Ophthalmic Surgery, Lasers and Imaging Retina

Clinical Science 

Perfluorodecalin Versus Densiron 68 Heavy Silicone Oil in the Management of Inferior Retinal Detachment Recurrence

Tomaso Caporossi, MD; Ruggero Tartaro, MD; Lucia Finocchio, MD; Francesco Barca, MD; Fabrizio Giansanti, MD; Fabrizio Franco, MD; Stanislao Rizzo, MD

Abstract

BACKGROUND AND OBJECTIVE:

To assess the efficacy of perfluorodecalin (PFD) or Densiron 68 heavy silicone oil (HSO) in the management of inferior complex retinal detachment recurrence.

PATIENTS AND METHODS:

A retrospective, comparative consecutive case series study. Twenty-four eyes of 24 patients affected by inferior complex retinal detachment recurrence underwent pars plana vitrectomy with PFD or HSO as endotamponade. All patients recruited were affected by complicated inferior retinal detachments and had already undergone at least one vitreoretinal procedure. The primary endpoint was anatomical success with primary and secondary surgery. The secondary endpoints were functional outcome and inflammatory complications.

RESULTS:

Out of 24 cases of inferior retinal detachment recurrence, 12 were tamponed with PFD (PFD group) and 12 with HSO (D68 group). Retinal reattachment rate at first surgery was 50% for the D68 group and 66.6% for the PFD group. Final reattachment rate after two or more surgical operations was 91.6% for the PFD group and 83.3% for the D68 group. Best-corrected visual acuity improved in both groups from a mean of 1.00 logMAR (20/200; standard deviation [SD]: 1) to 0.60 logMAR (20/80; SD: 0.3), and from a mean of 1.81 logMAR (20/2000; SD: 1.1) to a mean of 2.00 logMAR (20/2,000; SD:1) for the PFD and D68 groups, respectively.

CONCLUSION:

Both the endotamponades used showed good results in solving inferior retinal detachment recurrence with a slightly better rate in the PFD group, but it was not statistically significant (P > .05).

[Ophthalmic Surg Lasers Imaging Retina. 2019;50:274–280.]

Abstract

BACKGROUND AND OBJECTIVE:

To assess the efficacy of perfluorodecalin (PFD) or Densiron 68 heavy silicone oil (HSO) in the management of inferior complex retinal detachment recurrence.

PATIENTS AND METHODS:

A retrospective, comparative consecutive case series study. Twenty-four eyes of 24 patients affected by inferior complex retinal detachment recurrence underwent pars plana vitrectomy with PFD or HSO as endotamponade. All patients recruited were affected by complicated inferior retinal detachments and had already undergone at least one vitreoretinal procedure. The primary endpoint was anatomical success with primary and secondary surgery. The secondary endpoints were functional outcome and inflammatory complications.

RESULTS:

Out of 24 cases of inferior retinal detachment recurrence, 12 were tamponed with PFD (PFD group) and 12 with HSO (D68 group). Retinal reattachment rate at first surgery was 50% for the D68 group and 66.6% for the PFD group. Final reattachment rate after two or more surgical operations was 91.6% for the PFD group and 83.3% for the D68 group. Best-corrected visual acuity improved in both groups from a mean of 1.00 logMAR (20/200; standard deviation [SD]: 1) to 0.60 logMAR (20/80; SD: 0.3), and from a mean of 1.81 logMAR (20/2000; SD: 1.1) to a mean of 2.00 logMAR (20/2,000; SD:1) for the PFD and D68 groups, respectively.

CONCLUSION:

Both the endotamponades used showed good results in solving inferior retinal detachment recurrence with a slightly better rate in the PFD group, but it was not statistically significant (P > .05).

[Ophthalmic Surg Lasers Imaging Retina. 2019;50:274–280.]

