Eye (1991) 5, 333-337

Removal of Silicone Oil-Rewards and Penalties

W. A. FRANKS and P. K. LEAVER

London

Summary
Silicone oil is a useful tool in retinal reattachment surgery in selected cases,l-4 but
complications, particularly cataract, glaucoma and keratopathy, have led to worries
about its use for prolonged internal tamponade.5-8 Removal of silicone oil has been
recommended to preempt or reverse these complications. A retrospective review of
120 eyes in which temporary silicone oil tamponade had been employed is presented.
One hundred and twelve eyes were examined six months and two years after removal
of silicone oil. Retinal redetachment occurred in 21 eyes (19%).
Cataract formation was delayed by early removal of silicone oil, but after two
years the majority of eyes had undergone surgery for cataract or had developed lens
opacities.
Removal of silicone oil was ineffective in reversing an established pressure rise in
nearly all cases. Three phakic eyes developed glaucoma after removal of silicone oil
but no new cases occurred in phakic eyes in the two years following silicone oil
removal.
Keratopathy was uncommon and was arrested and occasionally reversed by sili­
cone oil removal.
Visual acuities improved in the majority of eyes after removal of silicone oil.

Patients and Methods infusion cannula. In aphakic eyes silicone oil

A consecutive series of 120 eyes of 116 was removed through a 3 mm circumferential
patients who had undergone removal of sili­ limbal incision. Silicone oil removal was com­
cone oil following successful retinal reattach­ bined with other procedures in 22 eyes.
ment surgery from 1982 to 1987 were P ostoperatively topical antibiotics and
reviewed. Eyes with proliferative diabetic ret­ corticosteroids were administered four times
inopathy were excluded. daily for two weeks. All eyes were examined
All eyes had been treated with injection of by slit lamp biomicroscopy and indirect oph­
1000 cs silicone oil. Removal of silicone oil thalmoscopy on the first postoperative day, at
was performed under general or retrobulbar one week, four weeks, three months, six
anaesthesia. An infusion cannula was inserted months and two years postoperatively and
through a pars plana sclerotomy in the infer­ more frequently if necessary. Intraocular
otemporal quadrant, 4 mm behind the limbus pressure measurements were by Goldmann
in phakic eyes and 3.5 mm in aphakic eyes. In applanation tonometry.
phakic eyes a second pars plana sclerotomy Sixty nine left eyes were treated and 51
was made superotemporally and silicone oil right eyes. The average age of patients was
exchanged for balanced salt solution from the 41.5 years (range 12-81 years).

From: Moorfields Eye Hospital, City Road, London

Correspondence to: Mr P. K. Leaver FCOphth, Moorfields Eye Hospital, City Road, London EC1V 2PD
334 W. A. FRANKS AND P. K. LEAVER

Table I Effect of removal of silicone oil on the development of cataract: analysis of 60 phakic eyes with attached
retina at 2 years (excluding eyes which underwent reinjection of silicone oil)

Lens status Duration of intraocular silicone

At time of silicone oil removal <6/52 6/52-12/52 >12/52 p-value

phakic 19 26 15 <0.001
cataract 4 11 9 0.128
Six months after silicone oil removal
cataract surgery within 6 months 4 9 9 0.06
clear lens 5 4 1 0.13
phakic 15 17 6 <0.05
Two years after silicone oil removal
cataract surgery after two years 10 17 11 0.50
clear lens 4 3 1 0.35
phakic 9 9 4 0.11

*p-value for silicone oil removal at less than 12 weeks compared to greater than 12 weeks.

The duration of intraocular silicone oil in addition to the seven eyes in which the ret­
ranged from three weeks to five years, with a ina was seen to redetach peroperatively. Thir­
mean of 30 weeks. teen of these 17 eyes underwent successful
Eight patients failed to complete two years reattachment surgery. Between six months
follow-up, leaving 112 eyes for analysis at six and two years, four further redetachments
months and two years following removal of occurred, related to reproliferation of mem­
silicone oiL branes. Surgery was successful in reattaching
The indications for use of silicone oil were the retina in only one of these eyes.
giant retinal tear (57 eyes), giant retinal dialy­ Twelve eyes required further injection of
sis (one eye) and posterior breaks (16 eyes) silicone oil and two intraocular gas injection,
and proliferative vitreoretinopathy (46 eyes). while the retina remained detached in seven.

