3 To our knowledge, only one report has been published about the histopathologic characteristics of the hydroxyapatite after implantation in a patient's orbit; it described mild histologic reaction to the hydroxyapatite.3 We observed a moderately intense foreign-body giant-cell reaction in an orbital hydroxyapatite implant
Fig 1.—Top, Porous, coral-derived spherical hydroxyapatite orbital implant and the opened scierai shell (S). Fibrous tissue (arrowheads) invades the spherical implant at an area corresponding to the window
in the scierai shell. Bottom, The cut surface of the implant shows fibrous tissue ingrowth (arrowheads) into the pores of the hydroxyapa¬ tite implant.
that
was
removed
implantation.
19
days
after
Report of a Case. \p=m-\A9-year-old boy underwent enucleation of his right painful, blind eye. A 20-mm, hydroxyapatite spherical implant was wrapped around with preserved sclera and placed into the orbit. The postoperative course was uneventful. How¬ ever, histologie examination of the enucle¬ ated eye revealed an unexpected medulloepithelioma of the ciliary body with exten¬ sion into the optic nerve and sclera. The orbital implant was removed without any special surgical difficulty, and multiple or-
Fig 2. Photomicrograph of the decalcified orbital implant removed 19 days after implantation. Top, The advancing edge of the invading fibrovascular tissue is composed of a loose connective tissue matrix (L) and is denser superficially (D). An implant devoid of invading fibrous tissue is seen on the right side. Bottom, Intense giant-cell inflammatory reaction (arrowheads) lines the hydroxyapatite (H) (he¬ matoxylin-eosin, original magnification 24 [top], 59 [bottom]). —
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bital biopsy specimens removed at surgery did not reveal tumor extension into the orbit. Examination of the implant showed in¬ growth of fibrous tissue 6 mm into the porous hydroxyapatite through an anterior opening in the scierai shell (Fig 1). Follow¬ ing décalcification, histologie examination showed exuberant fibrovascular tissue in¬ vading the pores of the implant. The ad¬ vancing edge of this tissue consisted of loose connective tissue with edematous ma¬ trix, while the fibrovascular tissue at the surface of the implant was dense and ar¬ ranged in a lamellar pattern. A diffuse, giant-cell inflammatory reaction was ob¬ served in the fibrovascular ingrowth with the foreign-body giant cells lining the im¬ plant material (Fig 2). Loose granulation tissue was seen at the internal and external surfaces of the scierai shell. A foreign-body giant-cell reaction with chronic inflamma¬ tory infiltrate surrounded the 5-0 polyglactin 910 (Vicryl) suture material in the scier¬ ai shell and was not related to the giant-cell reaction seen within the hydroxyapatite
implant.
Comment. —This is the second histo¬
pathologic report, to our knowledge, of a hydroxyapatite implant that was re¬ moved from a patient's orbit. It dem¬ onstrates a fibrovascular ingrowth mainly at the site of the scierai win¬ dow, as described previously.3 This ingrowth, which penetrated the hy¬ droxyapatite to a depth of 6 mm within 19 days after implantation, was associ¬ ated with a giant-cell reaction. Our finding of an exuberant foreign-body giant-cell inflammatory reaction to the hydroxyapatite material in a child con¬ trasts with the previous report, which showed only rare giant cells in a simi¬ lar implant in a 69-year-old patient.3 However, while it has been suggested that inflammatory response might be more exuberant in children, the influ¬ ence of age on the severity of the inflammatory response is not definite. In studies in which hydroxyapatite was used as a bone graft substitute implanted in direct contact with bone, the response ranged from lack of in¬ flammatory response to an abundant giant-cell reaction.4 Since the implant is made from chemically processed nat¬ ural
This study was supported in part by core grant Y01792 from the National Eye Institute, Bethes¬ da, Md; a grant from the Lions of Illinois Founda¬ tion, Maywood; an unrestricted research grant from Research to Prevent Blindness Ine, New York, NY; grants from the Wolfson's Foundation, the American Israeli Ophthalmological Society, and the International Medical Scholars Program, Washington, DC; and gifts from the Clifford Saw¬ yer Estate and the McGraw Foundation, Arlington Heights, 111. Reprint requests to the Georgiana Dvorak Theo¬ bald Ophthalmic Pathology Laboratory, Depart¬ ment of Ophthalmology and Visual Sciences, Lions of Illinois Eye Research Institute, UIC Eye Cen¬ ter, University of Illinois at Chicago College of Medicine, 1855 W Taylor St, Chicago, IL 60612 (Dr
Tso). 1. Perry AC. Advances in enucleation. Ophthalmol Clin North Am. 1991;4:173-182. 2. Dutton JJ. Coralline hydroxyapatite as an ocular implant. Ophthalmology. 1991;98:370-377. 3. Shields CL, Shields JA, Eagle RC Jr, De Potter P. Histopathologic evidence of fibrovascular ingrowth four weeks after placement of the hydroxyapatite orbital implant. Am J Ophthalmol.
