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Long-Term Results of Successful Vitrectomy With Silicone Oil for Advanced Proliferative Vitreoretinopathy
Long-Term Results of Successful Vitrectomy With Silicone Oil for Advanced Proliferative Vitreoretinopathy Clive H. Sell, M . D . , Brooks W. McCuen II, M . D . , Maurice B. Landers III, M . D . , and Robert Machemer, M . D .
We have analyzed the six-month, one-year, and two-year follow-up examinations in 47 patients who had silicone oil injection in com bination with revision of vitrectomy for intrac table retinal detachment and advanced prolif erative vitreoretinopathy. A visual acuity of 5/200 or better was attained in 22 eyes at six months (47%), 17 eyes at one year (36%), and 14 eyes at two years (30%). Of eyes that were completely attached posterior to the buckle at six months, 77% remained attached at two years. In those eyes that were attached at six months, corneal decompensation was the most frequent cause of a loss of vision between six months and two years. Silicone oil was re moved in 22 eyes (47%). THE USE OF SILICONE OIL in the treatment of
complicated retinal detachments has been the subject of renewed interest. 19 Long-term follow-up of the early techniques of silicone oil surgery, however, demonstrated a high inci dence of late complications 1011 and poor visual results. 1213 Modern techniques combining vi trectomy and membrane peeling with silicone oil injection have produced encouraging shortterm results in complex retinal detachments. 2 " 6,9 The long-term effects of these techniques, how ever, remain controversial. The purpose of this report is to provide a two-year follow-up on those eyes that were anatomically successful six months after vitrectomy with silicone oil injection.
Material and Methods The records of all patients at the Duke Eye Center between August 1981 and August 1984 with recurrent retinal detachment with prolif erative vitreoretinopathy of grade C3 or greater in whom revision of vitrectomy with silicone oil injection was performed were reviewed. Eyes with retinal detachment that resulted from penetrating ocular trauma, giant retinal tears, or proliferative diabetic retinopathy were ex cluded. Of the 57 patients with a potential for a two-year follow-up, 47 patients had complete six-month, one-year, and two-year examina tions and constitute the database for this re port. All eyes had a complete preoperative ocular examination including visual acuity testing, measurement of intraocular pressure, slit-lamp examination, and contact lens and binocular indirect ophthalmoscopy. The retinal detach ment was graded with respect to the degree of proliferative vitreoretinopathy according to the Retina Society classification.14 Follow-up visits were scheduled six, 12, and 24 months after surgery. At each follow-up visit, a complete examination was performed. Anatomic success was defined as complete retinal reattachment posterior to the encircling scleral buckle.
Results Accepted for publication Oct. 14, 1986. From the Department of Ophthalmology, Duke Uni versity Eye Center, Durham, North Carolina. This study was supported by the Adler Foundation and the Nation al Society to Prevent Blindness, Research to Prevent Blindness, Inc., National Eye Institute (EY05903, EY05741, and EY02903), and the Helena Rubinstein Foundation. Reprint requests to Brooks W. McCuen II, M.D., Box 3802, Duke University Eye Center, Durham, NC 27710.
24
In 42 of the 47 eyes (89%) the ocular media were clear enough to assess the status of the retina. The retina was noted to be entirely reattached posterior to the encircling scleral buckle at the six-month follow-up examination in 31 of these 42 eyes (74%). In five of the 31 eyes (16%) with an attached retina, one or more additional retinal operations had been per formed before the six-month examination. Of
©AMERICAN JOURNAL OF OPHTHALMOLOGY 103:24-28, JANUARY, 1987
Vol. 103, No. 1
Vitrectomy With Silicone Oil
25
lOO SO X
E Y
SO 70
Fig. 1 (Sell and associates). Per centage of retinas successfully reattached posterior to the encircling scleral buckle at six-month, oneand two-year visits after silicone oil surgery.
