Intraocular Tamponade

❖ Dr. Sumit Pandey

❖ MD Ophthalmology Resident
❖ BPKLCOS
❖ Maharajgunj Medical Campus
 Contents

❖ Vitreous
❖ Vitreous Substitutes
❖ Intraocular Tamponade
❖ Intraocular Gases
❖ Perfluorocarbon Liquids
❖ Silicon Oil
Vitreous
 Vitreous
CONTENTS
❖ 99% water (vol-4ml)
❖ Proteins 200 to 1400 mg/ml
❖ Collagens-II(60-75%) ,IX,VI
❖ GAGs-hyaluronic acid, chondroitin sulfate, heparan sulfate
❖ Ascorbic acid
❖ Amino acids
❖ Fatty acids
❖ Cells –hyalocytes, fibrocytes, macrophages
 Vitreous Substitutes
❖ When do we substitute vitreous?

Vitreoretinal surgeries

>2ml vitreous removed

Major Vitreoretinal surgeries

 Ideal Substitute

NON TOXIC,
BIOCOMPATIBLE, ONE TIME
OPTICALLY IMPLANTATIO
NON VISCOELASTIC CLEAR
BIODEGRADABL N
E

ALLOW REASONABLE READILY

SELF COST AND
MOVEMENT OF AVAILABLE
RENEWABLE STORAGE
IONS AND
ELECTROLYTES
 Vitreous Substitutes
Gases Liquids Polymers

Salt solution,
Perfluorocarbon hydrogels,
Air liquids, smart hydrogels,
Expansile gases Semifluorinated Thermosetting
alkanes, hydrogels
silicone oil, etc.
 Intraocular Tamponade
❖ Tampon: a plug or tent inserted tightly into a wound, orifice,
etc, to arrest hemorrhage

surface tension across retinal breaks

prevents further fluid flow into the subretinal

space until the retinopexy (photocoagulation
or cryopexy) provides a permanent seal
Intraocular Tamponade
 Intraocular Tamponade
What are its indications?
❖ RD
❖ PDR
❖ GRT
❖ Macular hole
❖ PVR
❖ Trauma
 Intraocular Tamponade
AGENTS

❖ Gases: Air, Xenon, SF6, C3F8

❖ Liquids: PFCL, Silicon oil
 Just a thought!

❖ Are ‘Fluids’ and ‘Liquids’ same?

 Intra-Ocular Gases

Non-expanding Expanding

Air SF6

Xenon PFC
 Intra-Ocular Gases
PROPERTIES

• SURFACE TENSION
• BUOYANCY
• SOLUBILITY
• BIOCOMPATIBILITY
 Intra-Ocular Gases
SURFACE TENSION
❖ Surface tension – between gas
bubbles and surrounding fluids

❖ critical physical property of the

gases in retinal reattachment

❖ Electrostatic attractive forces

-van der Waals forces -weaker
and longer range
 Intra-Ocular Gases
BUOYANCY

• Buoyancy-ability to float
 Intra-Ocular Gases
BUOYANCY

• Due to large difference in specific gravity

of fluid and gas

• Buoyancy directs the effectiveness of the

tamponade, gases -upward gravitational
direction.

• Large bubbles and facedown positioning

are required to tamponade inferior retinal
breaks
 Intra-Ocular Gases
SOLUBILITY

❖ Solubility of a gas in the aqueous medium : determining

the reabsorption rate of a gas bubble from the vitreous
cavity
❖ If less soluble than nitrogen, expansion of the bubble
can occur.
 Intra-Ocular Gases
BIOCOMPATIBILITY
❖ SF6 and the perfluorocarbon gases have a purity of
99.8%
❖ Pure gases -chemically nonreactive, colorless, odorless,
and nontoxic
❖ SF6 may contain -0.3 ppm of hydrogen fluoride.
regarded as the most toxic contaminant found in SF6.
 Intra-Ocular Gases
GAS DYNAMICS