1991;111:363-366. 4. Misiek DJ, Kent JN, Carr RF. Soft-tissue
hydroxyapatite particles of different shapes. J Oral Maxillofac Surg. 1984;42:150-160.
responses to
Late Infectious Endophthalmitis From Exposed Glaucoma Setons
Seton implantation has become increasingly useful in the surgical management of glaucoma.1 Complications of this surgery include those
common
to any filtration surgery, such as cata-
ract, choroidal effusion or hemorrhage,
early or late endophthalmitis, retinal detachment, or Tenon cyst and others unique to the presence of an implanted foreign body, such as extrusion or late erosion through the overlying sclera and/or conjunctiva and Tenon's fascia.1
capable
of
single case of early postoperative endophthalmitis has also been reported.2 We treated two patients for late endophthalmitis following external erosion of the implant through the conjunctiva. To our knowledge, this complication has not been previously reported.
Report of Cases. \p=m-\Case1.\p=m-\A 65-year\x=req-\ woman with neovascular glaucoma following an ischemic central retinal vein occlusion underwent implantation of a shorttailed Krupin-Denver valve beneath a partial-thickness scleral flap in her right eye in 1984. Preoperative visual acuity was hand motions. During the following 2 years, the eye lost all light perception despite adequate control of intraocular pressure. In 1987, the posterior 2 mm of the implant eroded through the conjunctiva and lay exposed on the surface of the sclera. The patient refused corrective surgery and her condition was maintained with topical anti¬ old
biotic treatment. In April 1990 she presented with a 3-day history of aching in the right eye. Conjunc¬ tival injection, purulent discharge, and hypopyon were present (Figs 1 and 2). A diagnosis of acute bacterial endophthalmitis was made. To prevent the sequelae of un¬ treated bacterial endophthalmitis, such as corneal or scierai rupture, orbital cellulitis, and loss of the eye, the decision was made to perform surgery despite the fact that
light perception was not present. During a pars plana vitrectomy and anterior chamber paracentesis, copious amounts of purulent material were removed and cultured. The infection was successfully treated with in¬
travitreal gentamicin sulfate, vancomycin hydrochloride, and dexamethasone sodium phosphate; fortified topical gentamicin sul¬ fate and vancomycin hydrochloride; and oral ciprofloxicin hydrochloride. Laboratory culture subsequently yielded ß-hemolytic streptococci of group F.
Fig 1.—Exposed posterior aspect of a short-tailed Krupin-Denver valve with surrounding purulent discharge (large arrow). The limbus has been marked (small arrows).
coral, it is conceivable that compo¬
nents
A
inciting inflammation
present in certain types of coral may
remain after processing, and hence the variable inflammatory response. The long-term effects of such a gi¬ ant-cell reaction as well as its influence on ossification of the implant and even¬ tual effect on appearance remain to be
determined.