60 BO 40 30 SO
io o
6
MO
1
YH
2
the 31 eyes with attached retinas at six months, 27 retinas (87%) were also completely attached posterior to the encircling scleral buckle at the 12-month follow-up examination, and 24 (77%) at the two-year follow-up examination. Over all, at the 24-month examinations 27 of the 42 eyes (64%) in which the retina could be visual ized were successfully reattached (Fig. 1). There was a gradual decrease in visual acuity between six months and two years after silicone injection. A visual acuity of 5/200 or better was achieved in 22 of 47 eyes (47%) at six months, in 17 eyes (36%) at one year, and in 14 eyes (30%) at two years (Fig. 2). Overall, visual acuity improved in ten eyes from the six-month to the two-year follow-up, stayed the same in 15 eyes,
YR
and deteriorated in 22 of the 47 eyes. Of those 31 eyes considered anatomically successful at six months, visual acuity at two years was better in eight eyes (26%), the same in nine eyes (29%), and worse in 14 eyes (45%) than the visual acuity measured at six months. Factors accounting for the decrease in visual acuity between six months and two years noted in the 14 eyes included the following: late corneal decompensation (eight eyes), progressive macular pucker (two eyes), recurrent retinal de tachment (one eye), severe cataract (one eye), and unexplained visual loss (two eyes). Silicone oil was removed in 22 of the 47 eyes (47%). The time of silicone oil removal from injection ranged from three days to 26 months
100
so ao TO
Fig. 2 (Sell and associates). Per centage of eyes with visual acuity better than or equal to 5/200 at six-month, one- and two-year visits after silicone oil surgery.
CO BO 40 SO
so IO
o
MO
YH
S
YR
26
January, 1987
AMERICAN JOURNAL OF OPHTHALMOLOGY
with an average of 6.2 months. Fourteen of the 22 eyes underwent silicone oil removal within four months of injection, while the remaining eight eyes underwent silicone removal after four months. Of the 19 eyes that were com pletely reattached posterior to the buckle at the time of silicone removal, only two eyes (11%) developed postoperative recurrent retinal de tachment. All three eyes with partial retinal detachment posterior to the encircling scleral buckle at the time of silicone removal devel oped a total retinal detachment postoperatively. Corneal decompensation had occurred by the six-month examination in eight eyes (17%), within 12 months in 14 eyes (30%), and by 24 months in 20 of the 47 eyes (43%) (Fig. 3). Only two eyes underwent inferior peripheral iridectomy as described by Ando, 15 most procedures being done before the advent of this technique. Two eyes underwent penetrating keratoplasty at the time of silicone oil removal and one additional eye received a superficial keratectomy without removal of the oil. Corneal decom pensation usually was associated with exten sive and prolonged contact of the silicone oil with the corneal endothelium. A barrier be tween the silicone oil and the cornea afforded by the crystalline lens or an intact posterior lens capsule markedly reduced the likelihood of corneal decompensation, with corneal opacification noted in only one of nine eyes with such a barrier. The relationship between the timing of sili cone oil removal and the development of corne al decompensation was investigated. Six of the
14 eyes (43%) undergoing early silicone remov al (before four months) and four of the eight eyes (50%) in which the silicone oil was re moved after four months developed corneal decompensation. Four eyes remained phakic with clear lenses at the end of the primary silicone oil procedure. All of these patients had developed a cataract by the two-year follow-up examination, with three of the four lenses becoming cataractous within the first six months after surgery. Increased intraocular pressure above 25 mm Hg was present at the six-month examination in one eye (2%), at one year in zero eyes, and at two years in five of the 47 eyes (11%). Hypotony was a more common finding. The intra ocular pressure was less than 5 mm Hg in six eyes (13%) at six months, five eyes (11%) at one year, and in 12 of the 47 eyes (26%) at two years. There was no correlation with anatomic or visual outcome between normotensive and hypotonous eyes. Two of the 47 eyes were enucleated between six months and two years after the silicone oil procedure. Both of these operations were per formed because the patients had no useful vision and chronic ocular pain.
Discussion The use of silicone oil in conjunction with sophisticated vitreous surgical techniques has allowed retinal reattachment in some eyes pre viously considered unsalvageable. 29 Despite
iooSOBO"
X
E V E S
70BO"
Fig. 3 (Sell and associates). Per centage of eyes with corneal de compensation at six-month, oneand two-year visits after silicone oil surgery.
