Vol. 114, No. 5
Letters to The Journal
639
2. Guyer, D. R., Puliafito, C. A., Mones, J. M, Friedmann, E., Chang, W., and Verdooner, S. R.: Digital indocyanine-green angiography in chorioretinal disorders. Ophthalmology 99:287, 1992. 3. Benya, R., Quintana, J., and Brundage, B.: Ad verse reactions to indocyanine green. A case report and review of the literature. Cathet. Cardiovasc. Diagn. 17:231, 1989. 4. Greenberger, P. A.: Contrast media reactions. J. Allergy Clin. Immunol. 74:600, 1984. 5. Yannuzzi, L. A., Rohrer, K. T., Tindel, L. J., Sobel, R. S., Costanza, M. A., Shields, W., and Zang, E.: Fluorescein angiography complication survey. Ophthalmology 93:611, 1986.
Intraconjunctival Cavitary Inclusions of Silicone Oil Complicating Retinal Detachment Repair Sean P. Donahue, M.D., Thomas R. Friberg, M.D., and Bruce L. Johnson, M.D. Departments of Ophthalmology (S.P.D., T.R.F.) and Pathology (B.L.J.), Eye and Ear Institute, University of Pittsburgh. Inquiries to S. P. Donahue, M.D., Department of Oph thalmology, 203 Lothrop St., Pittsburgh, PA 15213. A 34-year-old man residing in a state psychi atric institution had an episode of self-inflicted trauma in which he struck himself about the head. He sustained a large retinal detachment with a superior flap tear and underwent pars plana vitrectomy, pars plana lensectomy, place ment of 1,000 cs silicone oil for tamponade, scierai buckle, and endolaser treatment three days after the injury. Over the next 2lh years, he had repeated episodes of self-inflicted trauma and eventually had a posttraumatic giant reti nal tear with a foveal detachment. When the conjunctiva was opened in the operating room, multiple subconjunctival deposits of silicone oil were observed 360 degrees around the ante rior globe and were not associated with any sclerotomy sites (Fig. 1). All three previous sclerotomy sites were well healed. Under the operating microscope, many episcleral and intrascleral microspherules of oil were present. Although many of these droplets could be washed from the surface of the globe, others remained within the sclera itself and could not be removed. When the silicone oil was replaced during the second surgical procedure, it was apparent that the oil had emulsified considera-
Fig. 1 (Donahue, Friberg, and Johnson). Case 1. Macroscopic view of the unfixed conjunctival biopsy specimen that contained numerous various-sized cavities filled with viscid clear material (x 20). bly, and multiple microscopic spherules had accumulated at the posterior surface of the cornea in this aphakic eye. Pathologic examination of the inferior bulbar conjunctiva demonstrated a pink, finely vascularized segment of tissue that was extremely buoyant in the fixative (Fig. 1). It contained multiple minute gray translucent cavities of up to 1 mm 8 in size. Microscopic examination dem onstrated clear vacuoles and silicone oil depos its in the substantia propria of the conjunctiva, some of which were lined by multinucleated foreign body-type giant cells (Fig. 2). Several large-series reviews of silicone oil
Fig. 2 (Donahue, Friberg, and Johnson). Case 1. Microscopic view of the biopsy specimen in Figure 1. Numerous various-sized clear vacuoles are seen deep within the conjunctival substantia propria (hematoxylin and eosin, x 100). Bar represents 500 ìðé.
640
AMERICAN JOURNAL OF OPHTHALMOLOGY
have been published during the past five years. None describes the apparent transscleral mi gration of emulsified oil.1 B Federman and Schu bert 3 described subconjunctival deposits of oil in four of 170 eyes (2.4%), but the deposits were thought to be secondary to extravasation of oil through the sclerotomy site and induced symptomatic pain. Our patient had multiple cavitary inclusions of silicone oil throughout both the conjunctiva and sclera anterior to the equator. The oil could have left the vitreous cavity by several mecha nisms. Although extrusion through the sclerot omy is plausible, the sclerotomy sites (as deter mined by the nylon suture remnants) were completely healed. Local scleromalacia was not evident, as might be seen if trauma-induced increases in intraocular pressure forced oil through healing sclerotomies. Furthermore, there was no increased density of oil droplets near the former sclerotomy sites. A direct trans scleral passage of emulsified oil droplets could explain the intrascleral deposits and the diffuseness of the process, and would be more likely to occur in a person with severe myopia with correspondingly thin sclera and whose eyes had increased intraocular pressure associ ated with repeated trauma. Finally, microscopic oil droplets could have reached the conjunctiva via the trabecular meshwork and the episcleral veins (the normal outflow tract of the eye), particularly because the patient struck his oilfilled eye repeatedly several months after the first operation. The patient was not cooperative enough to examine the angle structures gonioscopically. Because this patient's eye was not removed, the angle structures could not be examined histologically. On the basis of our clinical examination, coupled with the history of silicone oil emulsification followed by repeated direct ocular trau ma, we believe silicone oil can exit from an intact oil-filled eye. Although the complication must certainly be rare, it may lead to conjunctival hyperemia, foreign-body inflammation, and a grossly abnormal appearance of Tenon's cap sule and conjunctiva.
