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Optical coherence tomography (OCT) was used to assess the macular status of eyes undergoing planar vitrectomy (PPV) and intra-heavy silicone oil (HSO) packing for rhegmatogenous retinal detachment (RRD) with inferior rupture.Twenty eyes of 20 RRD patients were included in the study.Oxane HD is used as an eye packing in all surgeries.Postoperatively, assess for anatomical reduction, macular status using OCT imaging, and any long-term complications.The mean age was 60.4 ± 11.2 years (range 37-83).The duration of HSO tamponade was 15.3 ± 11.0 months (range, 6-48 months), with some postoperative complications such as HSO emulsification, increased intraocular pressure, and epiretinal membrane (ERM) formation.The mean follow-up time after HSO resection or ERM surgery was 19.5 ± 10.5 months (range 10-59).Primary reattachment was achieved in 90% of eyes, with a 100% success rate for further interventions.The ellipsoid zone (EZ) was contiguous in 13 of the 20 eyes, where OCT imaging performed as well as the fellow eye.PPV and heavy-duty silicone oil injections have good long-term EZ continuity for the treatment of RRD eyes due to hypospadias.The formation and removal of ERM did not affect the EZ.
Treatment of rhegmatogenous retinal detachment (RRD) with pars plana vitrectomy (PPV) has grown over the past decade with the invention of smaller transconjunctival incisions and an increase in vitrectomy rates.Despite these advances, RRD with inferior ruptures, especially proliferative vitreoretinopathy (PVR), remains challenging due to the difficulty in packing the underlying retina.Although intravitreal gas can be used as a tamponade for inferior wall ruptures, it is difficult to maintain postoperative positioning.Heavy-duty silicone oil (HSO) packing is another option for treating inferior fractures without postoperative localization because it is heavier in specific gravity than water.Oxane HD is an HSO that has been reported to be effective in the treatment of poor-quality RRD.A number of adverse postoperative complications have been reported to be associated with Oxane HD, such as cataracts, HSO emulsification, intraocular hypertension, retinal detachment and PVR, severe intraocular inflammation or uveitis, epiretinal membrane (ERM), intraretinal or Subretinal fibrosis.In addition, unexplained vision loss has been reported following HSO removal3.Using optical coherence tomography (OCT), we aimed to assess long-term macular status in patients undergoing PPV and extended HSO tamponade for RRD with inferior fractures.
All procedures performed in human participants were in accordance with the ethical standards of the Namık Kemal University Local Ethics Committee and the 1964 Declaration of Helsinki and its subsequent amendments or similar ethical standards.The experiment/research protocol was approved by the local ethics committee of Namık Kemal University (No. 2017/81/08/05).Informed consent was obtained from all individual participants included in the study.
From August 2011 to December 2020, 20 eyes of 20 patients who underwent PPV and HSO (Oxane-HD, Bausch-Lomb, USA) intracranial tamponade for RRD were evaluated.We evaluated all patients who had undergone OCT (Cirrus HD-OCT, Carl Zeiss Ophthalmic System Inc, USA) after HSO removal.All patients signed informed consent before surgery.
Patients with RRD and inferior fractures and PVR levels of B or higher using Retina Society Classification 4 grading were included in the study.Exclusion criteria were as follows: (1) eyes with uveitis or any inflammatory disease; (2) retinal vascular disease; (3) penetrating injury; (4) previous PPV with silicone oil injection.
Best-corrected visual acuity on the Snellen chart, slit-lamp examination of the anterior and posterior segments using non-contact and contact lenses, and intraocular pressure (IOP) measurements were performed.All patients underwent OCT evaluation by an experienced technician at the last visit.High definition (HD) 5-line raster at 0.25mm intervals centered on 6mm parallel lines, 1024 A-scans/B-scans and an average of 4 B-scans per image.Three consecutive measurements were taken at the fovea.The analysis was performed using the mean of the three measurements.Retina experts (FH) corrected any errors in the segmentation.
All operations were performed by the same experienced surgeon (FH) under subtenon anesthesia.All patients underwent 23/25-gauge transconjunctival sutureless vitrectomy.Standard surgical procedures are core vitrectomy, removal of the preretinal or subretinal membrane if there is proliferation, retinotomy if needed, perfluorocarbon fluid and/or fluid-air exchange and injection of HSO.Phakic surgery combined with phacoemulsification, intraocular lens implantation, and PPV.The HSO was removed using an 18-gauge cannula and another PPV procedure was performed on all eyes under subbulbar anesthesia.ERM surgery was performed using brilliant blue (Meran ILM dye, Turkey) and the inner limiting membrane (ILM) was removed from all eyes.