BO40-
soso-
ioo-
B
MO
1
YR
2
1
Vol. 103, No. 1
Vitrectomy With Silicone Oil
encouraging short-term results, the potential long-term complications associated with the use of liquid silicone have led some investiga tors to recommend against its clinical use. 1213 In this study, we analyzed the six-month, oneyear, and two-year data on patients undergoing silicone oil injection in combination with vitrec tomy for recurrent retinal detachment compli cated by advanced proliferative vitreoretinopathy in order to correlate the short-term anatomic and visual results with those over a more extended follow-up period. The retina was completely reattached poste rior to the encircling scleral buckle in 31 of the 42 eyes (74%) in which media clarity allowed retinal examination at six months after the silicone oil procedure. As 24 of these 31 retinas (77%) were still attached through the two-year follow-up examinations, we conclude that, in general, the early anatomic successes achieved with silicone oil are well maintained with long er follow-up.
27
Despite the relatively low fall-off in retinal reattachment between six and 24 months, we did note a significant progressive loss of visual function during this period. In those 31 eyes in which the retina was attached posterior to the buckle at six months, stabilization or improve ment in vision from the six-month to the twoyear follow-up examinations occurred in 17 (55%), while a decrease in visual acuity was noted in 14 (45%). Of the eyes that were suc cessfully operated on and subsequently lost vision between six months and two years, corneal decompensation, rather than recurrent retinal detachment, glaucoma, hypotony, or cataract, was the primary cause (Table). This is in contrast to Chan and Okun's series 11 in which the prominent cause of late visual failure was recurrent detachment. It is not possible to determine reliably whether or not any retinal toxicity secondary to silicone oil may have also played a role in the observed visual loss be cause of our inability to detect accurately clini-
TABLE PATIENTS WITH ANATOMIC SUCCESS AT SIX MONTHS WHO LOST VISUAL ACUITY
<;ORNEAL STATUS
VISUAL ACUITY 6 MO
12 MO
1
20/400
20/400
5/200
Clear
2
5/200
HM
LP
3
CF
CF
HM
4
20/200
CF
HM
Slightly hazy Slightly hazy Clear
5 6 7 8 9
CF 5/200 5/200 HM 20/80
CF CF 5/200 HM 20/80
HM CF HM LP 20/200
Clear Clear Clear Clear Clear
10
20/400
20/400
CF
11 12
HM CF
HM CF
LP HM
13
20/400
CF
HM
14
5/200
CF
CF
Slightly hazy Clear Slightly hazy Slightly hazy Clear
NO.
24 MO
6 MO
RETINAL STATUS*
12 MO
24 MO
Slightly hazy Hazy Slightly hazy Slightly hazy Clear Hazy Clear Clear Clear Hazy Clear Slightly hazy Slightly hazy Clear
REASON FOR DECREASED
12 MO
24 MO
Slightly hazy Hazy
AT
AT
Macular pucker
AT
AT
Corneal decompensation
Hazy
AT
AT
Corneal decompensation
Hazy
AT
AT
Corneal decompensation
Clear Hazy Clear Clear Slightly hazy Hazy
PDT AT AT AT PDT
DT AT AT AT AT
Recurrent detachment Corneal decompensation Unknown Unknown Mild corneal decompensation
AT
AT
Corneal decompensation
Clear Hazy
AT AT
UK AT
Dense cataract Corneal decompensation
Hazy
AT
UK
Corneal decompensation
Clear
AT
DT
Macular pucker
VISUAL ACUITY
*UK, unknown, could not determine; AT, attached posterior to buckle; PDT, partially detached posterior to buckle, macula on; and DT, detached posterior to buckle, macula off.
