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Removing silicone oil droplets from the posterior surface of silicone intraocular lenses
techniques
Removing silicone oil droplets from the posterior surface of silicone intraocular lenses Toshiyuki Kageyama, MD, Shigeo Yaguchi, MD ABSTRACT A 67-year-old woman had droplets of silicone oil adhering to her silicone intraocular lens (IOL) resulting from a previous silicone oil tamponade. A lens hook and intraocular irrigation were used in conjunction by inserting an infusion cannula to remove the droplets. This restored clarity of the visual axis, improved visual acuity, and eliminated the need for IOL replacement. The technique is simple and less invasive than IOL exchange and may become the preferred way to remove silicone droplets from an IOL. J Cataract Refract Surg 2000; 26:957–959 © 2000 ASCRS and ESCRS
T
he adhesion of silicone oil droplets to implanted silicone intraocular lenses (IOLs) can cause visual disturbances in patients who had removal of silicone oil used in previous vitreoretinal surgery.1,2 Although aspiration with a soft-tipped extrusion needle or replacement with a viscoelastic agent has been used to remove the oil droplets, it is difficult to remove them from the IOL surface.3–5 Thus, the IOL must be removed and replaced in some cases.1,2 We report a technique to remove silicone droplets on the posterior surface of a silicone IOL using a lens hook.
Surgical Technique An infusion cannula is placed in the inferotemporal pars plana to irrigate the vitreous cavity and anterior chamber with balanced salt solution (BSS威). A cutter is inserted through the limbal incision at the 10 o’clock Accepted for publication January 10, 2000. Reprint requests to Toshiyuki Kageyama, MD, Department of Ophthalmology, Showa University School of Medicine, Fujigaoka Hospital, 1-30 Fujigaoka, Aoba-ku, Yokohama, 227-8501, Japan. © 2000 ASCRS and ESCRS Published by Elsevier Science Inc.
position to aspirate discrete oil bubbles. A lens hook is inserted through the sclerotomy at the 2 o’clock position and is quickly moved from side to side, parallel to the IOL surface, to scrape away the oil droplets (Figure 1).
Case Report A 67-year-old Japanese woman developed non-insulin-dependent diabetes in 1985. In 1995, she developed proliferative diabetic retinopathy and had panretinal photocoagulation in both eyes. She had progressive cataract bilaterally. In January 1995, a 3-piece silicone IOL (SI-30NB, Allergan Medical Optics) was implanted in the left eye. On January 3, 1999, a vitreous hemorrhage occurred in that eye, and on January 12, pars plana vitrectomy, relaxing retinotomy, scleral encircling, fluid–silicone exchange, and endolaser treatment were performed. A posterior capsulotomy was also done to improve the intraoperative view of the retina, which was obscured by severe capsule opacification. The retinopathy gradually went into remission. On February 9, 1999, the silicone oil was removed. During the silicone–fluid exchange, droplets of silicone 0886-3350/00/$–see front matter PII S0886-3350(00)00306-0
TECHNIQUES: KAGEYAMA
perform objective refractometry because of the dense oil droplets on the IOL’s posterior surface. It was realized that the silicone droplets may have been causing the patient’s severe visual deterioration, and surgery to clear the IOL surface was performed on February 23, 1999, using the surgical technique described. Postoperatively, the visual axis was clear (Figure 3). Visual acuity improved to 20/400 with a refraction of – 4.75 –2.00 ⫻ 144. However, because of the presence of severe diabetic maculopathy, no further improvement in vision was attained. Slitlamp examination showed no damage to the IOL. Figure 1. (Kageyama) An infusion cannula is placed in the inferotemporal pars plana to irrigate the vitreous cavity and the anterior chamber with BSS. A lens hook (arrow) is inserted through the sclerotomy at the 2 o’clock position and is moved quickly from side to side to remove the oil droplets. The discrete oil bubbles in the anterior chamber are aspirated with a cutter inserted through the limbal incision.
