Occupational corneal argyrosis in art silver solderers

Subconjunctival Ocular Argyrosis following Treatment with Ruthenium 106 Brachytherapy for Choroidal Melanoma

Introduction

Ruthenium-106 (Ru-106) brachytherapy is one of the commonest eye-sparing treatments for choroidal melanoma. These patients require long-term surveillance of the treated tumour remnant to ensure there is no local recurrence. New or progressive pigmented lesions in treated eyes are often regarded as suspicious - especially if there are concerns of extra-scleral extension.

Case Presentations

We present two cases of posterior choroidal melanoma treated five and 10 years previously with Ru-106. Both cases developed subconjunctival dark/black lesions on the anterior surface of the eye in the quadrant of the conjunctival peritomy during Ru-106 treatment. Both had similar findings on histopathology: black, non-organic, particulate foreign material of varying confluence deposited on elastin and collagen fibres. Energy dispersive X-ray microanalysis confirmed the material contained silver.

Discussion

The Ru-106 applicator consists of a radioactive core of Ru-106 encapsulated within pure silver as a radiation shield. During surgical insertion, stainless steel suture needles and forceps can occasionally scratch the applicator's silver eyelets and scatter microscopic particles of elemental silver into the operative field. These particles were likely deposited within the subconjunctival tissues of these patients during brachytherapy administration, leading to localised ocular argyrosis. Iatrogenic ocular argyrosis should be considered in the differential diagnosis of new pigmented lesions in patients treated with Ru-106 brachytherapy. This study is the first to unequivocally identify the cause of some post-brachytherapy ocular surface pigmentation as caused by silver.

Clinical and Forensic Aspects of the Different Subtypes of Argyria

Argyria encompasses the different cosmetic alterations that can develop if enough silver particles deposit in a specific tissue, typically in the skin, ranging from localized dark-blue macules to a generalized slate-gray/bluish tinge following systemic absorption. This work aims to fully review the state of the art regarding pathophysiology, diagnosis, treatment, and relevant clinical and forensic features of argyria. Argyria has been diagnosed in a wide range of ages, both sexes and varied ethnicities, with no known individual predisposing factors. Ultraviolet radiation with subsequence increases of melanin production aggravates the discoloration due to a reduction in the silver deposits. Physical examination and silver exposure in the anamnesis can be highly suggestive of the diagnosis, but a histopathological analysis with Energy-Dispersive X-ray Spectroscopy is required to unequivocally determine the discoloration etiology. Safe and effective treatment has only been accomplished with laser techniques, though only a few cases have been reported and with limited follow-up time. In conclusion, argyria typically has an occupational or iatrogenic etiology. It should be suspected when a patient presents with typical skin or eye lesions. A seemingly viable treatment modality, with laser technology, is finally within the horizon.

Case Report: In Vivo Confocal Microscopic Appearance of Corneal Argyrosis

SIGNIFICANCE

This report details the natural history of corneal argyrosis over 3 years using in vivo confocal microscopy to document regression of hyperreflective deposits, as well as effects on corneal nerves and endothelial cell morphology.

PURPOSE

To report the in vivo confocal microscopic features and clinical characteristics of a case of bilateral corneal argyrosis.

CASE REPORT

A 52-year-old man referred to us 3 months following cautery of the palpebral conjunctiva of both eyes with a silver nitrate stick was observed over the course of 3 years, during which slit-lamp photography and in vivo confocal microscopy were performed. At the first visit, slit-lamp examination showed a light blue-green discoloration and a thick, yellow, oval discoloration in the right and left cornea, respectively. One year later, under slit-lamp examination, the right cornea appeared nearly transparent, and the discoloration in the left cornea had remarkably regressed. In vivo confocal microscopy done at that time showed highly reflective deposits in Descemet membrane of the right cornea and throughout Bowman layer, the stroma, and Descemet membrane of the left cornea. Three years later, no accumulation of silver was observed during slit-lamp examination of either eye. In vivo confocal microscopy of the right cornea did not reveal any silver deposits, and the corneal structure appeared normal. In the left cornea, some silver deposits were still evident in Descemet membrane, and alterations of corneal nerve and endothelial cell morphology were also evident.

CONCLUSIONS

This report reviews the 3-year natural history of a patient with corneal argyrosis. In vivo confocal microscopy demonstrates that over time the corneal argyrosis gradually resolves without any treatment. However, the presence of silver in the cornea may impact the corneal nerves and endothelial cells.

Diagnostic methods in ocular argyrosis: case report

Purpose

The aim of this report is to present a case of a patient, metal foundry worker, who had been exposed to industrial silver salts for over 20 years. It is well established that chronic exposure to silver compounds can cause accumulation of silver deposits in various tissues. This condition is referred to as argyrosis or argyria, whereas changes related to eye tissues are defined as ocular argyrosis.