28
January, 1987
AMERICAN JOURNAL OF OPHTHALMOLOGY
cal e v i d e n c e of retinal toxicity in t h e s e compli cated cases. Corneal decompensation eventually devel o p e d d u r i n g follow-up in 20 of t h e 47 e y e s (43%). As m o s t c a s e s of c o r n e a l d e c o m p e n s a tion w e r e associated w i t h silicone-corneal con tact, efforts to k e e p t h e silicone oil a w a y from the corneal e n d o t h e l i u m are i m p o r t a n t . In this series s u r g e r y w a s p e r f o r m e d before t h e a d v e n t of t h e inferior i r i d e c t o m y as d e s c r i b e d by A n d o . 1 5 A n inferior iridectomy r e d u c e s t h e p o s sibility of relative p u p i l l a r y block by t h e sili c o n e oil b u b b l e , t h u s m a k i n g f o r w a r d m o v e m e n t of the silicone oil into the a n t e r i o r c h a m b e r less likely. We s u s p e c t t h a t o u r inci d e n c e of corneal d e c o m p e n s a t i o n a n d s u b s e q u e n t visual loss will p r o v e to be less in o u r m o r e recent cases n o w t h a t we r o u t i n e l y p e r form a n inferior iridectomy in a p h a k i c a n d pseudophakic eyes. In o u r series silicone oil r e m o v a l w a s p e r formed in 22 of the 47 eyes (47%). R e c u r r e n t retinal d e t a c h m e n t o c c u r r e d in only two eyes (11%) w h e n silicone oil w a s r e m o v e d from a n eye w i t h c o m p l e t e retinal r e a t t a c h m e n t p o s t e r i or to the encircling scleral b u c k l e . C o n v e r s e l y , in all t h r e e eyes w i t h partial retinal d e t a c h m e n t p o s t e r i o r to the encircling scleral buckle at t h e time of silicone oil r e m o v a l , total r e c u r r e n t retinal d e t a c h m e n t d e v e l o p e d . We therefore r e c o m m e n d not r e m o v i n g t h e silicone oil in cases of partial retinal d e t a c h m e n t u n l e s s fur t h e r s u r g e r y c a n fully r e a t t a c h the retina p o s terior to the buckle. G o n v e r s 2 r e p o r t e d that the late c o m p l i c a t i o n s of silicone oil w e r e i n f r e q u e n t w h e n the sili c o n e oil w a s r o u t i n e l y r e m o v e d six to eight weeks after injection. In o u r series t h e r e w a s n o correlation w i t h corneal clarity or stability in visual acuity w h e n silicone oil w a s r e m o v e d before or four m o n t h s after injection. O n l y two p a t i e n t s w i t h a n a t o m i c success h a d silicone oil r e m o v e d before two m o n t h s . Based o n o u r d a t a , we c a n n o t d e t e r m i n e t h e a p p r o p r i a t e tim ing or i n d i c a t i o n s for silicone oil r e m o v a l . A l t h o u g h the u s e of silicone oil allows s u c cessful retinal r e a t t a c h m e n t in s o m e cases of o t h e r w i s e intractable retinal d e t a c h m e n t , t h e d e v e l o p m e n t of major l o n g - t e r m c o m p l i c a t i o n s associated w i t h p r o g r e s s i v e d e t e r i o r a t i o n of visual function over time reinforces o u r belief that silicone oil s h o u l d be r e s e r v e d o n l y for those cases of complex retinal d e t a c h m e n t n o t a m e n a b l e to c o n v e n t i o n a l v i t r e c t o m y tech niques.
References 1. Rinkoff, J. S., de Juan, E., and McCuen, B. W.: Silicone oil for retinal detachment with advanced proliferative vitreoretinopathy following failed vi trectomy for proliferative diabetic retinopathy. Am. J. Ophthalmol. 101:181, 1986. 2. Gonvers, M : Temporary silicone oil tamponade in the management of retinal detachment with prolif erative vitreoretinopathy. Am. J. Ophthalmol. 100:239, 1985. 3. McCuen, B. W., de Juan, E., and Machemer, R.: Silicone oil in vitreoretinal surgery. Part 1. Surgical techniques. Retina 5:189, 1985. 4. McCuen, B. W., de Juan, E., Landers, M. B., and Machemer, R.: Silicone oil in vitreoretinal sur gery. Part 2. Management of complications. Retina 5:198, 1985. 5. Zivojnovic, R., Mertens, D. A. E., and Peperkamp, E.: Das fluessige Silikon in der Amotiochirurgie (II) Bericht Ueber 280 Faelle - weitere Entwicklung der Technik. Klin. Monatsbl. Augenheilkd. 181:444, 1982. 6. McCuen, B. W., Landers, M. B., and Machemer, R.: The use of silicone oil following failed vitrectomy for retinal detachment with advanced proliferative vitreoretinopathy. Ophthalmology 92:1029, 1985. 