Introduction

Inferior retinal detachment recurrence remains a challenge even for expert vitreoretinal surgeons. Proliferative vitreoretinopathy (PVR) remains the major complication associated with retinal detachment surgery and the main reason for unsatisfactory anatomical and functional outcomes.1 Advanced inferior PVR can be managed with pars plana vitrectomy (PPV) and silicone oil, and moreover, a scleral buckle (SB) combined with PPV could also be carried out. Conventional lighter-than-water tamponades, such as standard silicone oil (SSO) or gas, support the superior retinal periphery and posterior pole; however, they do not tampon the lower retinal periphery, where a mixture of aqueous humor and growth factors (“PVR soup”) may gather. Heavier-than-water intraocular tamponades have many advantages over conventional tamponades, especially in the treatment of inferior retinal detachments with PVR of the lower-retinal periphery. A heavy endotamponade can efficiently tamponade breaks and retinotomy in the lower periphery in the upright position. It interrupts open communication between the subretinal space/retinal pigment epithelial (RPE) cells and the pre-retinal space, lowering the risks of PVR development and a reopening of the break. It displaces the proliferative mixture of residual aqueous, inflammatory, and RPE cells away from the lower retina and the posterior pole. The tamponade effect at the posterior pole may lead to a faster and lasting reattachment of the macula. Re-detachments are likely to occur predominantly in the superior periphery, where they are easier to treat with gas tamponades.1 Densiron 68 (Fluoron, Neu-Ulm, Germany) is a solution of perfluorohexyloctane (F6H8) and 5,000 centistoke silicone oil. The advantage of this solution is that it increases the viscosity of F6H8 from 2.5 mPa to 1,387 mPa, thereby reducing its tendency to disperse.2 It has been investigated in several clinical series, predominantly on patients with complex retinal detachments. Densiron 68 has been chosen as the heavy tamponade of choice in the Heavy Silicone Oil Study (HSO Study), the first multicenter, comparative trial of heavy versus conventional silicone oil tamponades.3

The application of perfluorocarbon liquids (PFCLs) has been widely used in vitreoretinal surgery and described by many authors.4–6 Its special chemical composition makes perfluorocarbon an excellent intraoperative tool to improve the efficiency and safety of surgical procedures in many challenging cases. Previous in vitro studies have evaluated the effects of direct toxicity and damage due to perfluoro-n-octane (PFO) gravity on human RPE cells and retinal ganglion cells.7,8 In contrast to previously published work, Mackiewicz et al. did not detect any tamponade-related structural damage to the retina after 3 months.9 Other authors showed no toxic effect on the retina nor occasional macrophages in the photoreceptor segments, with no ultrastructural change after 2 weeks.10,11 PFCLs have already been used as short-term postoperative tamponades (7 to 14 days) in the management of retinal detachment due to giant retinal tears, with no serious adverse effects.12–15

The aim of our study is to assess the efficacy of perfluorodecalin (PFD) or Densiron 68 heavy silicone oil (HSO) in the management of inferior complex retinal detachment recurrence.

Patients and Methods

This was a consecutive, retrospective, nonrandomized case review. The study was performed in accordance with the current version of the Declaration of Helsinki. We reviewed the records of 24 eyes of 24 patients affected by inferior retinal detachment recurrence complicated by PVR who underwent only one vitreoretinal intervention at Careggi University Hospital, Florence, Italy, between September 2015 and July 2017. The surgical procedures were performed by three experienced surgeons (SR, TC, FB). Twelve patients were tamponed with PFD (Biofluor; Omnia, Bucine [AR], Italy) (PFD group) and 12 patients with Densiron 68 HSO (Fluoron Co, Neu-Ulm, Germany) (D68 group). PFCL medium-term tamponade has been introduced in our clinical practice from 6 months, whereas D68 has been utilized from 5 years. From December 2012 to December 2017, the surgeons utilized only D68 in these complex cases. Conversely, from December 2017 until the present, surgeons started to utilize PFCL as medium-term tamponade. In the D68 group, eight cases had undergone encircling SB alone before recurrence and four patients had undergone encircling SB combined with pars plana vitrectomy (PPV) and SSO tamponade; in the PFD group, five patients had undergone encircling SB, three had undergone PPV with SSO tamponade, and four had undergone encircling SB combined with PPV with SSO tamponade.