oil adhered to the posterior surface of the IOL and could not be removed with a soft-tipped extrusion needle or a viscoelastic agent. Although visualization was difficult during the procedure, the remission of the retinopathy was confirmed with the limited view and the surgery completed. Two weeks later, slitlamp examination still showed the presence of dense silicone oil droplets on the IOL (Figure 2). Visual acuity in the left eye was limited to finger counting; it had been 20/50 with – 4.25 –1.00 ⫻ 90 before the vitreous hemorrhage. It was impossible to
Figure 2. (Kageyama) Slitlamp examination shows the presence of silicone oil droplets (arrow) on the posterior surface of an implanted silicone IOL before surgery to remove the droplets. 958
Discussion Several maneuvers to remove silicone oil droplets from the posterior surface of an IOL have been reported. Mein3 and Robertson4 show that applying a viscoelastic substance to the IOL’s posterior surface facilitates clearing, while Horgan and Cooling5 advocate simple aspiration of oil droplets using a Simcoe-style cannula. Although we used both methods in our patient, neither proved effective. We describe a new procedure that does not require the use of an expensive viscoelastic substance. It involves knocking the silicone oil droplets from the IOL surface rather than wiping them off. This approach may be effective in cases in which previous methods were unsuccessful. The relative short duration of the silicone oil tamponade in this case may, in part, explain our ability to
Figure 3. (Kageyama) Postoperatively, the number of silicone oil droplets is reduced and a clear visual axis restored.
J CATARACT REFRACT SURG—VOL 26, JULY 2000
TECHNIQUES: KAGEYAMA
mechanically remove the oil droplets. Intraocular lens exchange is a radical method that can be complicated and can present a problem to both patient and surgeon. Therefore, our approach to scraping the droplets with a lens hook may become the preferred intraoperative technique, especially when vitrectomy is performed.
References 1. Apple DJ, Federman JL, Krolicki TJ, et al. Irreversible silicone oil adhesion to silicone intraocular lenses; a clinicopathologic analysis. Ophthalmology 1996; 103:1555– 1562; discussion by TM Aaaberg Sr, 1561–1562
2. Kutner BN. Posterior surface condensation on silicone IOLs (letter). Ophthalmology 1995; 102:1412 3. Mein CE. Posterior surface condensation on silicone IOLs (letter). Ophthalmology 1995; 102:1412 4. Robertson JE Jr. The formation of moisture droplets on the posterior surface of intraocular lenses during fluid/gas exchange procedures (letter). Arch Ophthalmol 1992; 110:168 5. Horgan SE, Cooling RJ. Irreversible silicone oil adhesion (letter). Ophthalmology 1997; 104:898 – 899 From the Department of Ophthalmology, Showa University School of Medicine, Fujigaoka Hospital, Yokohama, Japan. Neither author has a proprietary interest in any product mentioned.
J CATARACT REFRACT SURG—VOL 26, JULY 2000
959
Removing silicone oil droplets from the posterior surface of silicone intraocular lenses Toshiyuki Kageyama, MD, Shigeo Yaguchi, MD ABSTRACT A 67-year-old woman had droplets of silicone oil adhering to her silicone intraocular lens (IOL) resulting from a previous silicone oil tamponade. A lens hook and intraocular irrigation were used in conjunction by inserting an infusion cannula to remove the droplets. This restored clarity of the visual axis, improved visual acuity, and eliminated the need for IOL replacement. The technique is simple and less invasive than IOL exchange and may become the preferred way to remove silicone droplets from an IOL. J Cataract Refract Surg 2000; 26:957–959 © 2000 ASCRS and ESCRS
T
he adhesion of silicone oil droplets to implanted silicone intraocular lenses (IOLs) can cause visual disturbances in patients who had removal of silicone oil used in previous vitreoretinal surgery.1,2 Although aspiration with a soft-tipped extrusion needle or replacement with a viscoelastic agent has been used to remove the oil droplets, it is difficult to remove them from the IOL surface.3–5 Thus, the IOL must be removed and replaced in some cases.1,2 We report a technique to remove silicone droplets on the posterior surface of a silicone IOL using a lens hook.
Surgical Technique An infusion cannula is placed in the inferotemporal pars plana to irrigate the vitreous cavity and anterior chamber with balanced salt solution (BSS威). A cutter is inserted through the limbal incision at the 10 o’clock Accepted for publication January 10, 2000. Reprint requests to Toshiyuki Kageyama, MD, Department of Ophthalmology, Showa University School of Medicine, Fujigaoka Hospital, 1-30 Fujigaoka, Aoba-ku, Yokohama, 227-8501, Japan. © 2000 ASCRS and ESCRS Published by Elsevier Science Inc.
position to aspirate discrete oil bubbles. A lens hook is inserted through the sclerotomy at the 2 o’clock position and is quickly moved from side to side, parallel to the IOL surface, to scrape away the oil droplets (Figure 1).
