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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 108  |  Issue : 1  |  Page : 15-20

Incidence of retinal redetachment after silicone oil removal in cases of severe eye injuries operated during the 25th of January Egyptian Revolution


Department of Ophthalmology, Faculty of Medicine, Alexandria University, Alexandria, Egypt

Date of Submission04-Nov-2014
Date of Acceptance26-Dec-2014
Date of Web Publication9-Jul-2015

Correspondence Address:
Ahmed M Abdel Hadi
MD, 24 Fawzy Moaz Street, Safwa 5, Entrance 2, Alexandria 21311
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2090-0686.160331

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  Abstract 

Purpose
This study aimed to evaluate the frequency of retinal redetachment after silicone oil removal (SOR) in cases of severe eye injuries operated during the 25th of January Egyptian Revolution; we also attempted to evaluate the causes behind the redetachment.
Patients and methods
This retrospective, noncomparative, interventional case series included patients who had undergone both vitrectomy and SOR. The cause for the primary intervention was penetrating posterior segment trauma with and without intraocular foreign body (IOFB). Indications for performing SOR were classified as increased intraocular pressure, decreasing best-corrected visual acuity because of incorrectable refractive error, and oil emulsification changes with a preceding adequate duration of silicone oil tamponade (at least 4 months) in the absence of any complication. After SOR, patients were followed up for a minimum duration of 3 months. Retinal redetachment was managed with a repeat vitrectomy and silicone oil infusion. Preoperative and intraoperative factors that might be related to the recurrent detachment were identified. We attempted to relate these factors to the redetachment.
Results
The age of the patients ranged from 15 to 46 years, with a mean age of 31.07 ΁ 8.3 years. The sample studied included 21 (70%) males. Preoperative retinal detachment (RD) was recorded before the first intervention in 17 (56.7%) eyes. IOFBs were found in 13 (43.3%) eyes. In nine (30%) cases, intraoperative retinotomy or retinectomy was performed to successfully flatten the retina. In the eyes with preoperative RD (17 eyes, 56.7%), an encircling band was fixed. The cause of SOR was found to be increased intraocular pressure in six (20%) eyes, decreasing best-corrected visual acuity because of incorrectable refractive error in 16 (53.3%) eyes, and oil emulsification changes in eight (26.7%) eyes. Before SOR all eyes showed an attached stable retina for a least 4 months. After 3 months of follow-up, seven (23.3%) eyes were found to have a recurrent RD. The cause for this recurrence was surmised to be because of proliferative vitreoretinopathy in two (6.7%) cases, reopening of an old break in another two (6.7%) eyes, and new breaks created because of aggressive proliferative vitreoretinopathy in three (10%) eyes. The recurrence of RD was not affected by the duration of silicone oil tamponade, preoperative RD, intraoperative retinotomy, an IOFB, the presence of vitreous remnants, and C3F8 fill with endolaser barrage at the conclusion of surgery (P = 0.76, 0.07, 0.64, 0.66, 0.54, 0.113, respectively). The only statistically significant correlation that we found was between the fixing of a tamponade and the rate of recurrence (P = 0.01).
Conclusion
The routine use of silicone tamponade in complicated cases such as those with penetrating trauma, even if RD was not identified beforehand and the usage of an encircling bands in difficult cases with RD, may increase the success rate after SOR.

Keywords: Endotamponade, retinal redetachment, silicone oil, vitrectomy


How to cite this article:
Abdel Hadi AM. Incidence of retinal redetachment after silicone oil removal in cases of severe eye injuries operated during the 25th of January Egyptian Revolution. J Egypt Ophthalmol Soc 2015;108:15-20

How to cite this URL:
Abdel Hadi AM. Incidence of retinal redetachment after silicone oil removal in cases of severe eye injuries operated during the 25th of January Egyptian Revolution. J Egypt Ophthalmol Soc [serial online] 2015 [cited 2020 Jun 5];108:15-20. Available from: http://www.jeos.eg.net/text.asp?2015/108/1/15/160331


  Introduction Top


Penetrating intraocular foreign bodies (IOFBs) resulting from gunshot wounds are sometimes associated with severe ocular injuries. A posterior segment IOFB has a 68% chance of causing one retinal lesion and a 21% chance of causing two or more retinal lesions [1]. A major aim when treating eyes with IOFBs is to treat associated conditions, such as endophthalmitis, retinal detachment (RD), and late metallosis [2].

RD associated with complex vitreoretinal abnormalities, such as that secondary to penetrating trauma with IOFBs, was considered unmanageable, with a majority of cases resulting in complete loss of vision. Pars plana vitrectomy with an injection of silicone oil is the standard for treating this type of RDs [2],[3],[4],[5].