Statistical analysis was performed using SPSS version 22 (IBM, USA).The Shapiro-Wilke normality test and descriptive statistics were performed on the dataset.Since the data were normally distributed, one-sample t-test, dependent-samples t-test, independent-samples t-test, regression analysis, and Pearson’s correlation analysis were performed as indicated.Statistical normalization was performed using 1/data transformation and regression analysis was performed as the silicone age did not conform to a normal distribution.
Twenty eyes (13 right, 7 left) of 20 patients (19 male, 1 female) with RRD due to inferior fractures were included in this study.The mean age was 60.4 ± 11.2 years (range 37-83 years).The macula was detached in 8 eyes and attached in 12 eyes.All 20 eyes had RRD with poor rest.All patients had no high myopia.Eight eyes had phakic and 12 eyes had pseudophakic.Eight phakic eyes had combined phakectomy because phakectomy was reported to produce better anatomical outcomes for phakic eyes at RRD5, which did not require grading of lens status per surgery.
Mean follow-up after silicone oil removal or ERM surgery was 19.5 ± 10.5 months (range, 10-59).The duration of tamponade in HSO was 15.3 ± 11.0 months (range, 6-48).Due to various reasons such as poor cooperation, missed visits, funding issues, etc., these patients cannot have their HSO removed early, which even poses challenges for routine examination and follow-up.
In the first operation, retinal reattachment was achieved in 18 eyes (90%).Recurrent PVR detachment occurred in 2 eyes after HSO removal, and retinal reattachment was achieved in both eyes after the second operation.The ILMs were removed in both eyes and recurred.Macular OCT data were obtained and evaluated postoperatively.The mean foveal thickness (CFT) was 191.7 ± 57.5 µm (range, 100–274 µm).The comparison between the mean CFT in our study and the reference mean CFT6 in the literature was not significantly different (p = 0.065).Postoperative OCT images of extramacular detachment cases are shown in Figure 1, and images of the fellow eye are shown in Figure 2.The ellipsoid zone (EZ) was contiguous in the eyes assessed by OCT (13 of 20 eyes).The patient also had persistent EZ in the fellow eye.
ERM formation occurred in 10 eyes (50%).In 5 eyes with ERM, HSO removal and ERM surgery were performed in the same session.ERM was performed on 3 eyes within the first 3 months after HSO removal and 1 eye between the 3rd and 6th month after HSO removal.ERM surgery was not performed in one eye of the ERM.In one eye, droplets of emulsified silicone oil after ERM surgery were removed using the F4H5 Washout (Fluoron Gmbh, Germany).When evaluating CFT in patients who underwent and did not undergo ERM surgery, mean CFTs of 162.8 ± 50.5 µm and 225.5 ± 48.4 µm were observed, respectively.When the correlation between ERM surgery and CFT was assessed, a statistically significant negative moderate correlation was found (p = 0.044, r = -0.565).According to simple linear regression analysis, ERM surgery in foveal thinning explained 31.9% of the variance (R2 = 0.319, β = – 62.6, 95% CI [- 123.4, - 1.8], p = 0.044).When comparing higher IOP and ERM, eyes with emulsified silicone and eyes with non-emulsified silicone were found to be insignificant (p = 0.463, p = 0.179, respectively).
When comparing preoperative (1.26±0.83) and final (0.73±0.51) visual acuity, a statistically significant increase in final visual acuity was found (p=0.009).When comparing preoperative and postoperative visual acuity in macular detachment patients, a statistically significant improvement in visual acuity was observed (p = 0.018), whereas there was no statistically significant increase in visual acuity in eyes that underwent ERM surgery (p = 0.263).
Elevated intraocular pressure (>21 mmHg) was observed in 11 eyes, which was controlled with medical therapy.Moderate aqueous humor inflammation was observed in one eye, but fibrin exudation and adhesions were not observed.Finally, emulsification of HSO was observed in 13 eyes.No other postoperative complications were observed in the patient.Complication rates for the case series are shown in Table 1.The clinical characteristics of the patients are shown in Table 2.