• Bubble Expansion- •Bubble dissolution: as

• Equilibrium with N2: partial
gas from surrounding gases diffuse out
pressures of both compartments
fluid enter the bubble equilibrate: o2/co2 diffuse rapidly, bubble decreases in
N2 slowly, maximum in 6-8 hours size
 Intra-Ocular Gases
RESPONSE TO CHANGE IN ALTITUDE
❖ airplane cabin pressure is only equal to atmosphere
pressure at an altitude of 8000 feet.
❖ Climb rate occurs at roughly 2000–3000 feet per minute
during airplane ascent, and the rapid expansion in
bubble size may be translated into IOP rise.
❖ Central retinal arterial occlusion may result.
 Intra-Ocular Gases
ROLE OF GAS BUBBLE
• Bubble larger than the break-surface tension of gas prevents it from passing
through the retinal break

• Gas bubble apposed to the posterior end of break

• Passage of fluid from the vitreous to SRF blocked

• SRF absorbed into RPE and choroid

Sp gravity of gas lower than water

• Buoyant forces push retina against RPE (max at apex ) 10x >
silicone oil)
• Head position till chorio- retinal adhesion
 Intra-Ocular Gases
ADVANTAGES

❖ When visualisation of retina is difficult-optical window

❖ Allows fluid gas exchange
❖ Mechanical barrier-cellular elements & growth factors
“compartmentalisation”
 Intra-Ocular Gases
HOW TO INJECT?
• Inject using 30 g , 13 mm needle
• Injected moderately briskly, not too briskly, nor too slowly

0.3-0.5ml injected rapidly into the eye to avoid “fish egg bubble” formation
 Intra-Ocular Gases
POSTOPERATIVE POSITIONING
❖ This is done such that the break is located at the uppermost part of the eye, and be in
direct contact with the bubble.
❖ Facedown posturing with the usage of expansile gas has another advantage of
preventing pupil block glaucoma or optic capture.
❖ Another potential advantage is that this reduces the contact between the posterior
surface of the lens in a phakic patient with the gas bubble, and reduces the risk of
cataract development.
❖ This should be done by assuming a facedown or prone posture immediately after
surgery. If facedown or prone posture is difficult, or the patient needs to take rest
fromprolonged facedown position, lying laterally on the opposite side of the break is
also accepted (i.e., lying on the left for a right side break). This could be facilitated with
the use of pillows designed for posturing purposes. As chorioretinal adhesion from
laser or cryotherapy takes 2–3 days to become effective, the initial tamponade by bubble
is the main force to keeping the retina attached.
 Intra-Ocular Gases
Factors affecting dissolution
❖ Vitreous currents
❖ Surface area of bubble
❖ Gas solubility in fluid
❖ Diffusion coefficient of gas
❖ Partial pressures
❖ Ocular blood flow
 Intra-Ocular Gases
Maximal Non-
Gas Molecular Duration expansile Expansivity
weight expansion (times)
(hours) concentration

Air 29 N/A 5-7 N/A 0

SF6 146 24-48 1-2 weeks 20% 2

C2F6 138 36-60 4-5 weeks 16% 3.3

C3F8 188 72-96 6-8 weeks 12% 4

 Intra-Ocular Gases

Air injection is useful in three specific ways.

❖ First, the intraocular pressure is restored after the air injection.
❖ Second, the surface tension of the air bubble means that the
retina can be kept opposed and attached (had saline been
injected instead, the liquid might go through the retinal breaks
and the retina might redetach again).
❖ Third, air is nonexpansile. There is no concern about causing
traction to the inferior retina and causing new retinal breaks.
This
 Intra-Ocular Gases

