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Removal of Solid Silicone Rubber Exoplants After Retinal Detachment Surgery
REMOVAL OF SOLID SILICONE RUBBER EXOPLANTS AFTER RETINAL DETACHMENT SURGERY ROBERT A. WIZNIA, M.D. New Haven, Connecticut
A prospective study of 255 eyes undergoing scierai buckling proce dures with solid silicone rubber elements as exoplants disclosed a 1.2% incidence (three of 255 eyes) of buckling element removal after a minimum follow-up period of two years. This rate was lower than that reported in series using solid silicone rubber implants or sponge silicone rubber exoplants. Most retinal detachment operations in volve placement of permanent scierai buckling elements. An infrequent but serious complication of such surgery is the exposure of these elements; associat ed ocular inflammation and discomfort necessitate their removal. Previous attempts to determine the surgical technique that produces the low est incidence of this complication have been retrospective. Higher removal rates were found in cases in which the mini mum postoperative follow-up periods were longer. Reported rates of element removal in cases in which sponge silicone exoplants were used have ranged from 1.3% to 24%.1_7 In studies in which sponge exoplants were used and the mini mum postsurgical follow-up was six months, investigators found removal rates between 4% and 24%.^7 Solid sili cone rubber implants buried beneath scierai flaps had a 2.3% removal rate in a series with a six-month minimum followup8 and a 4.9% removal rate in a study
Accepted for publication Jan. 31, 1983. From the Retina Service, Section of Ophthalmolo gy, Department of Surgery, Hospital of St. Raphael, and the Department of Ophthalmology and Visual Science, Yale University School of Medicine, New Haven, Connecticut. Reprint requests to Robert A. Wiznia, M.D., 850 Howard Ave., New Haven, CT 06519.
with a 12-month minimum follow-up.9 Hilton and Wallyn5 reported a series with a six-month minimum follow-up in which solid silicone rubber exoplants were su tured to the scierai surface. The scierai buckle removal rate was 0.5%. I undertook a prospective study to de termine the long-term rate of scierai buckle removal in cases in which the solid silicone exoplant technique was used and to compare this rate with the long-term rates reported with other common tech niques: sponge silicone rubber exoplants and solid silicone rubber implants. SUBJECTS AND METHODS
From August 1975 through February 1980, I treated 261 eyes with rhegmatogenous retinal detachments by scierai buckling with cryotherapy applied to reti nal breaks, drainage of subretinal fluid when required, and placement of solid silicone rubber scierai buckling elements as encircling exoplants. This method of suturing solid silicone rubber elements to the outer surface of the sclera to achieve an encircling 360-degree buckle has been reported previously.10 Seventeen of these eyes had more than one operation, for a total of 282 procedures. The postsurgical follow-up periods ranged from a mini mum of 24 months to a maximum of 79 months (mean, 43 months). Of the 261 eyes, four were excluded because the
©AMERICAN JOURNAL OF OPHTHALMOLOGY 95:495-497, 1983
495
496
AMERICAN JOURNAL OF OPHTHALMOLOGY
APRIL, 1983
patients failed to return for follow-up examinations and two were excluded be cause the patients died before the twoyear minimum follow-up period was com plete. The analysis thus included 255 eyes that underwent primary procedures; 16 of these eyes also underwent second and third operations (Table), making a total of 275 procedures. The patients were examined as often as necessary during the first six months after surgery and then every six months for an additional 18 months. Any patient with ocular symptoms (discomfort, irritation, and the like) or abnormal findings was examined more often. After two years, the follow-up examinations were done annually unless the situation warranted more frequent visits. When an opening in the bulbar con junctiva and Tenon's layer disclosed an exposed buckling element, I prescribed topical antibiotic therapy. The choice of therapy was dictated by culture results. I recommended removal of the solid sili cone rubber materials if ocular inflamma tion and discomfort developed or persist ed despite antibiotic therapy.
one operation. In two of the three eyes, cultures were positive for Staphylococcus albus. In one of these cases, the exoplant, despite exposure, was well tolerated for two years. The other two scierai buckles, despite similar treatment with topical an tibiotics, had to be removed within three months of exposure. Sites of exoplant exposure were different in each case. Only one of the three eyes required a relatively large, 10-mm wide No. 280 exoplant. In the other two eyes 7-mm wide No. 276 exoplants were used. One of the three patients had diabetes mellitus, a condition frequently associated with poorer tissue healing capabilities after surgical procedures. In all three cases the conjunctival injection resolved and the patients' discomfort lessened within a few days of exoplant removal. In none of the three did retinal detachment or scierai necrosis occur. Thus, the exposure incidence was 0.4% for the first six months after surgery, and the removal rates were 0.8% in eyes that had only one operation, 6% in eyes that had more than one operation, and 1.2% overall.