Although silicone oil has been proven to be one of the best vitreous substitutes, it can also lead to various complications when left in place for prolonged periods. Commonly reported complications include corneal decompensation, progressive cataract formation, and increased intraocular pressure (IOP) or secondary glaucoma [6-9]. It also causes a decrease in the visual acuity if it emulsifies with time. As a result of the above-mentioned complications, silicone oil is usually removed after a period of retinal stability. Because it repositions a mobile detached retina, removal sometimes leads to redetachment [10],[11],[12],[13],[14],[15].

The aim of this study was to evaluate the frequency of retinal redetachment after the silicone oil removal (SOR) in cases of severe eye injuries operated during the 25th of January Egyptian Revolution and we attempted to evaluate the causes behind the redetachment.


  Patients and methods Top


This retrospective, noncomparative, interventional case series was designed to evaluate the incidence of retinal redetachment in a group of patients with severe ocular injuries treated during the 25th of January revolution in Egypt for traumatic RD. This study included patients who presented to the Emergency Department, Alexandria University Hospital, during the first 2 weeks after the 25th Egyptian Revolution, who underwent pars plana vitrectomy with silicone oil tamponade for RD, followed by SOR between January 2011 and January 2012. The confidentiality of the patients' records was ensured. Data collection was approved by the local ethics committee.

Inclusion criteria for this study were patients who had undergone both vitrectomy and SOR. The cause for primary intervention was penetrating posterior segment trauma with and without IOFB. Removal of silicone oil was performed in eyes that had a completely attached retina as determined by a 90 D slit-lamp examination and had adequate duration of silicone oil endotamponade from 4 to 6 months. Any case with failed retinal reattachment or recurrence with silicone oil in place within the follow-up period was excluded from the study and dealt with according to the specific situation.

All patients had undergone pars plana vitrectomy using the standard three-port technique, with the use of heavy liquids to stabilize the posterior segment in case of mobile RD. Viscoelastic material was applied and later removed completely when needed to protect the macula at the time of extraction of an IOFB if present. Depending on the intraoperative situation, additional procedures were performed [Figure 1] during pars plana vitrectomy that included the use of a scleral buckle, membrane peeling, endodrainage of subretinal fluid, endolaser coagulation, cryopexy, and relaxing retinotomies. One thousand centistokes silicone oil was used in all cases. Phakic patients were rendered pseudophakic with an intraocular lens at the time of pars plana vitrectomy so that an additional phacoemulsification procedure is not required in the future because of silicone oil-induced cataract formation 7.
Figure 1: Additional procedures were performed during pars plana vitrectomy, for example, scleral buckle (a) and endolaser coagulation ( b).

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The patients were followed for at least 4 months after surgery in the outpatient clinic, where best-corrected visual acuity (BCVA), using a Snellen eye chart, and IOP were recorded. Anterior and posterior segments were examined at every visit to identify any complications. Anatomical success was defined as a completely attached, flat retina on examination of the fundus without any retinal traction, or ongoing proliferative phenomenon during the follow-up period.

Indications for performing SOR were classified as increased IOP, decreasing BCVA because of incorrectable refractive error, oil emulsification changes (as observed on slit-lamp examination) with a preceding adequate duration of silicone oil tamponade (at least 4 months) in the absence of any complication. Removal of silicone oil was performed using the posterior approach by three 23 G sclerotomies 3.5 mm posterior to the limbus. After SOR, patients recruited in the study were followed up for a minimum duration of 3 months. Retinal redetachment was managed with a repeat vitrectomy and silicone oil infusion.

Preoperative and intraoperative factors that might be related to the recurrent detachment were identified. We attempted to relate these factors to the redetachment.

To reduce the influence of external factors, the study included only patients in whom pars plana vitrectomy and removal of silicone oil had been performed by one surgeon.

All data were collected on an MS-Excel 2000 spreadsheet (Microsoft Corporation, Redmond, Washington, USA) and analyzed using SPSS, 20.0 for Windows (SPSS Inc., Chicago, Illinois, USA). For all statistical tests, P value less than 0.05 was considered significant.


  Results Top


In this retrospective, interventional case series, thirty eyes of 30 patients were included with a follow-up of at least 3 months after SOR.

The age of the patients ranged from 15 to 46 years, with a mean age of 31.07 ± 8.3 years. The sample studied included 21 (70%) males. Preoperative RD was recorded before the first intervention in 17 (56.7%) eyes by B scan ultrasonography.

During the first procedure, which entailed vitrectomy, phacoemulsification with intraocular lens implantation, IOFBs were found in 13 (43.3%) patients and extracted successfully in all these cases. In nine (30%) cases, intraoperative retinotomy or retinectomy was performed to successfully flatten the retina. In the eyes with preoperative RD (17 eyes, 56.7%), an encircling band was fixed. Eyes were followed up for a duration ranging from 4 to 8 months, with a mean follow-up of 5.3 ± 1.05 months before the SOR was attempted.