Sulphur hexafluoride (SF6)- When the retinal breaks are

multiple and their locations widely separated (in terms of clock-
hours), to have a large postoperative bubble.
❖ The nonexpansile concentration of SF6 is 20%. As a rule of thumb,
if the vitreous cavity were totally filled, a bubble of 20% SF6/air
would last for about 2weeks. The bubble would be relatively
large in the first few days to give a sufficiently large area of
tamponade to widely separated retinal breaks.
❖ SF6 is seldom used neat. It is inert, nontoxic, colorless, and is five
times heavier than air.
 Intra-Ocular Gases

The Perfluorocarbon gases have the generic chemical formula

(CnF2n+2).
❖ These are inert gases with no odor or color.
❖ Water solubility varies according to the carbon chain length. The
longer the carbon chain, the lower the solubility in water, hence the
longer is the intraocular longevity.
❖ For instance as a rough guide, 1 mL of pure C2F6 expands 3.3 times
when injected into the eye, and stays in the eye for 4–5 weeks; but for
1 mL of C3F8, the same volume expands four times, and stays for 6–8
weeks.
The most common indications for intraocular gas injection is to
assist:
(1) retinal detachment surgery with vitrectomy;
(2) pneumatic retinopexy;
(3) retinal detachment surgery with scleral buckle;
(4) macular hole surgery;
(5) displacement of subretinal hemorrhage
(6) postvitrectomy gas exchange in vitrectomized eyes.
 Intra-Ocular Gases

❖ Change to use of an expandable gas (SF6, C3F8, or C2F6). The

maximum concentrations to be used are 20% for SF6, 14% for
C3F8, and 17% for C2F6; these levels ensure that eye pressure
is not increased.
❖ RD in the inferior quadrant alone, or associated multiple
breaks in various quadrants is an indication for use of a long-
acting gas such as C3F8
 Intra-Ocular Gases

❖ A 0.3 mL gas bubble in humans covers more than 45° of

arc of the retina, but it takes approximately a 1.2 mL
bubble to cover 80–90°.
❖ a highly myopic eye requires a larger volume of gas
than an emmetropic eye.
 Intra-Ocular Gases
COMPLICATIONS

Cataract Corneal opacity

• On contact with corneal
• When bubble is large enough ,
covers the back of the lens, a endothelium -causes
cataract develops unless the increased inflammation,
patient is positioned so that a more with SF6 than
layer of fluid covers the perfluoropropane
posterior surface of the lens
• Persistent corneal edema
• Face-down or lateral positioning and retro- corneal membrane
is necessary to prevent - interference with nutrition
continuous contact of the gas
of the endothelium rather
bubble with the cornea and lens
than to a specific toxic effect
 Intra-Ocular Gases
COMPLICATIONS

Glaucoma Central Retinal Artery

• Large bubble- if the patient Occlusion
remains supine, fluid from ❖ -Overfilling of the eye with
the ciliary body fills the expansile gas
posterior segment & air
bubble blocks fluid egress Endophthalmitis
through the trabecular Subretinal gas
meshwork
•
New tears
Medium size- peripheral
anterior synechiae with total ❖ -7% to 23% of patients treated
angle closure with pneumatic retinopexy
Intra-Ocular Gases
 Intra-Ocular Gases
COMPLICATIONS
Laser treatment -undesirable
burns
❖ Reflections of internal fluid–air and
air–fluid surfaces.
❖ Avoid treatment through a gas–fluid or
fluid–gas interface
❖ Perpendicular to the interface: intensity
of a reflected beam increases as the
angle of incidence decreases. -A
divergent beam should be used
Gas injection into
vitreous base accidentally
❖ A. Donut sign when gas
encircles the lens posteriorly.
❖ B. B. Sausage sign when gas
partially encircles the lens
posteriorly.
❖ In both cases the gas bubble is
immobile
Intra-Ocular Gases
COMPLICATIONS
 Pneumatic retinopexy
❖ Pneumatic retinopexy (PR) was developed in an attempt to
minimize the problems of Scleral buckling and PPV.
❖ This outpatient procedure for retinal reattachment consists
of an intravitreal gas injection with transconjunctival
cryopexy or laser photocoagulation, followed by
appropriate head positioning. No incisions are required.
❖ PR is substantially less expensive than scleral buckling or
vitrectomy and has become widely accepted as the
treatment of choice for elected retinal detachments
Pneumatic retinopexy
 Pneumatic retinopexy
❖ Macular breaks and other posterior retinal breaks.
❖ Redetachment or persistent detachment after scleral
buckling.
❖ Isolated tears under the superior rectus.
❖ Isolated tears under the superior rectus.
❖ Impending macular detachment.
❖ Bullous detachment.
 Perfluorocarbon liquids