All cases underwent 23- or 25-gauge PPV (Alcon Laboratories, Fort Worth, TX). In the PFD group, we first carried out encircling SB with perfluorodecalin endotamponade on the cases who had not undergone SB during previous surgery. A chandelier endo-illuminator was used to facilitate bimanual maneuvers. A complete vitrectomy with a meticulous vitreous base shaving was performed. To facilitate PVR removal, a mixture of vital dye was injected (Trypan Blue and Brilliant Blue G [Membrane Blue-Dual; DORC, Netherlands]). All PVR peeling maneuvers were performed under perfluorodecalin to stabilize detached retina movements. PVR was removed as much as possible. When the peeling did not seem to release sufficient traction, a relaxing retinectomy was performed (three cases in the PFD group and four cases in the D68 group). A peripheral 360° endo-laser was carried out. In the PFD group, the surgery ended by filling the vitreous cavity with perfluorodecalin and suturing the sclerotomy with a single suture (Vicryl 7-0; Ethicon, Somerville, NJ) (Figure 1). In the D68 group, a direct perfluoro-silicone oil exchange completed the procedure (Figure 2). During the postoperative, period all patients were asked to maintain a face-up position as much as possible. For the endotamponade removal procedure, a 25-gauge PPV was chosen for the PFD group and a 23-gauge for the D68 group. After the endotamponade was removed, the ERM remnants were highlighted with vital dye and peeled if found. Additional laser treatment was applied in order to reinforce previous laser retinopexy. A final tamponade was chosen depending on the status of the retina (See Supplemental Video below).

(A, C) Patient ID 2 before and after perfluorodecalin (PFD) removal. (B, D) Patient ID 4 before and after PFD removal.

Figure 1.

(A, C) Patient ID 2 before and after perfluorodecalin (PFD) removal. (B, D) Patient ID 4 before and after PFD removal.

Intraoperative fundus image during the first surgery (A); intraoperative fundus image during heavy silicone oil removal (B); fundus image 2 months after surgery (C).

Figure 2.

Intraoperative fundus image during the first surgery (A); intraoperative fundus image during heavy silicone oil removal (B); fundus image 2 months after surgery (C).

The main outcome measures were the mean change in best-corrected visual acuity (BCVA) (logMAR, Snellen ratio), the anatomic reattachment of the retina following PFD or Densiron 68 removal, the rate of recurrences, the presence of inflammatory complications and intraocular pressure (IOP) alterations. The data also included the mean time of intraocular tamponade. Statistical analyses were performed by means of Stata 12.1 software (StataCorp, College Station, TX). The results were expressed as the mean ± standard deviation (SD) of the mean. Paired samples t-tests were used to compare preoperative and postoperative logMAR visual acuities (VAs). A P value of .05 or less was considered statistically significant.

Results

Twenty-four patients (male:female ratio = 19:5) affected by inferior retinal detachment recurrence complicated by inferior PVR grade C were included. The mean age was 60.7 years (SD: 17.3) for the PFD group and 58 years (SD: 15) for the D68 group. The characteristics of all patients are presented in Table 1 (D68 group) and in Table 2 (PFD group). Thirteen patients (five for the PFD group [41.6%] and eight for the D68 group [66.6%]) had had encircling SB before, eight patients (four for the PFD group [33.3%] and four in the D68 group [33.3%]) had had combined buckling and PPV with SSO, and three patients in the PFD group (25%) had had PPV with SSO. In this final subgroup, we performed encircling SB combined with a PFD tamponade. Only three cases in the PFD group combined encircling SB with PPV. All the patients recruited had encircling SB of 2.5 mm positioned in the equatorial site. The mean endotamponade permanence time was 15.09 days (SD: 0.8) for the PFD group and 120.3 days (SD: 11.1) for the D68 group. After the endotamponade removal, a final tamponade was chosen depending on the status of the retina; if the retina was found attached, sterile air was chosen at the end of the surgery as temporary endotamponade. In the PFD group, one case was tamponed with gas (retinal detachment recurrence) and three with SSO (retinal detachment recurrence with PVR); in the D68 group, one patient was tamponed with gas (retinal detachment recurrence), four with SSO, and one with Densiron 68 HSO again (retinal detachment recurrence with PVR).

