SILICONE OIL–INDUCED CORNEAL PERFORATION FOLLOWING COMPLEX RETINAL DETACHMENT Aaron M. Yeung, MRCOPHTH,* Anupama Pherwani, FRCOPHTH,*† Naing L. Tint, MRCOPHTH,*† Shu Ho, MRCOPHTH,† Anwar Zaman, FRCOPHTH,† Harminder S. Dua, FRCOPHTH*†
Purpose: To report a case of silicone oil–induced corneal perforation following complex retinal detachment surgery. Methods: Case report. Results: Two months following a second retinal detachment repair, the patient presented to eye casualty with a corneal perforation secondary to silicone oil keratopathy. Conclusion: The pathophysiology of silicone oil–related perforation is not clearly understood. Poor corneal nutrition due to the presence of oil may be an important contributory factor. Close monitoring of patients for early signs of silicone oil keratopathy could preempt perforation. RETINAL CASES & BRIEF REPORTS 3:367–368, 2009
From the *Division of Ophthalmology and Visual Sciences, University of Nottingham, and †Department of Ophthalmology, Queen’s Medical Centre, Nottingham, United Kingdom.
One month postoperatively, during a planned outpatient visit, the fundal view was obscured due to vitreous hemorrhage and ultrasound revealed an inferior detachment in the right eye. The cornea was noted to be clear. The patient had further retinal detachment repair that included retinectomy, endolaser treatment, and silicone oil insertion. His recovery was otherwise uneventful and 3 weeks postoperatively a small silicone oil bubble was noted in his anterior chamber, but no contact with the corneal endothelium was noted. Two months after silicone oil insertion the patient presented to eye casualty with a 3-day history of discomfort, lacrimation, and redness in his right eye. On examination, visual acuity was light perception in the inferior quadrant only, the eye was soft, and the cornea showed signs of edema with associated haziness (Figure 1A). In addition, there was corneal melt in the center with leakage of aqueous from a small full-thickness perforation. The anterior chamber was shallow and contained silicone oil. The corneal melt was sealed with cyanoacrylate glue (Figure 1B) and a bandage contact lens. During the procedure, small bubbles of silicone oil were noted in the perforation. Once the eye stabilized, silicone oil was seen filling the anterior chamber and was seen to be in contact with the cornea (Figure 1C). His visual acuity in the right eye improved to hand motions. The eye continued to stabilize and following further discussions, a unanimous decision was made to leave the silicone oil in the eye due to the high risk of redetachment. Five months after the initial presentation, the eye became phthisical and the corneal glue was removed (Figure 1D).
A
number of complications are associated with the use of intraocular silicone oil for vitreoretinal surgery including cataract, band keratopathy, fibrous epiretinal and subretinal proliferations, and glaucoma.1,2 Full-thickness corneal perforation is extremely rare and may be associated with the length of time that silicone oil is left in situ. Case Report A 70-year-old bilateral pseudophakic man presented with a bullous retinal detachment with multiple breaks and noted proliferative vitreoretinopathy (PVR) in the right eye with visual acuity of hand motions. He underwent retinal detachment repair involving pars plana vitrectomy, membrane peel, 240° temporal buckling, and C3F8 gas insertion. Postoperative intraocular pressure was elevated but settled subsequently on treatment, with flat retina noted throughout.
The authors have no proprietary interest in this work. Reprint requests: Harminder S. Dua, FRCOphth, Division of Opthalmology and Visual Sciences, B Floor, Eye and ENT Building, Queens Medical Centre, Nottingham, NG7 2UH, UK; e-mail: [email protected]
Discussion Silicone oil is widely used in complex retinal detachment with associated PVR. This has been popu367
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Fig. 1. A, Full-thickness perforation on presentation to eye casualty. B, Post cyanoacrylate glue and reformation of anterior chamber. C, Silicone oil touching corneal endothelium (delineated by arrows). D, Post glue removal.