RESULTS
DISCUSSION
Of the 255 eyes included in this series, three eventually required exoplant re moval because of exposure. One scierai buckle became exposed within two months of the retinal detachment sur gery. Exposure occurred in two other eyes 26 and 34 months after surgery. One of these eyes had undergone more than
Burying solid silicone rubber elements beneath an additional layer of scierai flaps does not decrease the need for scierai buckle removal. Yoshizumi 8 reported a 2.3% removal rate in a retrospective study. All eyes that underwent scierai buckle removal had exposed implants, but only 76.5% had ocular pain or con-
TABLE I N C I D E N C E O F BUCKLE REMOVAL
Scierai Buckle Removal
Type of Procedure
No. of Procedures
No. of Eyes
No.
%
Primary Secondary Total
255 20 275
255 16 255
2 1 3
0.8 6.0 1.2
VOL. 95, NO. 4
SILICONE RUBBER EXOPLANTS
junctival hyperemia or both. Stratford9 noted a 4.9% rate of removal, but did not indicate the number of eyes with exposed implants. Infection was the reason for removal in 73.9% of his cases. Sponge silicone exoplants also have a higher inci dence of removal, ranging from 4% to 24% in several series with six-month min imum follow-up periods.2"7 Using solid silicone rubber elements as exoplants compares favorably with these other methods in terms of the incidence of scierai buckle removal. Solid silicone rubber exoplants have an excellent reten tion rate. Although S. alhus was identified in two of three cases at the time of element removal, the infection may have devel oped secondarily after the exposure of the exoplant had already occurred. This or ganism is relatively common in routine conjunctival cultures. In one of the eyes with a positive culture, the scierai buckle was tolerated for two additional years. Treatment with topical antibiotics should be attempted, particularly in cases in which exposure occurs soon after retinal detachment surgery because retention of the scierai buckle for one year or longer is associated with a much lower rate of redetachment.8,11 In this series all the exoplants that required removal had been
497
in place for more than two years, and no redetachments occurred. REFERENCES 1. Flindall, R. J., Norton, E. W. D., Curtin, V. T., and Gass, J. D. M.: Reduction of extrusion and infection following episcleral silicone implants and cryopexy in retinal detachment surgery. Am. J. Ophthalmol. 71:835, 1971. 2. Hahn, Y. S., Lincoff, A., Lineoff, H., and Kreissig, I.: Infection after sponge implantation for scierai buckling. Am. J. Ophthalmol. 87:180, 1979. 3. Lincoff, H., Nadel, A., and O'Connor, P.: The changing character of the infected scierai implant. Arch. Ophthalmol. 84:421, 1970. 4. McPherson, A., and Moura, R.: Full-thickness scierai buckling in retinal detachment surgery. A review of 447 cases. In Pruett, R. C , and Regan, C. D. J. (eds.): Retina Congress. New York, Appleton-Century-Crofts, 1972, pp. 325-353. 5. Hilton, G. F., andWallyn, R. H.: The removal of scierai buckles. Arch. Ophthalmol. 96:2061, 1978. 6. Ulrich, R. A., and Burton, T. C : Infections following scierai buckling procedures. Arch. Oph thalmol. 92:213, 1974. 7. Russo, C. E., and Ruiz, R. S.: Silicone sponge rejection. Arch. Ophthalmol. 85:647, 1971. 8. Yoshizumi, M. O.: Exposure of intrascleral im plants. Ophthalmology 87:1150, 1980. 9. Stratford, T. P. : Fate of the reattached retina following removal of silicone elements. In Pruett, R. C , and Regan, C. D. J. (eds.): Retina Congress. New York, Appleton-Century-Crofts, 1972, pp. 623628. 10. Aaberg, T. M., and Wiznia, R. A.: The use of solid soft silicone rubber exoplants in retinal detach ment surgery. Ophthalmic Surg. 7:98, 1976. 11. Schwartz, P. L., and Pruett, R. C : Factors influencing retinal redetachment after removal of buckling elements. Arch. Ophthalmol. 95:804, 1977.