Methods

A complete eye examination, corneal confocal microscopy, kinetic and static visual field test, posterior segment optical coherent tomography, pattern visual evoked potentials (PVEP), flash visual evoked potentials, multifocal electroretinogram, pattern electroretinogram (PERG), full-field electroretinography (FERG) and electrooculogram were all performed.

Results

Eye examination revealed decreased visual acuity, corneal deposits and drusenoid changes within the macula. Although electrophysiology tests did not show changes in the function of retinal pigment epithelium, they revealed abnormal function of photoreceptors in the central and peripheral retina. PERG abnormalities and delayed latency of P100 wave in PVEP confirmed impaired function of the inner layers of the retina in the macular region.

Conclusions

Corneal confocal microscopy and electrophysiological tests may help confirm the diagnosis of ocular argyrosis.

Ocular argyrosis secondary to long-term ingestion of silver nitrate salts

This case report describes the clinical, autofluorescence, and optical coherent tomography findings in a patient with panocular argyrosis secondary to chronic intake of diluted silver nitrate salts in his water supply. An 86-year-old Caucasian male with a distinctive gray-bluish hue of the skin presented to our clinic, having developed a slow decrease in visual acuity in both eyes and nyctalopia for the past 2 years. Based on the patient’s history of chronic intake of silver nitrate salts and a positive skin biopsy (performed by the dermatology department, data not shown), a diagnosis of panocular argyrosis was made. Fluorescein angiography showed choroidal blockage with a completely dark choroid. Fundus autofluorescence was within normal limits. Optical coherent tomography showed multiple excrescences of retinal pigment epithelium in both eyes. Although the drusen-like changes on fundus examination and retinal pigment epithelium changes may account for the diminished vision, the presence of concomitant nyctalopia suggests underlying damage of the photoreceptors.

A pharmacological and toxicological profile of silver as an antimicrobial agent in medical devices

Silver is used widely in wound dressings and medical devices as a broad-spectrum antibiotic. Metallic silver and most inorganic silver compounds ionise in moisture, body fluids, and secretions to release biologically active Ag(+). The ion is absorbed into the systemic circulation from the diet and drinking water, by inhalation and through intraparenteral administration. Percutaneous absorption of Ag(+) through intact or damaged skin is low. Ag(+) binds strongly to metallothionein, albumins, and macroglobulins and is metabolised to all tissues other than the brain and the central nervous system. Silver sulphide or silver selenide precipitates, bound lysosomally in soft tissues, are inert and not associated with an irreversible toxic change. Argyria and argyrosis are the principle effects associated with heavy deposition of insoluble silver precipitates in the dermis and cornea/conjunctiva. Whilst these changes may be profoundly disfiguring and persistent, they are not associated with pathological damage in any tissue. The present paper discusses the mechanisms of absorption and metabolism of silver in the human body, presumed mechanisms of argyria and argyrosis, and the elimination of silver-protein complexes in the bile and urine. Minimum blood silver levels consistent with early signs of argyria or argyrosis are not known. Silver allergy does occur but the extent of the problem is not known. Reference values for silver exposure are discussed.

Confocal microscopy in ocular argyrosis

PURPOSE

To identify the presence of silver deposits in the cornea using a new-generation confocal microscopy technique.

METHODS

Case report.

RESULTS

A 70-year-old man, who had been a jeweler for many years, was referred to our center for assessment of corneal opacity and ocular pigmentation. Slit-lamp examination revealed grayish, dense confluent deposits in the central and peripheral cornea, deep stroma, and Descemet's membrane. On confocal microscopy, we observed typical images of hyperreflective keratocytes across the entire stromal surface and two hyperreflective plaques coinciding with areas of metal deposition, one at Descemet's membrane and the other at Bowman's membrane. This last deposition site has not been previously identified in vivo by confocal microscopy.

CONCLUSIONS

Confocal microscopy is a useful tool for the diagnosis of corneal argyrosis because it allows the in vivo visualization of silver deposits at different corneal levels.

Ocular argyrosis after long-term self-application of eyelash tint

PURPOSE

To report cases of ocular argyrosis that developed after long-term self-application of commercially available eyelash tint.

DESIGN

Observational case series.

METHODS

Case review, clinicopathologic analysis, and literature review.

RESULTS

Three patients developed ocular argyrosis after the long-term self-application of Revlon Professional Roux Lash and Brow Tint (Colomer USA Corp, New York, New York, USA). Clinical evaluation revealed various degrees of silver deposition on the upper eyelid, lid margin, caruncle and conjunctiva, and diffuse Descemet's membrane deposits. In one case, histologic examination demonstrated silver deposition in the basement membrane and superficial substantia propria of the conjunctiva.

CONCLUSIONS

Argyrosis can occur after long-term application of readily available eyelash tints, and the deposition of silver may be permanent. In certain circumstances, conjunctival argyrosis may simulate benign and malignant lesions, including conjunctival melanoma. These products should only be applied by trained cosmetologists.