Surgical Techniques of

Silicone Oil Infusion

Dr. Bhumika Rath
 General Consideration
• Commercially available SO has viscosities ranging from 1000 cSt to 5700 cSt.
• The lower viscosity SO (i.e., 1000 cSt) was used in the Silicone Study, while the
5000 cSt SO is the only SO approved by the Food and Drug Administration for
intraocular use in the United States.
• 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; and
(3) risk of emulsification.
• The tamponade effect appears to be similar among SO with different
viscosities.
• Injection can be done either with an automated pneumatic pump or
manually.
• This has the advantage of being faster and allows more surgeon-
control through a foot pedal-controlled system. The disadvantage of
this system is that there is no pressure-feedback mechanism, hence a
risk of over- or underfill exists and is dependent on the surgeon's
experience.
• An IOP of around 10 mmHg is desirable at the end of the surgery.
 Considerations of Lens Status

• Some believe that leaving the eye phakic would enhance the tamponade effect
of the oil to the superior and inferior retina.
• Cataract invariably occurs following SO tamponade, even if SO is removed
shortly after surgery (i.e., 6 weeks).
• In this regard, many surgeons prefer removing the lens at the same sitting.
Rendering the eye pseudophakic facilitates vitreous base dissection and
shaving.
• Phacovitrectomy is commonly the standard approach by retinal
surgeons in most countries except in the United States, where the
referral pattern discourages retinal specialists from carrying out
phacoemulsification themselves.
• Rendering the patient totally aphakic is unacceptable as it would
increase the risk of oil keratopathy even if an inferior peripheral
iridectomy was performed.
• An IOL made up of polymethyl methacrylate (PMMA) or acrylic should
be used to avoid the risk of undesirable adhesions of SO to the IOL.
 Air–Silicone Oil Exchange
• The presence of fluid inside the vitreous cavity predisposes to underfilling of SO.
• Endolaser photocoagulation should have been performed to seal all retinal
breaks. Injection of SO is then carried out, with the injection cannula inserted
through either of the two open sclerotomies.
• The illumination should be withdrawn after the initial gush of SO has been
infused. This allows air inside the eye to escape through the vacant sclerotomy,
as SO is being filled progressively.
• The endpoint of SO infusion is either when it fills up to the vacant sclerotomy –
SO is seen filling the infusion tube from internally – or when it reaches the iris
plane in aphakic eyes.
• In pseudophakic eyes a sign that signifies near complete fill is when
the enlarging SO bubble touches the undersurface of the posterior
capsule, which can be seen easily under the microscope.
• The IOP should be normal, or at around 10 mmHg at the end of
surgery.
• In aphakic eyes, an inferior peripheral iridectomy (Ando's PI) needs to
be done.
• This prevents pupil block by the SO droplet and allows a passageway
for aqueous to egress through the pupil plane.
 Perfluorocarbon Liquid–Silicone Oil Exchange

• First, a PFCL–fluid exchange has to be done.

• PFCL is injected via one of the ports, while the other port is left vacant, until the
eye is almost full.
• SO can block the flute needle.
• It has been shown that for giant retinal tear or 360° retinotomy, a direct SO–
PFCL exchange is less likely to cause slippage.
• Both SO and PFCL are hydrophobic and prefer to be in contact with one and
other. Once joined, the two liquids form a single bubble and exclude aqueous
from the interface.
Complications
 Silicone Oil in the Anterior Chamber
• This occurs in cases where the barrier at the level of the lens–iris diaphragm is
inadequate to stop SO from migrating into the AC.
• This can be due to aphakia, loose zonular support, blockage of the inferior
peripheral iridectomy, or a break in the posterior capsule.
• When the AC is completely filled with SO, it can be undetected, because there
is no fluid meniscus present.
• Confirmatory signs of an AC completely filled with SO include a
slightly posterior bulging iris, shimmering reflex on the iris crypts, and
absence of aqueous flare in the AC.
• The pupil can also appear mid-dilated with a raised IOP.
• The SO can be displaced back into the vitreous cavity at the end of the
surgery with air or viscoelastic agents.
• An inferior peripheral iridectomy needs to be done, and the patient
should be postured upright or slightly face-down.
• SO can egress into the AC in a pseudophakic or phakic eye during surgery.
• This can sometimes occur as a result of overfilling of the eye with SO.
• During the postoperative period, SO migration into the AC sometimes occurs.
• Blockage of the peripheral iridectomy frequently occurs if there was extensive
surgery involving retinotomies, 360° photocoagulation, and extensive
cryotherapy. If left alone, it can cause visual disturbance, induce corneal
endothelial cell loss, and trabecular damage.
• Late migration of SO into the AC is commonly due to recurrent detachment or
hypotony. Hypotony is usually caused by a combination of ciliary body shutdown
and overdrainage by the uveal–scleral pathway (especially where large
retinotomies have been done).
• Conservative management is appropriate.
Glaucoma
• Rise in IOP after surgery with SO can be grossly divided into:
• (1) pupil block glaucoma;
• (2) overfill of SO;
• (3) secondary open angle glaucoma;
• (4) migration of SO into the AC;
• (5) secondary angle closure glaucoma.
• Pupil block glaucoma occurs in an aphakic eye, usually during the early
postoperative period, where the peripheral iridectomy is nonfunctioning.
• When the peripheral iridectomy is nonfunctioning, aqueous accumulates behind
the iris and forces the SO bubble through the pupil.
• Pupil block results when this phenomenon progresses.
• Treatment involves reopening the peripheral iridectomy, either with a YAG laser
or surgically.
• If the cause of IOP rise is due to overfill of the eye with SO, the AC will appear
shallow.
• In the aphakic eye, overfill can be treated with removal of oil via a corneal or
pars plana incision.
• Secondary angle closure glaucoma is a diagnosis of exclusion.
• The cause of secondary open angle glaucoma associated with SO could be due
to mechanical blockage of the trabecular meshwork, or trabeculitis induced by
emulsified SO.
• Medication comprises the initial treatment.
• If IOP continues to rise, glaucoma surgery in the form of drainage
device is preferable over trabeculectomy.
• One of the reasons why trabeculectomy gives rise to failure is thought
to be fibrosis; SO under the conjunctiva is known to cause periocular
fibrosis involving foreign body giant cell reaction.
• Some also suggested that simply removing the in situ SO would be
beneficial in terms of IOP.
• IOP remains elevated in most patients, even with SO removal.
• This may be due to the problem of incomplete removal of SO from the eye,
especially those trapped within the trabecular meshwork.
• If damage has already been made to the trabecular meshwork, and scarring has
already set in, removal of SO at a later stage may not bring about an IOP
lowering effect.
 Chronic Hypotony

