Sir,

While the correlation between a systemic disease and breast implant leakage continues to be debated,1, 2 we report a case that might confirm breast implants could be responsible for dry eye.

Case series

A 64-year-old female was referred for severe dry eye syndrome in both eyes that had appeared 6 months before. Her past medical history was relevant for breast augmentation with silicone implants 18 years before. She presented with complaints of bilateral fluctuating blurry vision, severe dry eye sensation, and retrobulbar pain. She also reported a recent loss of weight and asthenia. Best corrected visual acuity was 20/20 in both eyes. Ophthalmologic examination revealed severe dry eye syndrome in both eyes with mild superficial punctuate keratitis, decreased tear breakup time, and decreased Schirmer test value. There was no sign of intraocular inflammation. Hypertrophia of both lacrimal glands was observed on orbital MRI (Figure 1a).

Figure 1
figure 1

MRI showing the lacrimal gland before (a) and after (b) breast implant removal. A substantial decrease in size was observed. The lung scan shows a triangular, pleura-based opacity, and ground-glass opacities before implant removal (c) and a few months later (d). The opacities have almost completely disappeared.

Full size image

Considering the hypertrophic lacrimal glands and the deterioration of the patient’s general status, a complete check-up was performed. The only abnormality was a lung tomography that showed bilateral alveolo-interstitial opacities (Figure 1c). She underwent bronchoalveolar lavage and a transparietal lung biopsy. The final diagnosis was organized pneumonia secondary to silicone breast implant leakage. Oral steroids (1 mg/kg/day) were given and the implants were removed. Their macroscopic evaluation did not reveal any abnormality. However, as a sign of silent breast implant leakage, a few months later, cutaneous siliconomas were observed in the residual breast cavity clinically and with breast MRI.

Vast improvement in the clinical asthenia symptoms and in the clinical and radiologic signs of pneumonia was observed after corticosteroid treatment and breast implant removal (Figure 1d). Moreover, the dry eye syndrome completely resolved with absence of symptoms, normal dry eye tests, and a normal lacrimal gland size on MRI (Figure 1b).

In the present study, the association of organized pneumonia, dry eye syndrome, and lacrimal gland hypertrophia suggested a connectivitis.1 Although the correlation between a systemic disease and breast implant leakage continues to be debated,1, 2 the improvement of systemic and ocular signs after implants removal might confirm their responsibility in the present case. Steroids may have played a role in the improvement of patient symptoms. Nevertheless, this treatment was stop after implant removal and no recurrence of systemic or ocular manifestations was observed during the follow-up. Moreover, even if oral steroids improved organized pneumonia, they have never been able to treat any dry eye syndrome.3, 4 Indeed, breast implant removal was the probable cause of the radical improvement of ocular signs.

Comment

The pathophysiology of dry eye syndrome is complex and may require further explorations when atypical.5 Considering this observation, the patient should be asked whether breast implant surgery has been performed in the assessment of dry eye diseases. In this particular case, implant rupture or leakage should be ruled out.