Densiron 68 Group

Table 1:

Densiron 68 Group

Perfluorodecalin Group

Table 2:

Perfluorodecalin Group

The mean preoperative BCVA was 1.00 logMAR (20/200) (SD: 1) in the PFD group and 1.81 logMAR (20/2,000) (SD: 1.1) in the D68 group. The final BCVA after one or more interventions was 0.60 logMAR (20/80) (SD: 0.3) and 2.00 logMAR (20/2,000) (SD: 1) for the PFD and Densiron 68 groups, respectively. Visual improvement was statistically significant only in PFD group (P < .05).

Four patients (33.3%) in the D68 group had inflammatory complications, two had anterior chamber emulsification without IOP increase, four had ocular hypertension, and three maintained elevated IOP even after HSO removal. One patient with anterior chamber emulsification had corneal opacity. No patient had glaucoma incisional surgery. In the PFD group, three patients out of 12 (25%) had ocular hypertension due to a PFD bubble in the anterior chamber during the period of PFD permanence. In all three cases, the IOP returned to normal after PFD removal. No other inflammatory complications were reported in the PFD group. The retinal reattachment rate after one surgical operation was 50% (six out of 12) in the D68 group and 66.6% (eight out of 12) in the PFD group. The final reattachment after two or more surgical operations was 91.6% (11 out of 12) in the PFD group and 83.3% (10 out of 12) in the D68 group. The difference in final reattachment rate was not statistically significant between the two groups (P > .05).

Discussion

Inferior retinal detachment recurrence complicated by PVR is still considered a challenge. The lack of a complete endotamponade for the inferior quadrants of the retina leads many surgeons to experiment various solutions. Many authors have reported D68 case series with good results. The retinal reattachment rate after one surgical intervention goes from 30% in the Sandner series to 86% in the Wong series, with a final retinal reattachment rate from 75% to 92.5% and 93% in the Auriol and Wind series, respectively.16–19 The application of PFCLs has been widely used in vitreoretinal surgery and described by many authors.4–6 PFCLs have already been used as short-term postoperative tamponades (7 to 14 days) in the management of retinal detachment due to giant retinal tears, as reported by Sirimaharaj et al.,12 Ventura et al.,13 Eiger-Moscovich et al.,15 and Bottoni et al.14 Recently, perfluorocarbon has been described to manage complicated retinal detachment as a short-term tamponade (2 to 3 weeks),20–21 with an encouraging retinal reattachment rate (87.5%). Perfluorocarbon has recently been used as a short-term tamponade in the management of choroidal detachment with good anatomical results.22 The rationale to use perfluorocarbon in place of silicone oil was related to the low viscosity of perfluorocarbon and its higher tamponade strength that leads to a better tamponade effect over irregular surfaces such as a bulbous choroidal detachment.

In our case series, the choice of using encircling buckling to relax peripheral vitreous and retinal contraction induced an irregularity on the retinal surface that was difficult to tamponade completely using silicone oil. Perfluorodecalin ensures a better tamponade than HSO on irregular retinal surfaces such as those induced by SB indentation. The inferior retinal detachment recurrence rate was 50% (three out of six) in the D68 group and 25% (one out of four) in the PFD group. In the PFD group, only an inferior retinal detachment recurrence was found, whereas in the D68, we found three cases.