7. Diddie, K. R., Stern, W. H., Ober, R. R., Irvine, A., and Ryan, S. J.: Intraocular silicone oil for recurrent proliferative vitreoretinopathy in vitrectomized eyes. ARVO Abstracts. Supplement to Invest. Ophthalmol. Vis. Sci. Philadelphia, J. B. Lippincott, 1983, p. 173. 8. Fletcher, M. E., and Peyman, G. A.: A simpli fied technique for the removal of liquid silicone from vitrectomized eyes. Retina 5:168, 1985. 9. Cox, M. S., and Trese, M. T.: Silicone oil for advanced proliferative vitreoretinopathy. Ophthal mology 93:646, 1986. 10. Leaver, P. K., Grey, R. H. B., and Garner, A.: Silicone oil injection in the treatment of massive preretinal retraction. II. Late complications in 93 eyes. Br. J. Ophthalmol. 63:361, 1979. 11. Chan, C , and Okun, E.: The question of ocular tolerance to intravitreal liquid silicone. Ophthalmol ogy 93:651, 1986. 12. Watzke, R. C : Silicone retinopiesis for retinal detachment. Arch. Ophthalmol. 77:185, 1967. 13. Cockerman, W. D., Schepens, C. L., and Freeman, H. M.: Silicone injection in retinal detach ment. Arch. Ophthalmol. 83:704, 1970. 14. The Retina Society Terminology Committee: The classification of retinal detachment with prolifer ative vitreoretinopathy. Ophthalmology 90:121, 1983. 15. Ando, F.: Intraocular hypertension resulting from pupillary block by silicone oil. Am. J. Ophthal mol. 99:87, 1985.
We have analyzed the six-month, one-year, and two-year follow-up examinations in 47 patients who had silicone oil injection in com bination with revision of vitrectomy for intrac table retinal detachment and advanced prolif erative vitreoretinopathy. A visual acuity of 5/200 or better was attained in 22 eyes at six months (47%), 17 eyes at one year (36%), and 14 eyes at two years (30%). Of eyes that were completely attached posterior to the buckle at six months, 77% remained attached at two years. In those eyes that were attached at six months, corneal decompensation was the most frequent cause of a loss of vision between six months and two years. Silicone oil was re moved in 22 eyes (47%). THE USE OF SILICONE OIL in the treatment of
complicated retinal detachments has been the subject of renewed interest. 19 Long-term follow-up of the early techniques of silicone oil surgery, however, demonstrated a high inci dence of late complications 1011 and poor visual results. 1213 Modern techniques combining vi trectomy and membrane peeling with silicone oil injection have produced encouraging shortterm results in complex retinal detachments. 2 " 6,9 The long-term effects of these techniques, how ever, remain controversial. The purpose of this report is to provide a two-year follow-up on those eyes that were anatomically successful six months after vitrectomy with silicone oil injection.
Material and Methods The records of all patients at the Duke Eye Center between August 1981 and August 1984 with recurrent retinal detachment with prolif erative vitreoretinopathy of grade C3 or greater in whom revision of vitrectomy with silicone oil injection was performed were reviewed. Eyes with retinal detachment that resulted from penetrating ocular trauma, giant retinal tears, or proliferative diabetic retinopathy were ex cluded. Of the 57 patients with a potential for a two-year follow-up, 47 patients had complete six-month, one-year, and two-year examina tions and constitute the database for this re port. All eyes had a complete preoperative ocular examination including visual acuity testing, measurement of intraocular pressure, slit-lamp examination, and contact lens and binocular indirect ophthalmoscopy. The retinal detach ment was graded with respect to the degree of proliferative vitreoretinopathy according to the Retina Society classification.14 Follow-up visits were scheduled six, 12, and 24 months after surgery. At each follow-up visit, a complete examination was performed. Anatomic success was defined as complete retinal reattachment posterior to the encircling scleral buckle.
Results Accepted for publication Oct. 14, 1986. From the Department of Ophthalmology, Duke Uni versity Eye Center, Durham, North Carolina. This study was supported by the Adler Foundation and the Nation al Society to Prevent Blindness, Research to Prevent Blindness, Inc., National Eye Institute (EY05903, EY05741, and EY02903), and the Helena Rubinstein Foundation. Reprint requests to Brooks W. McCuen II, M.D., Box 3802, Duke University Eye Center, Durham, NC 27710.