• This complication usually occurs during the late postoperative period.

• It is defined as having IOP ≤5 mmHg in the Silicone Study.
• This cutoff level is arbitrary.
• Large retinectomies are thought to be the cause of increased aqueous uveal–
scleral outflow. Ciliary body alterations are thought to be the cause of reduced
aqueous production.
• Treatment of this condition has been disappointing so far.
• Removal of SO risks the progression to phthisis, hence hypotony with IOP
 Cataract Formation

• The exact mechanism remains uncertain, although the possibility of impaired

metabolic exchange across the posterior capsule and direct toxicity has been
speculated.
• As with the case of gas tamponade, posterior subcapsular feathery lens opacity
can be seen in the early postoperative period.
• The lens swells up quickly over a matter of days, with leakage of protein into the
AC and brisk uveitis.
• However, this usually resolves spontaneously with time. If SO is kept in situ for
long-term tamponade purposes, cataract inevitably forms, which could be in the
form of posterior subcapsular cataract or nucleus sclerosis.
• Intraocular lens power calculations can be difficult without prior planning.
• It is recommended that, routinely, all patients undergoing vitrectomy
and SO infusion should have B-mode axial length measurements done
prior to surgery.
• SO in contact with the posterior surface of the intraocular lens would
greatly reduce the refractive power.
• Most intraocular lenses have biconvex configuration.
• There are intraocular lenses specifically designed for the use of SO,
with a concave posterior surface, such that the intended final
correction will be correct even with SO in situ.
• SO adherent to intraocular lens implant can give rise to blurred vision, polyopia,
and distortion.
• The astigmatism present is often irregular and cannot be corrected by glasses.
This occurs where there is a breach in the posterior capsule, such that SO comes
into direct contact with the IOL.
• With ultrasound biometry, measurements of axial lengths in SO filled eyes may be
affected by differences in the speed of sound wave in vitreous and SO.
• The speed of sound wave in SO is 986 meters per second (m/s), and that in
vitreous fluid is 1552 m/s.
• Hence, if an eye is filled with SO, the time taken for the sound wave to return to
the receiving sensor is longer than when the same eye is filled with vitreous.
• The resulting axial length may be falsely long, which would cause a
hyperopic shift if the uncorrected measurement were used for IOL power
calculation.
• Care must be taken, as specific SO-formulae are used when the eye is filled
with SO.
• A “conversion factor” of 0.71 has been found to give good accuracy with a
mean of only 0.74 diopters difference between the predicted and actual
postoperative refraction.
• An additional consideration is that a myopic shift has been reported with the
use of combined phacovitrectomy and intraocular lens implantation, with or
without tamponade.
 Recurrent Retinal Detachment

• Missed retinal breaks give rise to recurrent retinal detachments, even in the
absence of PVR, either with SO in situ or after SO removal.
• It is highly doubtful whether there is a state of total tamponade that can be
achieved with SO fill; the evidence points to the contrary.
• Results from the Silicone Study showed that the rates of redetachment were not
significantly different when comparing eyes randomized to SO or to gas use.
 Emulsification

• Dispersion of SO is the breaking-up of large bubbles into smaller droplets.

• The surface energy of these smaller droplets is higher, and therefore they have a
tendency to coalesce to form a larger bubble.
• Emulsification only occurs when surface energy of the droplets is reduced in the
presence of surfactants.
• Surfactants may include phospholipid, protein, lipoprotein, or even solid cellular
debris.
• Dispersion requires shear force between the oil and the retinal surface and is
dependent on rate of eye movement.
• Emulsification can lead to glaucoma, inflammation, and PVR formation.
• Emulsification can occur as quickly as 1 week after surgery, but the most
common timeframe is a few months after surgery.
 Keratopathy

• Prolonged use of SO is associated with keratopathy, either in the form of band

keratopathy, which is more commonly seen in early stages, and bullous
keratopathy in the late stages.
Unexplained Visual Loss Following Silicone Oil Tamponade

• It can be speculated that it may be the sudden change in physiologic

environment affecting ionic exchange.