A prospective study of 255 eyes undergoing scierai buckling proce dures with solid silicone rubber elements as exoplants disclosed a 1.2% incidence (three of 255 eyes) of buckling element removal after a minimum follow-up period of two years. This rate was lower than that reported in series using solid silicone rubber implants or sponge silicone rubber exoplants. Most retinal detachment operations in volve placement of permanent scierai buckling elements. An infrequent but serious complication of such surgery is the exposure of these elements; associat ed ocular inflammation and discomfort necessitate their removal. Previous attempts to determine the surgical technique that produces the low est incidence of this complication have been retrospective. Higher removal rates were found in cases in which the mini mum postoperative follow-up periods were longer. Reported rates of element removal in cases in which sponge silicone exoplants were used have ranged from 1.3% to 24%.1_7 In studies in which sponge exoplants were used and the mini mum postsurgical follow-up was six months, investigators found removal rates between 4% and 24%.^7 Solid sili cone rubber implants buried beneath scierai flaps had a 2.3% removal rate in a series with a six-month minimum followup8 and a 4.9% removal rate in a study
Accepted for publication Jan. 31, 1983. From the Retina Service, Section of Ophthalmolo gy, Department of Surgery, Hospital of St. Raphael, and the Department of Ophthalmology and Visual Science, Yale University School of Medicine, New Haven, Connecticut. Reprint requests to Robert A. Wiznia, M.D., 850 Howard Ave., New Haven, CT 06519.
with a 12-month minimum follow-up.9 Hilton and Wallyn5 reported a series with a six-month minimum follow-up in which solid silicone rubber exoplants were su tured to the scierai surface. The scierai buckle removal rate was 0.5%. I undertook a prospective study to de termine the long-term rate of scierai buckle removal in cases in which the solid silicone exoplant technique was used and to compare this rate with the long-term rates reported with other common tech niques: sponge silicone rubber exoplants and solid silicone rubber implants. SUBJECTS AND METHODS
From August 1975 through February 1980, I treated 261 eyes with rhegmatogenous retinal detachments by scierai buckling with cryotherapy applied to reti nal breaks, drainage of subretinal fluid when required, and placement of solid silicone rubber scierai buckling elements as encircling exoplants. This method of suturing solid silicone rubber elements to the outer surface of the sclera to achieve an encircling 360-degree buckle has been reported previously.10 Seventeen of these eyes had more than one operation, for a total of 282 procedures. The postsurgical follow-up periods ranged from a mini mum of 24 months to a maximum of 79 months (mean, 43 months). Of the 261 eyes, four were excluded because the
©AMERICAN JOURNAL OF OPHTHALMOLOGY 95:495-497, 1983
495
496
AMERICAN JOURNAL OF OPHTHALMOLOGY
APRIL, 1983
patients failed to return for follow-up examinations and two were excluded be cause the patients died before the twoyear minimum follow-up period was com plete. The analysis thus included 255 eyes that underwent primary procedures; 16 of these eyes also underwent second and third operations (Table), making a total of 275 procedures. The patients were examined as often as necessary during the first six months after surgery and then every six months for an additional 18 months. Any patient with ocular symptoms (discomfort, irritation, and the like) or abnormal findings was examined more often. After two years, the follow-up examinations were done annually unless the situation warranted more frequent visits. When an opening in the bulbar con junctiva and Tenon's layer disclosed an exposed buckling element, I prescribed topical antibiotic therapy. The choice of therapy was dictated by culture results. I recommended removal of the solid sili cone rubber materials if ocular inflamma tion and discomfort developed or persist ed despite antibiotic therapy.
one operation. In two of the three eyes, cultures were positive for Staphylococcus albus. In one of these cases, the exoplant, despite exposure, was well tolerated for two years. The other two scierai buckles, despite similar treatment with topical an tibiotics, had to be removed within three months of exposure. Sites of exoplant exposure were different in each case. Only one of the three eyes required a relatively large, 10-mm wide No. 280 exoplant. In the other two eyes 7-mm wide No. 276 exoplants were used. One of the three patients had diabetes mellitus, a condition frequently associated with poorer tissue healing capabilities after surgical procedures. In all three cases the conjunctival injection resolved and the patients' discomfort lessened within a few days of exoplant removal. In none of the three did retinal detachment or scierai necrosis occur. Thus, the exposure incidence was 0.4% for the first six months after surgery, and the removal rates were 0.8% in eyes that had only one operation, 6% in eyes that had more than one operation, and 1.2% overall.