24
In 42 of the 47 eyes (89%) the ocular media were clear enough to assess the status of the retina. The retina was noted to be entirely reattached posterior to the encircling scleral buckle at the six-month follow-up examination in 31 of these 42 eyes (74%). In five of the 31 eyes (16%) with an attached retina, one or more additional retinal operations had been per formed before the six-month examination. Of
©AMERICAN JOURNAL OF OPHTHALMOLOGY 103:24-28, JANUARY, 1987
Vol. 103, No. 1
Vitrectomy With Silicone Oil
25
lOO SO X
E Y
SO 70
Fig. 1 (Sell and associates). Per centage of retinas successfully reattached posterior to the encircling scleral buckle at six-month, oneand two-year visits after silicone oil surgery.
60 BO 40 30 SO
io o
6
MO
1
YH
2
the 31 eyes with attached retinas at six months, 27 retinas (87%) were also completely attached posterior to the encircling scleral buckle at the 12-month follow-up examination, and 24 (77%) at the two-year follow-up examination. Over all, at the 24-month examinations 27 of the 42 eyes (64%) in which the retina could be visual ized were successfully reattached (Fig. 1). There was a gradual decrease in visual acuity between six months and two years after silicone injection. A visual acuity of 5/200 or better was achieved in 22 of 47 eyes (47%) at six months, in 17 eyes (36%) at one year, and in 14 eyes (30%) at two years (Fig. 2). Overall, visual acuity improved in ten eyes from the six-month to the two-year follow-up, stayed the same in 15 eyes,
YR
and deteriorated in 22 of the 47 eyes. Of those 31 eyes considered anatomically successful at six months, visual acuity at two years was better in eight eyes (26%), the same in nine eyes (29%), and worse in 14 eyes (45%) than the visual acuity measured at six months. Factors accounting for the decrease in visual acuity between six months and two years noted in the 14 eyes included the following: late corneal decompensation (eight eyes), progressive macular pucker (two eyes), recurrent retinal de tachment (one eye), severe cataract (one eye), and unexplained visual loss (two eyes). Silicone oil was removed in 22 of the 47 eyes (47%). The time of silicone oil removal from injection ranged from three days to 26 months
100
so ao TO
Fig. 2 (Sell and associates). Per centage of eyes with visual acuity better than or equal to 5/200 at six-month, one- and two-year visits after silicone oil surgery.
CO BO 40 SO
so IO
o
MO
YH
S
YR
26
January, 1987
AMERICAN JOURNAL OF OPHTHALMOLOGY
with an average of 6.2 months. Fourteen of the 22 eyes underwent silicone oil removal within four months of injection, while the remaining eight eyes underwent silicone removal after four months. Of the 19 eyes that were com pletely reattached posterior to the buckle at the time of silicone removal, only two eyes (11%) developed postoperative recurrent retinal de tachment. All three eyes with partial retinal detachment posterior to the encircling scleral buckle at the time of silicone removal devel oped a total retinal detachment postoperatively. Corneal decompensation had occurred by the six-month examination in eight eyes (17%), within 12 months in 14 eyes (30%), and by 24 months in 20 of the 47 eyes (43%) (Fig. 3). Only two eyes underwent inferior peripheral iridectomy as described by Ando, 15 most procedures being done before the advent of this technique. Two eyes underwent penetrating keratoplasty at the time of silicone oil removal and one additional eye received a superficial keratectomy without removal of the oil. Corneal decom pensation usually was associated with exten sive and prolonged contact of the silicone oil with the corneal endothelium. A barrier be tween the silicone oil and the cornea afforded by the crystalline lens or an intact posterior lens capsule markedly reduced the likelihood of corneal decompensation, with corneal opacification noted in only one of nine eyes with such a barrier. The relationship between the timing of sili cone oil removal and the development of corne al decompensation was investigated. Six of the
14 eyes (43%) undergoing early silicone remov al (before four months) and four of the eight eyes (50%) in which the silicone oil was re moved after four months developed corneal decompensation. Four eyes remained phakic with clear lenses at the end of the primary silicone oil procedure. All of these patients had developed a cataract by the two-year follow-up examination, with three of the four lenses becoming cataractous within the first six months after surgery. Increased intraocular pressure above 25 mm Hg was present at the six-month examination in one eye (2%), at one year in zero eyes, and at two years in five of the 47 eyes (11%). Hypotony was a more common finding. The intra ocular pressure was less than 5 mm Hg in six eyes (13%) at six months, five eyes (11%) at one year, and in 12 of the 47 eyes (26%) at two years. There was no correlation with anatomic or visual outcome between normotensive and hypotonous eyes. Two of the 47 eyes were enucleated between six months and two years after the silicone oil procedure. Both of these operations were per formed because the patients had no useful vision and chronic ocular pain.