References 1. Lucke, K. H., Foerster, M. H., and Laqua, H.: Long-term results of vitrectomy and silicone oil in 500 cases of complicated retinal detachments. Am. J. Ophthalmol. 104:624, 1987.
November, 1992
2. Riedel, K. G., Jabel, V., Newbauer, L., Kampik, A., and Lund, O.: Intravitreal silicone oil injection. Complication and treatment of 415 consecutive pa tients. Graefes Arch. Clin. Exp. Ophthalmol. 228:19, 1990. 3. Federman, J. L., and Schubert, H. D.: Complica tions associated with the use of silicone oil in 150 eyes after retina vitreous surgery. Ophthalmology 95:870, 1988. 4. Lucke, K. H., and Laqua, H.: Silicone Oil in the Treatment of Complicated Retinal Detachments. Ber lin, Springer-Verlag, 1990, p. 161. 5. Casswell, A. G., and Gregor, Z. J.: Silicone oil removal. 1. The effect on the complications of sili cone oil. Br. J. Ophthalmol. 71:893, 1987.
Conjunctival Concretions Vera O. Kowal, M.D., A n t h o n y P. A d a m i s , M.D., and D a n i e l M. Albert, M.D. Department of Ophthalmology, Massachusetts Eye and Ear Infirmary. inquiries to Anthony P. Adamis, M.D., Cornea Service, Massachusetts Eye and Ear Infirmary, 243 Charles St., Boston, MA 02114. A 19-year-old black, South African woman had a three-year history of intermittent bilater al ocular irritation and foreign-body sensation. She had no other associated symptoms. She denied any history of external eye disease and had never used any eye medications. Visual acuity was 20/20 in both eyes. The eyes appeared to be white with no signs of active inflammation. Minimal superficial punc tate keratitis was noted at the superior aspect of both corneas. Herbert's pits were not present. Numerous yellow-white concretions of varying size were present on the superior palpebrai conjunctivae of both eyes (Fig. 1). Some concre tions were protruding through the conjunctival epithelium and could easily be dislodged with a 27-gauge needle. Conjunctival scarring was notably absent. Results of the remainder of the ocular examination were normal. Microbiologie studies of the concretions were negative, and the patient's serum calcium and cholesterol profile was normal. Histologie ex-
Letters to The Journal
639
2. Guyer, D. R., Puliafito, C. A., Mones, J. M, Friedmann, E., Chang, W., and Verdooner, S. R.: Digital indocyanine-green angiography in chorioretinal disorders. Ophthalmology 99:287, 1992. 3. Benya, R., Quintana, J., and Brundage, B.: Ad verse reactions to indocyanine green. A case report and review of the literature. Cathet. Cardiovasc. Diagn. 17:231, 1989. 4. Greenberger, P. A.: Contrast media reactions. J. Allergy Clin. Immunol. 74:600, 1984. 5. Yannuzzi, L. A., Rohrer, K. T., Tindel, L. J., Sobel, R. S., Costanza, M. A., Shields, W., and Zang, E.: Fluorescein angiography complication survey. Ophthalmology 93:611, 1986.
Intraconjunctival Cavitary Inclusions of Silicone Oil Complicating Retinal Detachment Repair Sean P. Donahue, M.D., Thomas R. Friberg, M.D., and Bruce L. Johnson, M.D. Departments of Ophthalmology (S.P.D., T.R.F.) and Pathology (B.L.J.), Eye and Ear Institute, University of Pittsburgh. Inquiries to S. P. Donahue, M.D., Department of Oph thalmology, 203 Lothrop St., Pittsburgh, PA 15213. A 34-year-old man residing in a state psychi atric institution had an episode of self-inflicted trauma in which he struck himself about the head. He sustained a large retinal detachment with a superior flap tear and underwent pars plana vitrectomy, pars plana lensectomy, place ment of 1,000 cs silicone oil for tamponade, scierai buckle, and endolaser treatment three days after the injury. Over the next 2lh years, he had repeated episodes of self-inflicted trauma and eventually had a posttraumatic giant reti nal tear with a foveal detachment. When the conjunctiva was opened in the operating room, multiple subconjunctival deposits of silicone oil were observed 360 degrees around the ante rior globe and were not associated with any sclerotomy sites (Fig. 1). All three previous sclerotomy sites were well healed. Under the operating microscope, many episcleral and intrascleral microspherules of oil were present. Although many of these droplets could be washed from the surface of the globe, others remained within the sclera itself and could not be removed. When the silicone oil was replaced during the second surgical procedure, it was apparent that the oil had emulsified considera-
Fig. 1 (Donahue, Friberg, and Johnson). Case 1. Macroscopic view of the unfixed conjunctival biopsy specimen that contained numerous various-sized cavities filled with viscid clear material (x 20). bly, and multiple microscopic spherules had accumulated at the posterior surface of the cornea in this aphakic eye. Pathologic examination of the inferior bulbar conjunctiva demonstrated a pink, finely vascularized segment of tissue that was extremely buoyant in the fixative (Fig. 1). It contained multiple minute gray translucent cavities of up to 1 mm 8 in size. Microscopic examination dem onstrated clear vacuoles and silicone oil depos its in the substantia propria of the conjunctiva, some of which were lined by multinucleated foreign body-type giant cells (Fig. 2). Several large-series reviews of silicone oil
Fig. 2 (Donahue, Friberg, and Johnson). Case 1. Microscopic view of the biopsy specimen in Figure 1. Numerous various-sized clear vacuoles are seen deep within the conjunctival substantia propria (hematoxylin and eosin, x 100). Bar represents 500 ìðé.