Results Cataract: (Table I)

The incidence of cataract was analysed in
Perioperative Complications of Silicone Oil
three groups according to the duration of
Removal
intraocular silicone; five weeks or less, six to
Hyphaema occurred following silicone-oil
12 weeks and greater than 12 weeks, to see if
removal in 12 eyes and vitreous haemorrhage
shorter duration of silicone oil tamponade
in ten. All haemorrhages cleared sponta­
was associated with a reduction in the number
neously without requiring further surgical
of eyes developing cataract. There was a high
intervention.
incidence of cataract in all three groups with
Hypotony occurred in 27 eyes in the first
no statistical difference between the number
two weeks after surgery. Two eyes with
of eyes developing cataract at six months and
attached retinae had intraocular pressures
two years. There was a trend, however,
less than 8 mmHg at six months and two
towards slower development of cataract the
years.
earlier silicone oil was removed and the lens
One suffered expulsive haemorrhage at the
was significantly more likely to be retained at
time of surgery and a second occurred in the
six months if silicone oil was removed before
eye undergoing Molteno tube implant two
12 weeks. After two years most eyes had
weeks after removal of silicone oiL Retinal
developed cataract.
redetachment was noted at the time of sili­
cone oil removal in seven eyes. Glaucoma: (Table II)
Raised intraocular pressure requiring medical
Postoperative Complications or surgical treatment was present in ten
Retinal Redetachment phakic eyes and 18 aphakic eyes at the time of
Retinal redetachment occurred in ten eyes in removal of silicone oiL After two years no
the first six months after silicone oil removal further phakic eyes had developed glaucoma
 REMOVAL OF SILICONE OIL-REWARDS AND PENALTIES 335

Table 2 Analysis of potential risk factors for glaucoma in eyes with temporary silicone oil tamponade

Total Glaucoma at 2 years p-value

Aphakia 39 21 <0.001
Raised lOP at time of oil removal 27 24 <0.001
Giant tear 51 17 0.02
PVR 45 11 NS
Post break 15 3 NS
Scleral buckle 79 23 NS

but three additional aphakic eyes commenced If eyes with retinal redetachment are
treatment for raised intraocular pressure. excluded, visual acuity improved in 52 eyes,
Aphakia was a significant risk factor for the worsened in 20 and was unchanged in 19.
presence of glaucoma at the time of silicone Improvement in vision was associated with
oil removal (p<O.OOl). Of 18 eyes which cataract extraction, continued improvement
underwent lensectomy at the time of silicone in retinal function after successful retinal reat­
oil injection, ten required treatment for glau­ tachment, removal of silicone oil emulsion
coma after two years (55% ) and of 18 eyes and reduction in the optical effects of the sili­
aphakic prior to silicone oil injection, 11 cone oil bubble. Deterioration of vision was
(61 %) required treatment for glaucoma two related to development of cataract, glau­
years after silicone oil removal, a similar pro­ coma, macular pucker and keratopathy.
portion in each group.
In aphakic eyes there was a trend towards Discussion
an increase in the incidence of glaucoma with Visual acuity following silicone oil removal
duration of intraocular silicone. The mean was improved in the majority of eyes in this
duration of intraocular silicone was 75 weeks series and in 30, visual acuities were 6/18 or
in eyes with glaucoma compared to 58 weeks better. This level of vision was useful to many
in those not developing this complication, but binocular patients and temporary silicone-oil
the numbers were small, and did not reach tamponade may be of benefit to patients with
statistical significance. good vision in the fellow eye. Removal of
The number of previous retinal procedures, silicone oil exerts some beneficial effects by
type of retinal detachment, and the use of abolishing variable vision associated with
scleral buckling did not correlate significantly movement of the silicone oil bubble and
with the subsequent development of reducing visual disturbance caused by emul­
glaucoma. sion.9 Many eyes underwen< conventional
extracapsular cataract surgery with intra­
Keratopathy ocular lens implantation. Removal of silicone
Keratopathy occured in five aphakic eyes. In is advantageous in these cases as it allows
one, corneal opacification reversed after sili­ accurate biometry, reduces capsular opacifi­
cone oil removal and one underwent pen­ cation and abolishes the variable optical
etrating keratoplasty at the time silicone oil effects caused by the silicone oil bubble.
was removed. In two, keratopathy remained Silicone oil removal was associated with
stable and one developed bullous kerato­ retinal redetachment in 19% of eyes. This is a
pathy. similar finding to that in other series.5-8 In
most cases the retina was reattached but in
Advantages of Silicone Oil Removal seven eyes it remained detached. Redetach­
VISual Acuity: (Fig. 1) ment of the retina also occurs in eyes where
Mean best corrected visual acuity at the time silicone oil has not been removed, usually as a
Df silicone oil removal was 6/60, improving to result of reproliferation of membranes. In
6136 at six months and maintained at two such eyes the recruitment of subretinal fluid
years. In 30 eyes visual acuity was 6/18 or bet­ may be limited by silicone oil and macular
ter after two years. vision may be spared but if silicone oil is
336 w. A. FRANKS AND P. K. LEAVER

