During the past 3 years, 12 patients (14 eyes) were encountered with severe reactions to virgin silk sutures used in cataract surgery. These reactions included nodular episcleritis, peripheral corneal ulceration, and wound necrosis with dehiscence, sometimes resulting in endophthalmitis or epithelial downgrowth. Conjunctival and scleral histopathologic studies in four eyes showed acute and chronic inflammation with multinucleated giant cells. Successful treatment included removal of the virgin silk sutures, resuturing with 10-0 nylon sutures, securing the necrotic tissue with cyanoacrylate adhesive, and resection of the inflamed superior conjunctiva. All four patients who had bilateral cataract surgery experienced either simultaneous flare-ups of both eyes or accelerated reactions after surgery on the second eye, which suggests a possible role of prior sensitization.