The cause of SOR was found to be increased IOP in six (20%) eyes, decreasing BCVA because of incorrectable refractive error in 16 (53.3%) eyes, and oil emulsification changes (as observed on slit-lamp examination) in eight (26.7%) eyes. Before SOR all eyes showed a stable attached retina for at least 4 months.

At the conclusion of surgery, 18 (60%) eyes had an endolaser barrage with C3F8 fill before closure. After 3 months of follow-up, seven (23.3%) eyes developed a recurrent RD. The cause for this recurrence was surmised to be because of proliferative vitreoretinopathy (PVR) in two (6.7%) cases, reopening of an old break in another two (6.7%) eyes, and new breaks created because of aggressive PVR in three (10%) eyes. These eyes were managed with a repeat vitrectomy and an infusion of silicone oil (5000 centistokes).

The duration of silicone oil tamponade was not affected by the presence or absence of RD before the original surgery, but rather the condition of the retina postoperatively. The mean duration before SOR in cases with preoperative RD was 5.35 ± 0.9 versus 5.23 ± 1.1 months for cases where the retinal was considered to be attached preoperatively as shown by B scan ultrasonography. This was not statistically significant (P = 0.76).

After statistical analysis of all preoperative and intraoperative factors that might affect the recurrence of RD post-SOR, we found that the eyes with preoperative RD were more likely to have a subsequent recurrence after SOR (35.3%) compared with eyes without a preoperative RD (7.7%). Yet, this difference in incidence was not statistically significant (P = 0.07) [Figure 2] and [Table 1].
Figure 2: Inferior traumatic retinal detachment because of a penetrating small shrapnel, inferonasal to the optic disc (a), and attached retina after vitrectomy with silicone oil (b, c).

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Table 1: Characteristics of the two groups

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Performing an intraoperative retinotomy was not significantly correlated with the development of recurrence [Figure 3]. Four (13.3%) patients with recurrence had undergone a retinotomy or retinectomy at the time of vitrectomy versus three (10%) eyes that were not subjected to retinotomy (P = 0.64). Again, the presence of IOFB did not correlate significantly with the rate of recurrence as four (13.3%) of the eyes that developed recurrence had an IOFB, whereas the rest (three eyes, 10%) had no IOFB by computed tomography before surgery (P = 0.66).
Figure 3: A case with penetrating FB (red arrow), with exit from the temporal retina (yellow arrow); vitrectomy with inferior retinotomy (blue arrow) was performed to reposition the retina and silicone 1000 centistokes was injected.

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During SOR, vitreous remnants because of incomplete shaving of the vitreous base were identified intraoperatively in 10 (33.3%) eyes. This was not significantly correlated with the rate of recurrence as only three (10%) eyes in which vitreous remnants were found showed recurrence of RD after SOR (P = 0.54).

Perfluoropropane-air exchange (12%) immediately after SOR with endolaser barrage was not associated with a lower recurrence rate. Six eyes developed a recurrence despite C3F8 fill and endolaser versus 12 eyes that had been subjected to the same procedure done, which remained stable till the end of the follow-up period. This was not statistically significant (P = 0.113).

No statistically significant association was found between the duration of silicone oil in situ and the rate of redetachment. The mean duration of silicone oil tamponade in cases that developed recurrence was 5.4 ± 1.1 months whereas that in the eyes with a successful outcome 3 months after surgery was 5.26 ± 1.05 months; this was not statistically significant (P = 0.735).

The only statistically significant correlation that we found was between the fixing of a scleral buckle and the rate of recurrence (P = 0.01). None of the eyes with a scleral buckle (17 eyes, 56.7%) developed recurrence during the follow-up period, whereas 23.3% (seven eyes) of eyes without a scleral buckle developed a recurrence - whatever the cause [Figure 4].
Figure 4: The left graph showing the relation between the preoperative RD as identified by ultrasound and the number of recurrent RD cases; the right graph shows the relation between the application of scleral buckle and the number of eyes that developed recurrence during the follow-up period. RD, retinal detachment.

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  Discussion Top


Vitrectomy surgery has improved the prognosis of perforating globe injuries, and a meta-analysis of published reports on eyes subjected to vitrectomy showed anatomical success in 69% and a visual acuity of more than or equal to 5/200 in 56% of the eyes. The timing of vitrectomy for perforating injuries remains controversial, and can be early (within 2 days), delayed (7-14 days), or late (after 30 days) [16],[17].