Discussion The use of silicone oil in conjunction with sophisticated vitreous surgical techniques has allowed retinal reattachment in some eyes pre viously considered unsalvageable. 29 Despite
iooSOBO"
X
E V E S
70BO"
Fig. 3 (Sell and associates). Per centage of eyes with corneal de compensation at six-month, oneand two-year visits after silicone oil surgery.
BO40-
soso-
ioo-
B
MO
1
YR
2
1
Vol. 103, No. 1
Vitrectomy With Silicone Oil
encouraging short-term results, the potential long-term complications associated with the use of liquid silicone have led some investiga tors to recommend against its clinical use. 1213 In this study, we analyzed the six-month, oneyear, and two-year data on patients undergoing silicone oil injection in combination with vitrec tomy for recurrent retinal detachment compli cated by advanced proliferative vitreoretinopathy in order to correlate the short-term anatomic and visual results with those over a more extended follow-up period. The retina was completely reattached poste rior to the encircling scleral buckle in 31 of the 42 eyes (74%) in which media clarity allowed retinal examination at six months after the silicone oil procedure. As 24 of these 31 retinas (77%) were still attached through the two-year follow-up examinations, we conclude that, in general, the early anatomic successes achieved with silicone oil are well maintained with long er follow-up.
27
Despite the relatively low fall-off in retinal reattachment between six and 24 months, we did note a significant progressive loss of visual function during this period. In those 31 eyes in which the retina was attached posterior to the buckle at six months, stabilization or improve ment in vision from the six-month to the twoyear follow-up examinations occurred in 17 (55%), while a decrease in visual acuity was noted in 14 (45%). Of the eyes that were suc cessfully operated on and subsequently lost vision between six months and two years, corneal decompensation, rather than recurrent retinal detachment, glaucoma, hypotony, or cataract, was the primary cause (Table). This is in contrast to Chan and Okun's series 11 in which the prominent cause of late visual failure was recurrent detachment. It is not possible to determine reliably whether or not any retinal toxicity secondary to silicone oil may have also played a role in the observed visual loss be cause of our inability to detect accurately clini-
TABLE PATIENTS WITH ANATOMIC SUCCESS AT SIX MONTHS WHO LOST VISUAL ACUITY
<;ORNEAL STATUS
VISUAL ACUITY 6 MO
12 MO
1
20/400
20/400
5/200
Clear
2
5/200
HM
LP
3
CF
CF
HM
4
20/200
CF
HM
Slightly hazy Slightly hazy Clear
5 6 7 8 9
CF 5/200 5/200 HM 20/80
CF CF 5/200 HM 20/80
HM CF HM LP 20/200
Clear Clear Clear Clear Clear
10
20/400
20/400
CF
11 12
HM CF
HM CF
LP HM
13
20/400
CF
HM
14
5/200
CF
CF
Slightly hazy Clear Slightly hazy Slightly hazy Clear
NO.