larized due to its transparency, high interfacial surface tension with water, stability of tamponade, and relatively low retinal toxicity. Silicone oil keratopathy was first reported in 19783 when granular deposits of calcium phosphate were found in the Bowman’s membrane in patients who had identical keratopathy following extensive retinal detachment repair and silicone oil insertion. Previous studies of the effects of silicone oil on the cornea have demonstrated marked reduction in endothelial cell population in light microscopy and an associated flattening and thinning of the remaining cells with electron microscopy.4 In addition, silicone oil applied to animal experimental models have demonstrated a 40% reduction in endothelial density within 6 days.5 Similar light microscopic corneal changes were noted in air or SF6 gas bubble injected into anterior chambers of experimental animal models6 and thus it has been postulated that the corneal changes are due to a barrier effect, preventing adequate nutrition reaching the endothelium from the aqueous humor. Perforation of the cornea following silicone oil insertion for complex retinal detachment is very rare, with one such reported case in literature to date.7 The authors reported a case of a 17-year-old boy who had undergone multiple, extensive retinal detachment surgery and believed that longer duration of oil in the eye, aphakia, silicone oil in the anterior chamber, and extensive multiple surgeries were risk factors for spontaneous perforation. As with the previous case, our patient had undergone extensive multiple surgery;
however, he was older, pseudophakic, and silicone oil, which was in situ for only 2 months, was present much shorter than in the previous case. There was no condition predisposing to corneal perforation present in this patient before his retinal detachment surgery. In conclusion, we report a rarely encountered but serious complication of silicone oil use in complex vitreoretinal surgery. The pathophysiology of silicone oil– related perforation is not clearly understood. Poor corneal nutrition due to the presence of oil may be an important contributory factor. Close monitoring of patients for early signs of silicone oil keratopathy could preempt perforation. However, the decision to remove oil must be balanced against the risk of redetachment. References 1.
2. 3. 4. 5. 6.
7.
Federman JL, Schubert HD. Complications associated with the use of silicone oil in 150 eyes after retina-vitreous surgery. Ophthalmology 1988;95:870–876. Azuara-Blanco A, Dua HS, Pillai CT. Pseudo-endothelial dystrophy associated with emulsified silicone oil. Cornea 1999;18:493–494. Brodrick JD. Keratopathy following retinal detachment surgery. Arch Ophthalmol 1978;96:2021–2026. Choi WC, Choi SK, Lee JH. Silicone oil keratopathy. Korean J Ophthalmol 1993;7:65–69. Sternberg P Jr, Hatchell DL, Foulks GN, Landers MB 3rd. The effect of silicone oil on the cornea. Arch Ophthalmol 1985;103:90–94. Van Horn DL, Edelhauser HF, Aaberg TM, Pederson HJ. In vivo effects of air and sulfur hexafluoride gas on rabbit corneal endothelium. Invest Ophthalmol 1972;11:1028–1036. Venkatesh P, Chawla R, Tewari HK. Spontaneous perforation of the cornea following silicone oil keratopathy. Cornea 2005;24:347–348.
Purpose: To report a case of silicone oil–induced corneal perforation following complex retinal detachment surgery. Methods: Case report. Results: Two months following a second retinal detachment repair, the patient presented to eye casualty with a corneal perforation secondary to silicone oil keratopathy. Conclusion: The pathophysiology of silicone oil–related perforation is not clearly understood. Poor corneal nutrition due to the presence of oil may be an important contributory factor. Close monitoring of patients for early signs of silicone oil keratopathy could preempt perforation. RETINAL CASES & BRIEF REPORTS 3:367–368, 2009
From the *Division of Ophthalmology and Visual Sciences, University of Nottingham, and †Department of Ophthalmology, Queen’s Medical Centre, Nottingham, United Kingdom.
One month postoperatively, during a planned outpatient visit, the fundal view was obscured due to vitreous hemorrhage and ultrasound revealed an inferior detachment in the right eye. The cornea was noted to be clear. The patient had further retinal detachment repair that included retinectomy, endolaser treatment, and silicone oil insertion. His recovery was otherwise uneventful and 3 weeks postoperatively a small silicone oil bubble was noted in his anterior chamber, but no contact with the corneal endothelium was noted. Two months after silicone oil insertion the patient presented to eye casualty with a 3-day history of discomfort, lacrimation, and redness in his right eye. On examination, visual acuity was light perception in the inferior quadrant only, the eye was soft, and the cornea showed signs of edema with associated haziness (Figure 1A). In addition, there was corneal melt in the center with leakage of aqueous from a small full-thickness perforation. The anterior chamber was shallow and contained silicone oil. The corneal melt was sealed with cyanoacrylate glue (Figure 1B) and a bandage contact lens. During the procedure, small bubbles of silicone oil were noted in the perforation. Once the eye stabilized, silicone oil was seen filling the anterior chamber and was seen to be in contact with the cornea (Figure 1C). His visual acuity in the right eye improved to hand motions. The eye continued to stabilize and following further discussions, a unanimous decision was made to leave the silicone oil in the eye due to the high risk of redetachment. Five months after the initial presentation, the eye became phthisical and the corneal glue was removed (Figure 1D).