640
AMERICAN JOURNAL OF OPHTHALMOLOGY
have been published during the past five years. None describes the apparent transscleral mi gration of emulsified oil.1 B Federman and Schu bert 3 described subconjunctival deposits of oil in four of 170 eyes (2.4%), but the deposits were thought to be secondary to extravasation of oil through the sclerotomy site and induced symptomatic pain. Our patient had multiple cavitary inclusions of silicone oil throughout both the conjunctiva and sclera anterior to the equator. The oil could have left the vitreous cavity by several mecha nisms. Although extrusion through the sclerot omy is plausible, the sclerotomy sites (as deter mined by the nylon suture remnants) were completely healed. Local scleromalacia was not evident, as might be seen if trauma-induced increases in intraocular pressure forced oil through healing sclerotomies. Furthermore, there was no increased density of oil droplets near the former sclerotomy sites. A direct trans scleral passage of emulsified oil droplets could explain the intrascleral deposits and the diffuseness of the process, and would be more likely to occur in a person with severe myopia with correspondingly thin sclera and whose eyes had increased intraocular pressure associ ated with repeated trauma. Finally, microscopic oil droplets could have reached the conjunctiva via the trabecular meshwork and the episcleral veins (the normal outflow tract of the eye), particularly because the patient struck his oilfilled eye repeatedly several months after the first operation. The patient was not cooperative enough to examine the angle structures gonioscopically. Because this patient's eye was not removed, the angle structures could not be examined histologically. On the basis of our clinical examination, coupled with the history of silicone oil emulsification followed by repeated direct ocular trau ma, we believe silicone oil can exit from an intact oil-filled eye. Although the complication must certainly be rare, it may lead to conjunctival hyperemia, foreign-body inflammation, and a grossly abnormal appearance of Tenon's cap sule and conjunctiva.
References 1. Lucke, K. H., Foerster, M. H., and Laqua, H.: Long-term results of vitrectomy and silicone oil in 500 cases of complicated retinal detachments. Am. J. Ophthalmol. 104:624, 1987.
November, 1992
2. Riedel, K. G., Jabel, V., Newbauer, L., Kampik, A., and Lund, O.: Intravitreal silicone oil injection. Complication and treatment of 415 consecutive pa tients. Graefes Arch. Clin. Exp. Ophthalmol. 228:19, 1990. 3. Federman, J. L., and Schubert, H. D.: Complica tions associated with the use of silicone oil in 150 eyes after retina vitreous surgery. Ophthalmology 95:870, 1988. 4. Lucke, K. H., and Laqua, H.: Silicone Oil in the Treatment of Complicated Retinal Detachments. Ber lin, Springer-Verlag, 1990, p. 161. 5. Casswell, A. G., and Gregor, Z. J.: Silicone oil removal. 1. The effect on the complications of sili cone oil. Br. J. Ophthalmol. 71:893, 1987.
Conjunctival Concretions Vera O. Kowal, M.D., A n t h o n y P. A d a m i s , M.D., and D a n i e l M. Albert, M.D. Department of Ophthalmology, Massachusetts Eye and Ear Infirmary. inquiries to Anthony P. Adamis, M.D., Cornea Service, Massachusetts Eye and Ear Infirmary, 243 Charles St., Boston, MA 02114. A 19-year-old black, South African woman had a three-year history of intermittent bilater al ocular irritation and foreign-body sensation. She had no other associated symptoms. She denied any history of external eye disease and had never used any eye medications. Visual acuity was 20/20 in both eyes. The eyes appeared to be white with no signs of active inflammation. Minimal superficial punc tate keratitis was noted at the superior aspect of both corneas. Herbert's pits were not present. Numerous yellow-white concretions of varying size were present on the superior palpebrai conjunctivae of both eyes (Fig. 1). Some concre tions were protruding through the conjunctival epithelium and could easily be dislodged with a 27-gauge needle. Conjunctival scarring was notably absent. Results of the remainder of the ocular examination were normal. Microbiologie studies of the concretions were negative, and the patient's serum calcium and cholesterol profile was normal. Histologie ex-
