From the University of Miami (RAS, AMB, TGM), Miller School of Medicine, Bascom Palmer Eye Institute, Miami; and Florida Hospital (ECM), Orlando, FL.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Robert A. Sisk, MD, Bascom Palmer Eye Institute, 900 NW 17th Street, Miami, FL 33136.
Perfluorocarbon liquids (PFCLs) have been used as an adjunct to vitrectomy for complicated retinal detachments involving giant retinal tears and proliferative vitreoretinopathy (PVR). The use of PFCLs for extended tamponade has been limited due to concerns of toxic and mechanical damage to the retina and corneal endothelium. In experimental models, albino rabbit eyes demonstrated dispersion of PFCL and degenerative retinal changes in the inferior retina similar to those observed in the superior retina of silicone filled eyes.1 Dispersed or emulsified bubbles are associated with an inflammatory response and may favor the recurrence of PVR.2
PVR typically occurs inferiorly, in the aqueous phase of silicone, saline, or gas filled eyes, or where gravity allows it to settle in nonvitrectomized eyes. Due to their buoyancies, silicone oil and intraocular gases are an ineffective tamponade for complex retinal detachments in patients with inferior breaks who cannot maintain postoperative positioning.3
A 3-month-old child was referred and found to have extensive peripheral retinoschisis in both eyes with associated macula-involving retinal detachment in the right eye confirmed by B-scan ultrasonography and optical coherence tomography during examination under anesthesia. (Fig. 1) The fellow eye had hemorrhage inferiorly into a retinoschisis cavity. (Fig. 2) 20-gauge pars plana vitrectomy was performed on the right eye with temporal retinectomy, endolaser, and silicone oil tamponade. One month later, PVR had developed with inferior tractional retinal detachment (TRD), necessitating lensectomy, membrane stripping, inferior retinectomy, and silicone oil exchange. Recurrent TRD developed again, and he received scleral buckling and silicone oil exchange along with EDTA chelation for band keratopathy. Six weeks later, PVR produced recurrent inferior TRD. Following retinectomy, removal of perfluoro-n-octane (PFnO) resulted in slippage of the retina with macular folds. Despite multiple attempts with fluid-air exchange, these folds could only be flattened under PFnO, so the decision was made to leave PFnO as an endotamponade at the conclusion of vitrectomy surgery. The PFCL was removed 25 days later and a localized inferior TRD was treated with vitrectomy, membrane peel, and silicone oil infusion without further retinectomy. (Fig. 3) Emulsified PFnO without significant inflammation was observed in the anterior chamber at the time of its removal. The retina has remained attached during 11 months of observation with a Teller acuity of 0.86 cycles/cm at 55 cm with patching. (Fig. 4) The hemorrhage in the fellow eye resolved after 4 months of observation with a Teller acuity of 13 cycles/cm at 55 cm.
Figure 1. Montage Photograph of the Right Fundus at 3 Months of Age with Bullous Retinoschisis with Outer Layer Holes and Underlying Retinal Detachment Shallowly Extending Through the Macula.
Figure 2. Montage Photograph of the Left Fundus with Hemorrhage into an Inferior Schisis Cavity.
Figure 3. 4 Weeks After Extended Tamponade with PFnO, an Inferior Tractional Retinal Detachment Recurred but Spared the Macula. Numerous Emulsified PFnO Bubbles Are Seen Anteriorly.
Figure 4. Three Months After Removal of PFnO, the Retina Remains Attached Under Silicone Oil Tamponade.
Retinal detachments from proliferative vitreoretinopathy are especially common following vitrectomy in pediatric eyes because of an immature hyaloid that is difficult if not impossible to separate from the retina. Regardless of meticulous surgical technique, layers of cortical vitreous remain and act as a scaffold for epiretinal membrane proliferation. This leads to recurrent TRD that can be difficult to treat despite retinectomy and silicone oil placement. In our patient, the potential risks of mechanical and toxic damage to the retina and cornea from PFnO were deemed less than the risk of total functional vision loss associated with chronic retinal detachment and deprivational amblyopia. In addition, in contrast to silicone oil, there were significant advantages in postoperative positioning in this age group where immobility permits reliable supine positioning.
We achieved anatomic success during this limited observation period, though it is difficult to assess the eventual functional outcome at this age. Electroretinography would be unreliable due to the underlying structural abnormalities and extensive retinectomies in our patient and the reduced amplitudes produced by the insulating effects of silicone oils and PFCLs when used as vitreous substitutes. In eyes with multiple retinal detachments involving the fovea, the ischemic and degenerative changes that occur from the detachments already significantly limit the visual potential.
After removal of the PFCL, our patient received silicone oil tamponade. Silicone oils have the longest safety record of any permanent vitreous substitute and are frequently left in eyes requiring multiple surgeries for retinal detachment.
A number of vitreous substitutes termed “heavy silicone oils”4,5 have recently been developed for extended inferior retinal tamponade to address this issue and appear to have promising results. Most are combinations of silicone oil and semifluorinated alkanes, which have been well-tolerated with a low incidence of emulsification, dispersion, inflammation, or membrane development.4,5 However, none are currently FDA approved for extended tamponade or commercially available in the United States.
This case suggests a role for extended endotamponade using PFCLs to achieve anatomical reattachment of the retina in cases where other measures, including silicone oil tamponade, have failed. There is insufficient data in humans to comment on the safety and efficacy of this treatment, especially in the pediatric population. Limited data in human subjects using heavy silicone oils suggest these may be efficacious and safer for this application when they become commercially available.
- Hiscott P, Magee RM, Colthurst M, et al. Clinicopathological correlation of epiretinal membranes and posterior lens opacification following perfluorohexyloctane tamponade. Br J Ophthalmol. 2001; 85:179–183. doi:10.1136/bjo.85.2.179 [CrossRef]
- Fawcett IM, Williams RI, Wong D. Contact angles of substances used for internal tamponade in retinal detachment surgery. Graefes Arch Clin Exp Ophthalmol. 1994; 232:438–444. doi:10.1007/BF00186587 [CrossRef]
- Chang S, Sparrow JR, Iwamoto T, et al. Experimental studies of tolerance to intravitreal perfluoro-n-octane liquid. Retina. 1991; 11(4):367–374.
- Wolf S, Schön V, Meier P, Wiedemann P. Silicone oil-RMN3 mixture (“heavy silicone oil”) as internal tamponade for complicated retinal detachment. Retina. 2003June; 23(3):335–342. doi:10.1097/00006982-200306000-00008 [CrossRef]
- Rizzo S, Genovesi-Ebert F, Vento A, et al. A new heavy silicone oil (HWS 46-3000) used as a prolonged internal tamponade agent in complicated vitreoretinal surgery: a pilot study. Retina. 2007June; 27(5);613–620. doi:10.1097/01.iae.0000251228.33870.64 [CrossRef]