Visual acuity after silicone oil removal

(91 eyes with attached retinae)

6/6 0
IT]
if)
L
6/9
0 & [[]
0 0
Q) 6/12
>- 0
DO EE 0 0 0

N 6/18 0 0 IJ]]J EB 0
0
-+-'
[]] 8 co
0 6124
0 0
1:' 6/36
CD
[ill c:B@
:J qtJ
U 6/60
3 or::o 0
0
0 00
0
CF
[j:tJ
10 8J OJ 0
:J
if) HM 4 00 0
>
PL
0 0

6/60 6/36 6/24 6/18 6/12 6/9 6/6

PL HM CF

Pre op visual acuity

Fig 1. Visual acuity aftcr silicone oil removal (91 eyes with attached retinae).

removed, redetachment is likely to be rapid The principal risk factors for the develop­
and extensive and urgent surgical reinterven­ ment of glaucoma were aphakia and raised
tion is required. intraocular pressure at the time of silicone-oil
Early removal of silicone oil was associated removal. Following Ando's report13 in 1985,
with a trend towards a reduction in cataract an inferior iridectomy was employed in all
formation and the lens was retained in signifi­ aphakic eyes undergoing silicone oil injection.
cantly more eyes from which silicone oil was This reduced the number of eyes developing
removed after less than 12 weeks than in those angle closure glaucoma with pupil block, and
in which the duration of intraocular silicone the number of eyes with peripheral anterior
was longer. It appears that early removal of synechiae and chronic angle closure sub­
silicone oil delays the development of cataract sequently requiring drainage surgery. A few
but does not prevent it. cases of acute glaucoma continued to occur,
Glaucoma was common in this series, 23% however, when iridectomies became blocked
of eyes undergoing treatment for raised intra­ by fibrin.14
ocular pressure prior to silicone oil removal. Scleral buckling has been implicated in
Removal of silicone oil was ineffective in causing acute pressure rise following vitrec­
reversing an established pressure rise in all tomy,15 but we found no evidence of its influ­
but one eye. After silicone oil removal no ence on the incidence of glaucoma six months
further phakic eyes developed glaucoma and two years after removal of silicone oil.
despite the presence of persistent emulsion in The incidence of glaucoma was high com­
the anterior chamber drainage angle. Three pared to other series.5,7,8 The purity of the
aphakic eyes developed glaucoma in the two silicone oil used in different centres varies
year follow-up period, probably reflecting the considerabli6 and the use of 1000 centistoke
more severe anterior segment disturbance oils with a high proportion of small molecular
these eyes had suffered. weight components may contribute to emulsi-
 REMOVAL OF SILICONE OIL-REWARDS AND PENALTIES 337