RESULTS
DISCUSSION
Of the 255 eyes included in this series, three eventually required exoplant re moval because of exposure. One scierai buckle became exposed within two months of the retinal detachment sur gery. Exposure occurred in two other eyes 26 and 34 months after surgery. One of these eyes had undergone more than
Burying solid silicone rubber elements beneath an additional layer of scierai flaps does not decrease the need for scierai buckle removal. Yoshizumi 8 reported a 2.3% removal rate in a retrospective study. All eyes that underwent scierai buckle removal had exposed implants, but only 76.5% had ocular pain or con-
TABLE I N C I D E N C E O F BUCKLE REMOVAL
Scierai Buckle Removal
Type of Procedure
No. of Procedures
No. of Eyes
No.
%
Primary Secondary Total
255 20 275
255 16 255
2 1 3
0.8 6.0 1.2
VOL. 95, NO. 4
SILICONE RUBBER EXOPLANTS
junctival hyperemia or both. Stratford9 noted a 4.9% rate of removal, but did not indicate the number of eyes with exposed implants. Infection was the reason for removal in 73.9% of his cases. Sponge silicone exoplants also have a higher inci dence of removal, ranging from 4% to 24% in several series with six-month min imum follow-up periods.2"7 Using solid silicone rubber elements as exoplants compares favorably with these other methods in terms of the incidence of scierai buckle removal. Solid silicone rubber exoplants have an excellent reten tion rate. Although S. alhus was identified in two of three cases at the time of element removal, the infection may have devel oped secondarily after the exposure of the exoplant had already occurred. This or ganism is relatively common in routine conjunctival cultures. In one of the eyes with a positive culture, the scierai buckle was tolerated for two additional years. Treatment with topical antibiotics should be attempted, particularly in cases in which exposure occurs soon after retinal detachment surgery because retention of the scierai buckle for one year or longer is associated with a much lower rate of redetachment.8,11 In this series all the exoplants that required removal had been
497
in place for more than two years, and no redetachments occurred. REFERENCES 1. Flindall, R. J., Norton, E. W. D., Curtin, V. T., and Gass, J. D. M.: Reduction of extrusion and infection following episcleral silicone implants and cryopexy in retinal detachment surgery. Am. J. Ophthalmol. 71:835, 1971. 2. Hahn, Y. S., Lincoff, A., Lineoff, H., and Kreissig, I.: Infection after sponge implantation for scierai buckling. Am. J. Ophthalmol. 87:180, 1979. 3. Lincoff, H., Nadel, A., and O'Connor, P.: The changing character of the infected scierai implant. Arch. Ophthalmol. 84:421, 1970. 4. McPherson, A., and Moura, R.: Full-thickness scierai buckling in retinal detachment surgery. A review of 447 cases. In Pruett, R. C , and Regan, C. D. J. (eds.): Retina Congress. New York, Appleton-Century-Crofts, 1972, pp. 325-353. 5. Hilton, G. F., andWallyn, R. H.: The removal of scierai buckles. Arch. Ophthalmol. 96:2061, 1978. 6. Ulrich, R. A., and Burton, T. C : Infections following scierai buckling procedures. Arch. Oph thalmol. 92:213, 1974. 7. Russo, C. E., and Ruiz, R. S.: Silicone sponge rejection. Arch. Ophthalmol. 85:647, 1971. 8. Yoshizumi, M. O.: Exposure of intrascleral im plants. Ophthalmology 87:1150, 1980. 9. Stratford, T. P. : Fate of the reattached retina following removal of silicone elements. In Pruett, R. C , and Regan, C. D. J. (eds.): Retina Congress. New York, Appleton-Century-Crofts, 1972, pp. 623628. 10. Aaberg, T. M., and Wiznia, R. A.: The use of solid soft silicone rubber exoplants in retinal detach ment surgery. Ophthalmic Surg. 7:98, 1976. 11. Schwartz, P. L., and Pruett, R. C : Factors influencing retinal redetachment after removal of buckling elements. Arch. Ophthalmol. 95:804, 1977.