In the case of an inferior retina break, which lies just posteriorly to a scleral encircling, SSO may not provide a useful tamponing effect because the bubble does not conform well with the shape of the retinal encircling; therefore, the “PVR soup” could concentrate in the inferior retina facilitating PVR development and retinal detachment recurrence. We decided to use a heavier-than-water endotamponade for this reason. PFCL medium-term tamponade was revealed to be safer and more effective than D68 in these cases of inferior retinal detachment recurrence in eyes with an inferior retinal break that lies posteriorly to an encircling band. On the other hand, PFD due to its lower viscosity can tamponade retinal irregularity induced by scleral band indentation resulting in a lower rate of inferior PVR. This results in less accumulation of aqueous and cells in the inferior space between the endotamponade interface and the retinal surface over the indented retina, with less tendency to develop PVR in the inferior quadrants and therefore better anatomical results. Moreover, keeping the endotamponade in situ for a shorter period has been associated with fewer inflammatory complications, such as tamponade emulsification, increased IOP, or corneal opacities. Furthermore, the surgical time for PFD removal is quicker than HSO due to the higher viscosity of the latter, which may explain the better VA results due to less retinal stress.

In conclusion, both endotamponades demonstrate good final anatomical results, with no statistically significant difference in inferior retinal detachment recurrence complicated by advanced PVR. PFD shows better results after only one surgical intervention and with less inflammatory complications. Further studies are needed to confirm our results. In the future endotamponades with good eye tolerance and retinal surface fit may be the answer to reduce the development of retinal detachment recurrence.

References

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Densiron 68 Group

Patient ID/Age (Years)/Sex Eye Previous Surgery Retinal Detachment Description (Clock Hours Location) Retinal Break Location (Clock Hours) PVR Lens Status Preoperative BCVA, Snellen (logMAR) First Operation Time of Endotamponade Permanency (Days) Retinal Re-detachment After Endotamponade Removal Position of Recurrence Retinal Detachment Tamponade Used in Second Surgery Final BCVA, Snellen (logMAR) Result
1/53/M Left SB Posterior pole Myopic macular hole PVR C1 Phakic 20/20,000 (3) PE + PPV + HSO 125 Yes Inferior Gas 20/20,000 (3) Fav
2/54/F Left SB + PPV +SSO 5–8 7 PVR C2 Pseudophakic 20/20,000 (3) PPV + HSO 112 Yes Posterior pole SSO 20/20,000 (3) Unfav
3/70/M Right SB 5–10 6–8 (Multiple retinal breaks) PVR C1 Pseudophakic 20/250 (1, 1) PPV + HSO 121 No 20/200 (1) Fav
4/69/M Right SB 4–7 6 PVR C1 Pseudophakic 20/20,000 (3) PPV + HSO 103 No 20/20,000 (3) Fav
5/43/M Left SB + PPV + SSO 6–7 6 PVR C2 Pseudophakic 20/250 (1, 1) PPV + HSO 136,0 Yes Superior SSO 20/200 (1) Fav
6/80/M Right SB + PPV + SSO 4–8 6–7 (Multiple retinal breaks) PVR C2 Pseudophakic 20/20,000 (3) PPV + HSO 115,0 Yes Inferior SSO 20/20,000 (3) Unfav
7/66/M Right SB 3–9 7–8 (Large retinal break) PVR C1 Phakic 20/200 (1) PE + PPV + HSO 110 Yes Superior SSO 20/125 (0, 8) Fav
8/24/F Left SB Total 6–8 (Multiple retinal breaks) PVR C3 Phakic 20/20,000 (3) PE + PPV + HSO 127 Yes Inferior HSO 20/20,000 (3) Fav
9/71/M Right SB 2–10 5–7 (Multiple retinal breaks) PVR C1 Pseudophakic 20/400 (1, 3) PPV + HSO 122 No 20/200 (1) Fav
10/57/M Left SB + PPV + SSO 6–8 6 PVR C1 Pseudophakic 20/80 (0, 6) PPV + HSO 119,0 No 20/200 (1) Fav
11/61/M Right SB 5–11 8–9 (Large retinal break) PVR C2 Phakic 20/250 (1, 1) PE + PPV + HSO 112 No 20/125 (0, 8) Fav
12/53/M Left SB 1–7 6–7 (Multiple retinal breaks) PVR C1 Phakic 20/80 (0, 6) PE + PPV + HSO 142 No 20/50 (0, 4) Fav