❖ PFCL is a synthetic fluorinated hydrocarbon containing

carbon– more than C5
❖ Surface tension of approximately 14 to 16 dynes/cm measured
❖ against air –comparable to silicone oil
❖ Most remarkable property of the perfluorocarbon liquids is the
specific gravity, which is higher than that of water. (1.7 to 2.03)
 Perfluorocarbon liquids

❖ Enables the fluid to settle posteriorly, opening folds in

the retina while expressing subretinal fluid anteriorly
through preexisting retinal breaks
❖ Perfluorodecalin & perfluorophenanthrene -high
transparency to light in the visible spectrum
❖ No obstacle to laser photocoagulation
 Perfluorocarbon liquids
❖ Inferior corneal endothelial loss with subsequent corneal
opacity and thickening
❖ Dispersion and droplet formation will develop
• 1 month- Gial cell proliferation and retinal
disorganization
• 3 months- preretinal membranes, gliosis, and retinal
disorganization
• 6 months- retinal detachments
 Perfluorocarbon liquids
5 main indications:
• Giant retinal tears
• Detachments with complicated PVR
• Traumatic retinal detachments
• Removal of posterior lens fragments and posteriorly dislocated
intraocular lenses
• Macular rotation with a 360-degree retinotomy
• +ROP
ADVANTAGES
❖
DISADVANTAGES
Specific gravity of PFCLs -
effective for theintraoperative ❖ irreversible cell
repair of complex retinal tears damage
❖ Anterior and posterior segment ❖ Disorganization of
complications are uncommon
retinal cell growth
❖ Low viscosity of PFCLs allow
for tissue manipulation,
injection, and removal
 Silicone Oil
❖ Silicone is made up of
repeating units of siloxane.
❖ Silicone oil chains - helix
with six siloxane units per
turn.
❖ Polydimethylsiloxanes
(PDMS) all have a specific
gravity of 0.97 and they all
float in the presence of
water or aqueous.
 Silicon Oil
VISCOSITY

❖ Commercially available SO has viscosities ranging from 1000 cSt to

5700 cSt.
❖ Practical differences between SO of different viscosities are threefold
(1) difficulty in injection is higher as the viscosity goes up
(2) ease of removal is higher as the viscosity goes down
(3) risk of emulsification.
❖ The tamponade effect appears to be similar among SO with different
viscosities
 Silicon Oil
BUOYANCY
❖ Less buoyant than gases
❖ When buoyancy is large, as in gas bubbles, the bubble takes on the
shape of a spherical cap. A spherical cap is a sphere with a flat
bottom.
❖ When buoyancy is small, the bubble assumes a relative spherical
shape, as in the case of SO. For this reason, a gas bubble makes a
larger area of contact against the retinal surface, than an equivalent
volume of SO bubble.
❖ When SO use is intended, it is important to achieve a near 100% fill, in
order to achieve a good tamponade effect.
 REFRACTIVE STATE OF THE EYE
❖ Higher refractive index compared to vitreous
❖ Refractive shift depends on lens status
• Phakic eye-concave surface behind lens, acts as a minus lens-
making eye hyperopic-8D hyperopia
• Aphakic eye-convex surface as it bulges through pupillary
aperture-plus lens-myopic- Varies with pupillary aperture size-
from +12.5 to +5.6D
❖ Contact lens – to minimise the anisoconia
❖ IOL-plano posterior surface preferred
 Silicon Oil
INDICATIONS FOR SILICONE OIL