According to the binary logistic regression analysis performed, no correlation was found between the time of silicone presence in the eye and its emulsification (p = 0.396).According to a simple linear regression analysis performed, no correlation was found between the presence of silicone in the eye and the thickness of the foveal center (p = 0.715).
The use of internal tamponade is a challenging situation for eyes with poor RRD.After tamponade of the lower retina with conventional silicone oil and intraocular gas, the prone position should be performed to avoid unsupported retinal areas when positioned upright.However, for various reasons, the use of standard silicone oils may not be able to effectively and adequately pack the lower retina.Numerous studies have found that HSO is effective and safe for the treatment of retinal detachment7,8.However, in many studies, HSO was left in the eye as a filler for 3-6 months7,9,10.There are studies evaluating long-term effects, but cases of additional interventions were evaluated in these reports11,12.
In our study, we used HSO as the primary internal tampon in RRD patients and assessed the long-term outcomes of HSO.Prolonged HSO use had no negative effect on postoperative visual acuity.In turn, 15 eyes (75%) were improved and 16 eyes (80%) were improved or equal to 20/200.Visual outcomes were also improved in patients with macular detachment.Our visual results are comparable and acceptable to other studies11,12.In addition, long-term use of HSO did not affect CFT.In their study using OCT, Hostovsky et al. 13 observed that HSO can remain in the eye for up to 6 months due to mechanical effects, resulting in temporary and reversible retinal thinning.Short-term use has been reported to prevent long-term changes in the fovea.In addition, silicone oil has been reported to increase macular thickness in diabetic patients while causing retinal thinning in non-diabetic patients, and it has been reported that these structural changes may subside after silicone removal.Disturbances of the outer plexiform layer, photoreceptors and RPE have been reported due to the mechanical stress and toxic effects of silicone oils15,16,17.However, we observed that the EZ continuity was well preserved over the long term.
In the literature, the most common complication observed after HSO is cataract2,18.However, in our series, 40% of cases were phakic and cataract surgery was performed during primary PPV.The most common complication in our series was HSO emulsification in 65% of cases, a higher incidence than previously reported2,10,11,19,20,21.Although there was no relationship between silicone time in the eye and emulsification in the regression analysis, it is known that the main factor affecting emulsification trends is the time that elapses until these plugs are removed.The higher emulsification rate compared to the literature may be the result of the long-term presence of HSO in the eye.The vitreous cavity was cleaned using a perfluorobutylpentane (F4H5) solvent-assisted silicone oil removal technique due to emulsified silicone oil droplets in one patient.
The second most common complication is increased intraocular pressure.In our series, the rate of elevated intraocular pressure was higher than in literatures 2, 11, 12, 18.Although we found similar IOP elevation and ERM formation in eyes between emulsified and non-emulsified silicone oils, emulsified silicone oils have been reported to be prone to such complications21,24.Another reason could be overfilling.The elevated intraocular pressure in our series was controlled with medication and none of the eyes required surgery.Compared with literatures 11, 12, 18, the development of ERM is higher.Inflammatory responses due to the use of HSO, emulsified silica, or preretinal fluid accumulation and high inflammatory factors between the retina and HSO may be precursors to this condition.Furthermore, it is known that with HSO, the preretinal fluid concentrated in the inflammatory agent is pushed up on the horizontal axis, the ERM is concentrated above, and the posterior pole is protected26.Therefore, as in previous studies, inflammation and long-term presence of HSO may be responsible for this higher ERM rate.
The strengths of this study are; it reflects the experience of a single surgeon with single HSO tamponade as the primary procedure.Limitations of this study are its retrospective design and small number of patients.However, to our knowledge, our study is the first to give results on long-term HSO use as well as EZ continuity.
In conclusion, this report shows that long-term use of HSO to treat inferior ruptures in RRDin eyes results in good anatomical retinal reattachment and satisfactory functional outcomes.Furthermore, PPV and HSO injections in this case have good EZ continuity and long-term foveal thickness.However, long-term use of HSO increases emulsification rate, increased intraocular pressure, and ERM formation.Despite the high complication rate, it is possible to retain HSO in the eye for extended periods of time in a small subset of uncooperative patients, preventing multiple surgeries and the risk of hypotonia.Larger series of prospective studies are needed to further characterize the efficacy and safety of prolonged use of HSO in RRD.
Data sets generated and/or analyzed during the current study are available from the respective authors upon reasonable request.
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Post time: Jul-27-2022