Perfluorodecalin Group

Patient ID/Age (Years)/Sex Eye Previous Surgery Retinal Detachment Description (Clock Hours Location) Retinal Break Location (Clock Hours) PVR Lens Status Preoperative BCVA, Snellen (logMAR) First Operation Time of Endotamponade Permanency (Days) Retinal Re-Detachment After Endotamponade Removal Position of Recurrence Retinal Detachment Tamponade Used in Second Surgery Final BCVA, Snellen (logMAR) Result
1/73/M Left SB 4–7 6 PVR C1 Phakic 20/200 (1) PE + PPV + PFD 14 No 20/80 (0,6) Fav
2/67/M Right PPV + SSO 3–8 6 PVR C1 Pseudophakic 20/100 (0,7) SB + VPP + PFD 15 No 20/32 (0,2) Fav
3/84/F Left PPV + SSO 6–10 7 PVR C1 Pseudophakic 20/2000 (2) SB + VPP + PFD 16 Yes Inferior SSO 20/2000 (2) Fav
4/55/M Left SB Total 6 PVR C2 Phakic 20/2000 (2) PE + VPP + PFD 16 No 20/40 (0,3) Fav
5/47/M Left SB 5–7 6 PVR C2 Pseudophakic 20/2000 (2) VPP + PFD 14 Yes 20/80 (0,6) Fav
6/67/M Left SB Posterior pole Myopic macular hole PVR C1 Pseudophakic 20/2000 (2) VPP + PFD 15 No 20/200 (1) Unfav
7/41/F Left SB + PPV + SSO 3–9 7–8 (Large retinal break) PVR C1; sub retinal SSO Pseudophakic 20/2000 (2) VPP+ PFD 16 Yes Superior Gas 20/80 (0,6) Fav
8/39/M Left SB + PPV + SSO 3–9 4–7 (Multiple retinal breaks) PVR C2 Pseudophakic 20/200 (1) VPP+PFD 14 Yes Superior SSO 20/200 (1) Fav
9/84/M Right SB + PPV + SSO 5–9 6 PVR C1 Pseudophakic 20/100 (0,7) VPP + PFD 15 No 20/40 (0,3) Fav
10/75/F Left PPV + SSO 5–8 7 PVR C1 Pseudophakic 20/2000 (2) SB + PPV + PFD 16 No Posterior pole SSO 20/80 (0,6) Fav
11/63/M Left SB + PPV + SSO 4–10 6–7 (Multiple retinal breaks) PVR C1 Pseudophakic 20/200 (1) PPV + PFD 15 No 20/200 (1) Fav
12/34/M Right SB 3–9 7 PVR C1 Pseudophakic 20/100 (0,7) PPV + PFD 15 No 20/80 (0,6) Fav
Authors

From the Department of Translational Surgery and Medicine, Ophthalmology, University of Florence, Careggi, Florence, Italy.

The authors report no relevant financial disclosures.

Address correspondence to Tomaso Caporossi, MD, Azienda Ospedaliero-Universitaria Careggi, Largo Piero Palagi 1, Florence, Italy 50139; email: tomaso.caporossi@gmail.com.

Received: July 27, 2018
Accepted: November 06, 2018

10.3928/23258160-20190503-03

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