A. Retinal detachments with proliferative

vitreoretinopathy
❖ The Silicone Study- SO was found to be as effective as
C3F8, and better than SF6, in reattaching the retina. Both
SO and C3F8 were equivalent in terms of improving
visual function and low complication rates.
❖ Regarding postoperative
❖ complications, in particular hypotony and keratopathy,
SO did better than SF6.a
 Silicon Oil
INDICATIONS FOR SILICONE OIL
B. Severe Proliferative Diabetic Retinopathy
❖ Decreased post op hemorrhage
❖ Rapid recovery
❖ Especially in patients with anterior segment
neovascularisation/anterior hyaloid proliferation
❖ Acts by impending movement of vasoproliferative
factors from posterior segment to anterior segment
❖ PDR with rhegmatogenous RD involving the macula
 Silicon Oil
INDICATIONS FOR SILICONE OIL

C. Macular Hole
❖ • RD due to macular hole
❖ • Idiopathic/Traumatic macular hole
D. Giant Retinal Tears
❖ • Unfolding the tear
❖ • Long term tamponade
 Silicon Oil
INDICATIONS FOR SILICONE OIL
E. Retinal detachments associated with choroidal coloboma
F. Infectious retinitis
❖ RRD in CMV retinitis
❖ Gancyclovir implants with silicone tamponade
F. Endophthalmitis
❖ Increase concentration of intravitreal antibiotics
❖ Antibacterial properties of silicone oil
❖ Stabilise atrophic retina
 Silicon Oil
COMPLICATIONS
• Cataract
• Glaucoma
• Keratopathy
• Absorption of silicone oil by silicone intraocular lenses
• Migration of silicone oil into the optic nerve and rarely into the brain
• Emulsification
• Retinopathy
• Recurrent retinal detachments
 Silicon Oil
EMULSIFICATION
❖ Smaller silicone oil droplets at the interface of oil droplet and intra ocular
fluids
❖ Factors promoting emulsification:
-Difference in density of two liquids
-Lower viscosity
-Decrease in interfacial tension
-Adsorption of surface active agents
-Ocular saccadic motion
❖ 1%-1month, 11%-3 months ,85% 6 months, 100%- 1 year
 Silicon Oil

❖ Choice of IOL: heparin coated PMMA/ regular PMMA

❖ Silicone oil acts as a foreign substance and not
reabsorbed by the eye
❖ On removal-retinal redetachment 3-33%
 Silicon Oil
SILICON OIL REMOVAL

❖ Theoretically, chorioretinal adhesion would have formed certainly

by 1 month.
❖ However, SO is retained often longer than this, the rationale being
that the presence of the oil and the tamponade force might resist
any traction caused by reproliferation.
❖ The Silicone Study, SO removal was allowed after a minimum of 8
weeks after surgery.
❖ Removal within the first 6 months after surgery is generally
recommended.
 Silicon Oil
SILICON OIL REMOVAL

Indications for removal

❖ Glaucoma
❖ Keratopathy
❖ Reasonable chance that retina will remain attached
Silicon oil removal
 Silicon Oil
Advantages
• high surface tension, ease of
removal, low toxicity, and
transparency.
• tamponade effect on the
superior retina
• airplane or high elevation
travel is planned
• post-operative positioning is
difficult
Disadvantages
• can pass through retinal
breaks under traction
• Requires optical
adjustments
• tamponade of the inferior
retina is difficult
• Emulsification
• Complications
• Sticky silicone oil
 References

1. Ryan’s Retina; 5th Edition

2. Alovisi C, Panico C, de Sanctis U, Eandi CM. Vitreous
Substitutes: Old and New Materials in Vitreoretinal
Surgery. J Ophthalmol. 2017;2017:3172138.
3. Yanoff and Duker Ophthalmology; 4th Edition
Thank You
Have a wonderful day!!