A
number of complications are associated with the use of intraocular silicone oil for vitreoretinal surgery including cataract, band keratopathy, fibrous epiretinal and subretinal proliferations, and glaucoma.1,2 Full-thickness corneal perforation is extremely rare and may be associated with the length of time that silicone oil is left in situ. Case Report A 70-year-old bilateral pseudophakic man presented with a bullous retinal detachment with multiple breaks and noted proliferative vitreoretinopathy (PVR) in the right eye with visual acuity of hand motions. He underwent retinal detachment repair involving pars plana vitrectomy, membrane peel, 240° temporal buckling, and C3F8 gas insertion. Postoperative intraocular pressure was elevated but settled subsequently on treatment, with flat retina noted throughout.
The authors have no proprietary interest in this work. Reprint requests: Harminder S. Dua, FRCOphth, Division of Opthalmology and Visual Sciences, B Floor, Eye and ENT Building, Queens Medical Centre, Nottingham, NG7 2UH, UK; e-mail: [email protected]
Discussion Silicone oil is widely used in complex retinal detachment with associated PVR. This has been popu367
368
RETINAL CASES & BRIEF REPORTSℜ
●
2009
●
VOLUME 3
●
NUMBER 4
Fig. 1. A, Full-thickness perforation on presentation to eye casualty. B, Post cyanoacrylate glue and reformation of anterior chamber. C, Silicone oil touching corneal endothelium (delineated by arrows). D, Post glue removal.
larized due to its transparency, high interfacial surface tension with water, stability of tamponade, and relatively low retinal toxicity. Silicone oil keratopathy was first reported in 19783 when granular deposits of calcium phosphate were found in the Bowman’s membrane in patients who had identical keratopathy following extensive retinal detachment repair and silicone oil insertion. Previous studies of the effects of silicone oil on the cornea have demonstrated marked reduction in endothelial cell population in light microscopy and an associated flattening and thinning of the remaining cells with electron microscopy.4 In addition, silicone oil applied to animal experimental models have demonstrated a 40% reduction in endothelial density within 6 days.5 Similar light microscopic corneal changes were noted in air or SF6 gas bubble injected into anterior chambers of experimental animal models6 and thus it has been postulated that the corneal changes are due to a barrier effect, preventing adequate nutrition reaching the endothelium from the aqueous humor. Perforation of the cornea following silicone oil insertion for complex retinal detachment is very rare, with one such reported case in literature to date.7 The authors reported a case of a 17-year-old boy who had undergone multiple, extensive retinal detachment surgery and believed that longer duration of oil in the eye, aphakia, silicone oil in the anterior chamber, and extensive multiple surgeries were risk factors for spontaneous perforation. As with the previous case, our patient had undergone extensive multiple surgery;
however, he was older, pseudophakic, and silicone oil, which was in situ for only 2 months, was present much shorter than in the previous case. There was no condition predisposing to corneal perforation present in this patient before his retinal detachment surgery. In conclusion, we report a rarely encountered but serious complication of silicone oil use in complex vitreoretinal surgery. The pathophysiology of silicone oil– related perforation is not clearly understood. Poor corneal nutrition due to the presence of oil may be an important contributory factor. Close monitoring of patients for early signs of silicone oil keratopathy could preempt perforation. However, the decision to remove oil must be balanced against the risk of redetachment. References 1.
2. 3. 4. 5. 6.
7.
Federman JL, Schubert HD. Complications associated with the use of silicone oil in 150 eyes after retina-vitreous surgery. Ophthalmology 1988;95:870–876. Azuara-Blanco A, Dua HS, Pillai CT. Pseudo-endothelial dystrophy associated with emulsified silicone oil. Cornea 1999;18:493–494. Brodrick JD. Keratopathy following retinal detachment surgery. Arch Ophthalmol 1978;96:2021–2026. Choi WC, Choi SK, Lee JH. Silicone oil keratopathy. Korean J Ophthalmol 1993;7:65–69. Sternberg P Jr, Hatchell DL, Foulks GN, Landers MB 3rd. The effect of silicone oil on the cornea. Arch Ophthalmol 1985;103:90–94. Van Horn DL, Edelhauser HF, Aaberg TM, Pederson HJ. In vivo effects of air and sulfur hexafluoride gas on rabbit corneal endothelium. Invest Ophthalmol 1972;11:1028–1036. Venkatesh P, Chawla R, Tewari HK. Spontaneous perforation of the cornea following silicone oil keratopathy. Cornea 2005;24:347–348.