Mordechai Rosner, MD Deepak P. Edward, MD Mark O. M. Tso, MD Chicago, Ill
Downloaded From: http://archopht.jamanetwork.com/ by a Monash University Library User on 06/19/2015
Porous, coral-derived hydroxyapatite, a bone graft substitute, has recently
been used as an orbital implant after enucleation. The implant is enveloped with a scleral shell to allow attachment of the extraocular muscles and greater movement in the orbit.1,2 After implantation, the hydroxyapatite is infiltrated with fibrovascular tissue, which
minimizes extrusion and infection.1,2 This technique is gaining popularity because of the improved appearance of the patient and increased mobility of the implant.2,3 To our knowledge, only one report has been published about the histopathologic characteristics of the hydroxyapatite after implantation in a patient's orbit; it described mild histologic reaction to the hydroxyapatite.3 We observed a moderately intense foreign-body giant-cell reaction in an orbital hydroxyapatite implant
Fig 1.—Top, Porous, coral-derived spherical hydroxyapatite orbital implant and the opened scierai shell (S). Fibrous tissue (arrowheads) invades the spherical implant at an area corresponding to the window
in the scierai shell. Bottom, The cut surface of the implant shows fibrous tissue ingrowth (arrowheads) into the pores of the hydroxyapa¬ tite implant.
that
was
removed
implantation.
19
days
after
Report of a Case. \p=m-\A9-year-old boy underwent enucleation of his right painful, blind eye. A 20-mm, hydroxyapatite spherical implant was wrapped around with preserved sclera and placed into the orbit. The postoperative course was uneventful. How¬ ever, histologie examination of the enucle¬ ated eye revealed an unexpected medulloepithelioma of the ciliary body with exten¬ sion into the optic nerve and sclera. The orbital implant was removed without any special surgical difficulty, and multiple or-
Fig 2. Photomicrograph of the decalcified orbital implant removed 19 days after implantation. Top, The advancing edge of the invading fibrovascular tissue is composed of a loose connective tissue matrix (L) and is denser superficially (D). An implant devoid of invading fibrous tissue is seen on the right side. Bottom, Intense giant-cell inflammatory reaction (arrowheads) lines the hydroxyapatite (H) (he¬ matoxylin-eosin, original magnification 24 [top], 59 [bottom]). —
Downloaded From: http://archopht.jamanetwork.com/ by a Monash University Library User on 06/19/2015
bital biopsy specimens removed at surgery did not reveal tumor extension into the orbit. Examination of the implant showed in¬ growth of fibrous tissue 6 mm into the porous hydroxyapatite through an anterior opening in the scierai shell (Fig 1). Follow¬ ing décalcification, histologie examination showed exuberant fibrovascular tissue in¬ vading the pores of the implant. The ad¬ vancing edge of this tissue consisted of loose connective tissue with edematous ma¬ trix, while the fibrovascular tissue at the surface of the implant was dense and ar¬ ranged in a lamellar pattern. A diffuse, giant-cell inflammatory reaction was ob¬ served in the fibrovascular ingrowth with the foreign-body giant cells lining the im¬ plant material (Fig 2). Loose granulation tissue was seen at the internal and external surfaces of the scierai shell. A foreign-body giant-cell reaction with chronic inflamma¬ tory infiltrate surrounded the 5-0 polyglactin 910 (Vicryl) suture material in the scier¬ ai shell and was not related to the giant-cell reaction seen within the hydroxyapatite
implant.
Comment. —This is the second histo¬
pathologic report, to our knowledge, of a hydroxyapatite implant that was re¬ moved from a patient's orbit. It dem¬ onstrates a fibrovascular ingrowth mainly at the site of the scierai win¬ dow, as described previously.3 This ingrowth, which penetrated the hy¬ droxyapatite to a depth of 6 mm within 19 days after implantation, was associ¬ ated with a giant-cell reaction. Our finding of an exuberant foreign-body giant-cell inflammatory reaction to the hydroxyapatite material in a child con¬ trasts with the previous report, which showed only rare giant cells in a simi¬ lar implant in a 69-year-old patient.3 However, while it has been suggested that inflammatory response might be more exuberant in children, the influ¬ ence of age on the severity of the inflammatory response is not definite. In studies in which hydroxyapatite was used as a bone graft substitute implanted in direct contact with bone, the response ranged from lack of in¬ flammatory response to an abundant giant-cell reaction.4 Since the implant is made from chemically processed nat¬ ural
This study was supported in part by core grant Y01792 from the National Eye Institute, Bethes¬ da, Md; a grant from the Lions of Illinois Founda¬ tion, Maywood; an unrestricted research grant from Research to Prevent Blindness Ine, New York, NY; grants from the Wolfson's Foundation, the American Israeli Ophthalmological Society, and the International Medical Scholars Program, Washington, DC; and gifts from the Clifford Saw¬ yer Estate and the McGraw Foundation, Arlington Heights, 111. Reprint requests to the Georgiana Dvorak Theo¬ bald Ophthalmic Pathology Laboratory, Depart¬ ment of Ophthalmology and Visual Sciences, Lions of Illinois Eye Research Institute, UIC Eye Cen¬ ter, University of Illinois at Chicago College of Medicine, 1855 W Taylor St, Chicago, IL 60612 (Dr
Tso). 1. Perry AC. Advances in enucleation. Ophthalmol Clin North Am. 1991;4:173-182. 2. Dutton JJ. Coralline hydroxyapatite as an ocular implant. Ophthalmology. 1991;98:370-377. 3. Shields CL, Shields JA, Eagle RC Jr, De Potter P. Histopathologic evidence of fibrovascular ingrowth four weeks after placement of the hydroxyapatite orbital implant. Am J Ophthalmol.