Silicone oil has increasingly been used for retinal tamponade in cases with complicated RD [18-20]. As the use of silicone oil can lead to long-term complications such as secondary open-angle glaucoma, progressive cataract, and corneal endothelial decompensation, [6],[7],[21],[22] it should be removed after adequate duration of endotamponade.

The main aim of this study was to evaluate the risk factors leading to retinal redetachment after SOR in 30 eyes operated after penetrating eye trauma in the early days after the 25th January Egyptian Revolution.

The mean age of the patients in the current study was 31.07 ± 8.3 years, with 21 (70%) male patients. Colyer et al. [23], in their publication on perforating globe injuries during operation" Iraqi Freedom," found the mean age of their 65 patients to be 29 years. Similarly, in the work of Ehlers et al. [24], the average patient age was 33.0 years, with a male predominance (94%).

After SOR, all eyes were followed for 3 months; the rate of redetachment was 23.3% (seven eyes). The cause was because of PVR in two (6.7%) cases, reopening of an old break in another two eyes (6.7%), and new breaks created because of aggressive PVR in three (10%) eyes.

Factors without a significant influence on the retinal redetachment rate included the duration of intraocular silicone oil tamponade had no significant (P = 0.735) effect on the rate of postoperative retinal redetachment. Similar results were found in the work Jonas et al. [12], in which they found that the duration of intraocular silicone oil tamponade had no significant (P = 0.51) effect on the rate of postoperative retinal redetachment. This suggests that the retinal situation may stabilize after about 1-3 months. After this period of time, silicone oil may be removed or, if epiretinal membranes have reformed, re-pars plana vitrectomy may be considered. This may also be true in view of histological findings showing microscopic silicone oil-related changes in the retina occurring after 4 weeks of silicone oil tamponade [25].

The rate of recurrence was slightly higher in eyes with preoperative RD, but this did not reach a statistically significant level (P = 0.07). Similar results were reported in other studies, where they did not observe any association between a history of RD as having a worse prognosis compared with the ones who had naive retina at the initial presentation [12],[15].

An intraoperative retinotomy was not significantly correlated with higher recurrence (P = 0.64). Studies have shown lower rates of redetachment in eyes that had been subjected to retinotomies. If the retina is no longer in direct contact with the vitreous base in eyes with an inferior retinotomy, contracting remnants of the vitreous base may no longer be able to exert a direct traction on the retina [12].

In the current study, the presence of vitreous remnants was not correlated significantly with the rate of recurrence (P = 0.54). In contrast to our findings, different studies have reported that vitreous remnants found during or before SOR were an important risk factor for retinal redetachment. This, in their opinion, implies clinically that, during pars plana vitrectomy, one should intensively attempt to remove the vitreous base, especially in the region of peripheral retinal defects. Vitreous remnants in the periphery of the fundus may exert traction on the retina, which may only be compensated as long as the internal silicone oil tamponade presses the retina against the retinal pigment epithelium [12],[14]. This difference in results might be explained by the fact that these studies included cases with severe degrees of PVR, which was not the case in our studied sample.

Perfluoropropane-air exchange (12%) immediately after SOR with endolaser therapy did not pose any additional safety as the rate of recurrence was not lower in eyes tamponade with gas at the conclusion of surgery (P = 0.113). In contrast, different results were reported in other studies where they found that intraoperative 360° argon retinopexy before SOR has been observed to decrease the rate of redetachment by 75% [26],[27]. This may be explained by the fact that, in their work, they performed 360 laser before surgery for SOR; consequently, enough time elapsed giving additional safety for such eyes. In our series, we attempted this during vitrectomy and not before.

Factors influencing significantly the rate of redetachment in the current study were limited to fixing a scleral buckle (P = 0.01). None of the eyes with a scleral buckle developed recurrence during the follow-up period. Jonas and colleagues found in their study that postoperative retinal redetachment occurred significantly more often in eyes without an encircling band than in eyes with an encircling band. In their study, they reported that an encircling band was mainly used in apparently difficult situations. A circumferential buckling of the equator may release a slight traction of remnants of the vitreous base [12].

In the current study, more than 80% of the cases of retinal redetachment occurred within the first 8 weeks of the procedure. Because our sample size for patients with redetachment was small, we cannot comment on the association of the timing of redetachment with other prognostic factors. The small sample size, the short follow-up duration after SOR, the exclusion of cases with redetachment before SOR, and the inclusion of cases with less than optimum silicone fill are all limitations of the current study.


  Conclusion Top


The incidence of RD after SOR has reduced significantly since the procedure was introduced in 1962. The routine use of silicone tamponade in complicated cases such as those with penetrating trauma, even if RD was not identified beforehand, the usage of an scleral buckle in difficult cases with RD, may increase the success rate after SOR. New technology and better techniques can benefit patients from developed as well as underdeveloped countries.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

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