fication and damage to the anterior chamber detachment with advanced proliferative vitreo­
retinopathy. Ophthalmology1985, 92: 1029.
drainage angle. Higher viscosity silicone oils
"Leaver PK, Grey RHB, Garner A: Silicone oil in
have less impurities but are more difficult to the treatment of massive preretinal retraction.
11.
remove from the eye. Further studies are Late complications in93 eyes. Br J Ophthalmol
needed to assess if their use is associated with 1979,63: 361.
5 Chan C, Okun E: The question of ocular tolerance
a lower incidence of complications.
to intravitreal liquid silicone. A long-term analy­
sis. Ophthalmology1986,93: 651-9.
Conclusions 'Gonvers M: Temporary silicone oil tamponade in
An improvement in visual acuity and visual the management of retinal detachment with pro­
function follows removal of silicone oil, pro­ liferative vitreoretinopathy. Am J Ophthalmol
1985, 100: 239.
vided that the retina remains attached.
7 Casswell AG and Gregor ZJ: Silicone oil removal.
Most eyes develop cataracts but in eyes in 11. Operative and postoperative complications.
which silicone oil is removed at less than 12 Br J Ophthalmol1987,7 1: 898.
weeks their development is delayed. 'Zillis JD, McCuen BW, De Juan E, Steffansson E,
Machemer R: Results of silicone oil removal in
Glaucoma may be prevented by early
advanced proliferative vitreoretinopathy. Am J
removal of silicone oil but once a pressure rise Ophthalmol1989, 108: 15-21.
is established, removing silicone oil will not 9 Stefansson E and Tiedeman J: Optics of the eye with
reverse it. air or silicone oil. Retina1988, 8: 10.
Keratopathy in aphakic eyes can 10 Leaver PK, Cooling RJ, Feretis EB, Lean JS,
McLeod D: Vitrectomy and fluid/silicone
occasionally be reversed or arrested by remo­ exchange for giant retinal tears: results at six
val of silicone oil. months. Br J Ophthalmol1984, 68: 432-8.
Removal of silicone oil is recommended to 11 Billington BM and Leaver PK: Vitrectomy and fluid/

improve visual potential and reduce the risks silicone oil exchange for giant retinal tears: results
at18 months. Graefe's Arch Clin Exp Ophthalmol
of sight threatening complications in eyes in
1986,224,7-10.
which the retina has been successfully 12 Leaver PK and Billington BM: Vitrectomy and fluid/
reattached. silicone exchange for giant retinal tears: 5 years
Wherever possible it is recommended that follow-up. Graefes Arch Ophthalmol 1989, 227:
silicone oil be removed within 12 weeks of 323-7.
13 Ando F: Intraocular hypertension resulting from
injection. pupillary block by silicone oil. Am J Ophthalmol
1985,99: 87.
Key words: Cataract, Glaucoma, Internal Tampo­ I" Laganowski H and Leaver PK: Silicone oil in the
nade, Keratopathy, Retinal detachment, Silicone oil. aphakic eye: the influence of a six o'clock periph­
eral iridectomy. Eye1989, 3: 338-48.
References 15 Han DP, Lewis H, Lambrou FH, Mieler WF, Hartz
1 Cibis PA, Becker B, Okun E, Canaan S: The use of A: Mechanism of intraocular pressure elevation
liquid silicone in retinal detachment surgery. Arch after pars plana vitrectomy. Ophthalmology1989,
Ophthalmol1962, 68: 590-9. 96: 1354-62.
16
2 Scott JD: Treatment of massive vitreous retraction. P arel JM: Silicone oils: physicochemical properties.
Trans Ophthalmol Soc UK1975, 95: 429. In Retina. Ryan S, cd. Volume3. Surgical Retina.
3 McCuen BW, Landers MD, Machemer R: The use Glaser BM, Michels RG, eds. CV Mosby and Co.
of silicone oil following vitrectomy for retinal 1989. Ch.127, P263-266.