Case Report A 67-year-old Japanese woman developed non-insulin-dependent diabetes in 1985. In 1995, she developed proliferative diabetic retinopathy and had panretinal photocoagulation in both eyes. She had progressive cataract bilaterally. In January 1995, a 3-piece silicone IOL (SI-30NB, Allergan Medical Optics) was implanted in the left eye. On January 3, 1999, a vitreous hemorrhage occurred in that eye, and on January 12, pars plana vitrectomy, relaxing retinotomy, scleral encircling, fluid–silicone exchange, and endolaser treatment were performed. A posterior capsulotomy was also done to improve the intraoperative view of the retina, which was obscured by severe capsule opacification. The retinopathy gradually went into remission. On February 9, 1999, the silicone oil was removed. During the silicone–fluid exchange, droplets of silicone 0886-3350/00/$–see front matter PII S0886-3350(00)00306-0
TECHNIQUES: KAGEYAMA
perform objective refractometry because of the dense oil droplets on the IOL’s posterior surface. It was realized that the silicone droplets may have been causing the patient’s severe visual deterioration, and surgery to clear the IOL surface was performed on February 23, 1999, using the surgical technique described. Postoperatively, the visual axis was clear (Figure 3). Visual acuity improved to 20/400 with a refraction of – 4.75 –2.00 ⫻ 144. However, because of the presence of severe diabetic maculopathy, no further improvement in vision was attained. Slitlamp examination showed no damage to the IOL. Figure 1. (Kageyama) An infusion cannula is placed in the inferotemporal pars plana to irrigate the vitreous cavity and the anterior chamber with BSS. A lens hook (arrow) is inserted through the sclerotomy at the 2 o’clock position and is moved quickly from side to side to remove the oil droplets. The discrete oil bubbles in the anterior chamber are aspirated with a cutter inserted through the limbal incision.
oil adhered to the posterior surface of the IOL and could not be removed with a soft-tipped extrusion needle or a viscoelastic agent. Although visualization was difficult during the procedure, the remission of the retinopathy was confirmed with the limited view and the surgery completed. Two weeks later, slitlamp examination still showed the presence of dense silicone oil droplets on the IOL (Figure 2). Visual acuity in the left eye was limited to finger counting; it had been 20/50 with – 4.25 –1.00 ⫻ 90 before the vitreous hemorrhage. It was impossible to
Figure 2. (Kageyama) Slitlamp examination shows the presence of silicone oil droplets (arrow) on the posterior surface of an implanted silicone IOL before surgery to remove the droplets. 958
Discussion Several maneuvers to remove silicone oil droplets from the posterior surface of an IOL have been reported. Mein3 and Robertson4 show that applying a viscoelastic substance to the IOL’s posterior surface facilitates clearing, while Horgan and Cooling5 advocate simple aspiration of oil droplets using a Simcoe-style cannula. Although we used both methods in our patient, neither proved effective. We describe a new procedure that does not require the use of an expensive viscoelastic substance. It involves knocking the silicone oil droplets from the IOL surface rather than wiping them off. This approach may be effective in cases in which previous methods were unsuccessful. The relative short duration of the silicone oil tamponade in this case may, in part, explain our ability to
Figure 3. (Kageyama) Postoperatively, the number of silicone oil droplets is reduced and a clear visual axis restored.
J CATARACT REFRACT SURG—VOL 26, JULY 2000
TECHNIQUES: KAGEYAMA
mechanically remove the oil droplets. Intraocular lens exchange is a radical method that can be complicated and can present a problem to both patient and surgeon. Therefore, our approach to scraping the droplets with a lens hook may become the preferred intraoperative technique, especially when vitrectomy is performed.
References 1. Apple DJ, Federman JL, Krolicki TJ, et al. Irreversible silicone oil adhesion to silicone intraocular lenses; a clinicopathologic analysis. Ophthalmology 1996; 103:1555– 1562; discussion by TM Aaaberg Sr, 1561–1562
2. Kutner BN. Posterior surface condensation on silicone IOLs (letter). Ophthalmology 1995; 102:1412 3. Mein CE. Posterior surface condensation on silicone IOLs (letter). Ophthalmology 1995; 102:1412 4. Robertson JE Jr. The formation of moisture droplets on the posterior surface of intraocular lenses during fluid/gas exchange procedures (letter). Arch Ophthalmol 1992; 110:168 5. Horgan SE, Cooling RJ. Irreversible silicone oil adhesion (letter). Ophthalmology 1997; 104:898 – 899 From the Department of Ophthalmology, Showa University School of Medicine, Fujigaoka Hospital, Yokohama, Japan. Neither author has a proprietary interest in any product mentioned.
J CATARACT REFRACT SURG—VOL 26, JULY 2000
959