24 MO
6 MO
RETINAL STATUS*
12 MO
24 MO
Slightly hazy Hazy Slightly hazy Slightly hazy Clear Hazy Clear Clear Clear Hazy Clear Slightly hazy Slightly hazy Clear
REASON FOR DECREASED
12 MO
24 MO
Slightly hazy Hazy
AT
AT
Macular pucker
AT
AT
Corneal decompensation
Hazy
AT
AT
Corneal decompensation
Hazy
AT
AT
Corneal decompensation
Clear Hazy Clear Clear Slightly hazy Hazy
PDT AT AT AT PDT
DT AT AT AT AT
Recurrent detachment Corneal decompensation Unknown Unknown Mild corneal decompensation
AT
AT
Corneal decompensation
Clear Hazy
AT AT
UK AT
Dense cataract Corneal decompensation
Hazy
AT
UK
Corneal decompensation
Clear
AT
DT
Macular pucker
VISUAL ACUITY
*UK, unknown, could not determine; AT, attached posterior to buckle; PDT, partially detached posterior to buckle, macula on; and DT, detached posterior to buckle, macula off.
28
January, 1987
AMERICAN JOURNAL OF OPHTHALMOLOGY
cal e v i d e n c e of retinal toxicity in t h e s e compli cated cases. Corneal decompensation eventually devel o p e d d u r i n g follow-up in 20 of t h e 47 e y e s (43%). As m o s t c a s e s of c o r n e a l d e c o m p e n s a tion w e r e associated w i t h silicone-corneal con tact, efforts to k e e p t h e silicone oil a w a y from the corneal e n d o t h e l i u m are i m p o r t a n t . In this series s u r g e r y w a s p e r f o r m e d before t h e a d v e n t of t h e inferior i r i d e c t o m y as d e s c r i b e d by A n d o . 1 5 A n inferior iridectomy r e d u c e s t h e p o s sibility of relative p u p i l l a r y block by t h e sili c o n e oil b u b b l e , t h u s m a k i n g f o r w a r d m o v e m e n t of the silicone oil into the a n t e r i o r c h a m b e r less likely. We s u s p e c t t h a t o u r inci d e n c e of corneal d e c o m p e n s a t i o n a n d s u b s e q u e n t visual loss will p r o v e to be less in o u r m o r e recent cases n o w t h a t we r o u t i n e l y p e r form a n inferior iridectomy in a p h a k i c a n d pseudophakic eyes. In o u r series silicone oil r e m o v a l w a s p e r formed in 22 of the 47 eyes (47%). R e c u r r e n t retinal d e t a c h m e n t o c c u r r e d in only two eyes (11%) w h e n silicone oil w a s r e m o v e d from a n eye w i t h c o m p l e t e retinal r e a t t a c h m e n t p o s t e r i or to the encircling scleral b u c k l e . C o n v e r s e l y , in all t h r e e eyes w i t h partial retinal d e t a c h m e n t p o s t e r i o r to the encircling scleral buckle at t h e time of silicone oil r e m o v a l , total r e c u r r e n t retinal d e t a c h m e n t d e v e l o p e d . We therefore r e c o m m e n d not r e m o v i n g t h e silicone oil in cases of partial retinal d e t a c h m e n t u n l e s s fur t h e r s u r g e r y c a n fully r e a t t a c h the retina p o s terior to the buckle. G o n v e r s 2 r e p o r t e d that the late c o m p l i c a t i o n s of silicone oil w e r e i n f r e q u e n t w h e n the sili c o n e oil w a s r o u t i n e l y r e m o v e d six to eight weeks after injection. In o u r series t h e r e w a s n o correlation w i t h corneal clarity or stability in visual acuity w h e n silicone oil w a s r e m o v e d before or four m o n t h s after injection. O n l y two p a t i e n t s w i t h a n a t o m i c success h a d silicone oil r e m o v e d before two m o n t h s . Based o n o u r d a t a , we c a n n o t d e t e r m i n e t h e a p p r o p r i a t e tim ing or i n d i c a t i o n s for silicone oil r e m o v a l . A l t h o u g h the u s e of silicone oil allows s u c cessful retinal r e a t t a c h m e n t in s o m e cases of o t h e r w i s e intractable retinal d e t a c h m e n t , t h e d e v e l o p m e n t of major l o n g - t e r m c o m p l i c a t i o n s associated w i t h p r o g r e s s i v e d e t e r i o r a t i o n of visual function over time reinforces o u r belief that silicone oil s h o u l d be r e s e r v e d o n l y for those cases of complex retinal d e t a c h m e n t n o t a m e n a b l e to c o n v e n t i o n a l v i t r e c t o m y tech niques.
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