1991;111:363-366. 4. Misiek DJ, Kent JN, Carr RF. Soft-tissue
hydroxyapatite particles of different shapes. J Oral Maxillofac Surg. 1984;42:150-160.
responses to
Late Infectious Endophthalmitis From Exposed Glaucoma Setons
Seton implantation has become increasingly useful in the surgical management of glaucoma.1 Complications of this surgery include those
common
to any filtration surgery, such as cata-
ract, choroidal effusion or hemorrhage,
early or late endophthalmitis, retinal detachment, or Tenon cyst and others unique to the presence of an implanted foreign body, such as extrusion or late erosion through the overlying sclera and/or conjunctiva and Tenon's fascia.1
capable
of
single case of early postoperative endophthalmitis has also been reported.2 We treated two patients for late endophthalmitis following external erosion of the implant through the conjunctiva. To our knowledge, this complication has not been previously reported.
Report of Cases. \p=m-\Case1.\p=m-\A 65-year\x=req-\ woman with neovascular glaucoma following an ischemic central retinal vein occlusion underwent implantation of a shorttailed Krupin-Denver valve beneath a partial-thickness scleral flap in her right eye in 1984. Preoperative visual acuity was hand motions. During the following 2 years, the eye lost all light perception despite adequate control of intraocular pressure. In 1987, the posterior 2 mm of the implant eroded through the conjunctiva and lay exposed on the surface of the sclera. The patient refused corrective surgery and her condition was maintained with topical anti¬ old
biotic treatment. In April 1990 she presented with a 3-day history of aching in the right eye. Conjunc¬ tival injection, purulent discharge, and hypopyon were present (Figs 1 and 2). A diagnosis of acute bacterial endophthalmitis was made. To prevent the sequelae of un¬ treated bacterial endophthalmitis, such as corneal or scierai rupture, orbital cellulitis, and loss of the eye, the decision was made to perform surgery despite the fact that
light perception was not present. During a pars plana vitrectomy and anterior chamber paracentesis, copious amounts of purulent material were removed and cultured. The infection was successfully treated with in¬
travitreal gentamicin sulfate, vancomycin hydrochloride, and dexamethasone sodium phosphate; fortified topical gentamicin sul¬ fate and vancomycin hydrochloride; and oral ciprofloxicin hydrochloride. Laboratory culture subsequently yielded ß-hemolytic streptococci of group F.
Fig 1.—Exposed posterior aspect of a short-tailed Krupin-Denver valve with surrounding purulent discharge (large arrow). The limbus has been marked (small arrows).
coral, it is conceivable that compo¬
nents
A
inciting inflammation
present in certain types of coral may
remain after processing, and hence the variable inflammatory response. The long-term effects of such a gi¬ ant-cell reaction as well as its influence on ossification of the implant and even¬ tual effect on appearance remain to be
determined.
Mordechai Rosner, MD Deepak P. Edward, MD Mark O. M. Tso, MD Chicago, Ill
Downloaded From: http://archopht.jamanetwork.com/ by a Monash University Library User on 06/19/2015
