“Inert” cotton fibers – Gossypiboma in silicone oil-filled eyes: A case series

Rushik Patel; Kushal Delhiwala; Bakulesh Khamar

doi:10.4103/ijo.IJO_902_21

CASE REPORT

Year : 2022 | Volume : 2 | Issue : 1 | Page : 134-135

“Inert” cotton fibers – Gossypiboma in silicone oil-filled eyes: A case series

Rushik Patel, Kushal Delhiwala, Bakulesh Khamar
Department of Vitreo Retina, Netralaya Superspeciality Eye Hospital, KD House, 1^st Floor, Above Andhra Bank, Parimal Cross Roads, Ellisbridge, Ahmedabad, Gujarat, India

Date of Submission	17-Apr-2021
Date of Acceptance	07-Jul-2021
Date of Web Publication	07-Jan-2022

Correspondence Address:
Dr. Rushik Patel
Department of Vitreo-Retina, Netralaya Superspeciality Eye Hospital, KD House, 1st Floor, Above Andhra Bank, Parimal Cross Roads, Ellisbridge, Ahmedabad - 380 006, Gujarat
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_902_21

Abstract

Retained cotton fibers (gossypiboma) are known following anterior segment surgeries. There is only one case report of pre retinal gossypiboma (retained cotton fibers; RCF) following pars plana vitrectomy (PPV) with silicone oil tamponade (SOI) for proliferative diabetic retinopathy. It was associated with dense exudation surrounding it. We report three cases (two retrolental and one preretinal) of inert RCF (gossypiboma), following PPV-SOI for rhegmatogenous retinal detachment.

Keywords: Absence of inflammation, gossypiboma, pars plana vitrectomy, retained cotton fibers, silicone oil tamponade

How to cite this article:
Patel R, Delhiwala K, Khamar B. “Inert” cotton fibers – Gossypiboma in silicone oil-filled eyes: A case series. Indian J Ophthalmol Case Rep 2022;2:134-5

How to cite this URL:
Patel R, Delhiwala K, Khamar B. “Inert” cotton fibers – Gossypiboma in silicone oil-filled eyes: A case series. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Jan 21];2:134-5. Available from: https://www.ijoreports.in/text.asp?2022/2/1/134/334990

Surgical materials are known to have been occasionally left (retained) inadvertently in the body cavity following surgery. These include cotton material, surgical instruments, or their components and are associated with inflammatory reaction and/or fibrosis.^[1] Cotton is the most common retained material following surgery and has been described as gossypiboma, textiloma, or gauzeoma.^[1] Retained metal fragments, cilium, suture needle, and cotton fibers have been documented following anterior segment surgeries.^{[2],[3],[4],[5]} However, there is a paucity of literature describing retained materials following pars plana vitrectomy (PPV). So far, a case of gossypiboma associated with intense preretinal inflammation has been reported following PPV with silicone oil tamponade (SOI).^[6] We describe series of three cases (three eyes of three patients) with presumed retained cotton fibers (RCF) in posterior segment following PPV-SOI and without any evidence of associated inflammation.

Case Reports

Three eyes of three patients who presented to us between July 2020 and December 2020 were found to have RCF in vitreous cavity. They had undergone unilateral PPV-SOI for recent onset rhegmatogenous retinal detachment (RRD) at least before 2 weeks. All three eyes were asymptomatic. Anterior segment evaluation revealed quiet anterior chamber and normal intraocular pressure. Two eyes were phakic and one was pseudophakic. Posterior segment examination revealed reattached retina and silicone oil in situ. RCF was seen in retrolental space in phakic eyes and in preretinal space in pseudophakic eye [Figure 1]. There was absence of any signs of associated inflammation in posterior segment of all three eyes. During follow-up evaluation (minimum duration of 4 weeks), all eyes remained asymptomatic with reattached retina and without evidence of inflammation. Characteristics of RCF are elaborated in [Table 1].

Figure 1: (a1) Anterior segment photograph showing retrolental cotton fibers (RCF) (white arrows) in case 1. (a2) Slit-illumination image of a1. (b) Retrolental cotton fibers (RCF) (white arrows) in case 2. (c) Pseudocolor fundus photo of case 3 showing preretinal RCF (white arrows); inset – red free image

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Table 1: Characteristic features of patients with retained cotton fibers

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Discussion

RCF following anterior segment surgeries is well known, while the same following vitreous surgeries is seldom reported. Weng et al.^[7] reported RCF only in anterior chamber following phaco-vitrectomy for cataract with epiretinal membrane. To the best of our knowledge, there is only single report of RCF in posterior segment described by Kumar et al. recently.^[6] RCF was noted following PPV-SOI for proliferative diabetic retinopathy (PDR) and was associated with dense sterile preretinal exudation. It responded to oral steroids. All three patients in our series had no evidence of inflammation at the time of diagnosis. Subsequent follow-up course was also uneventful and none of them required any additional treatment in form of oral steroids or other antiinflammatory therapy. The lack of inflammation in our case series may be attributed to any or both of following.

Surgical indication. All three eyes in our series underwent vitrectomy for RRD, while the case described by Kumar et al. underwent surgery for PDR. PDR is a chronic ischemic disease with a possible long interval between symptoms and surgery. Dan-Brezis et al.^[8] observed high coagulative and angiogenic activity in the vitreous of eyes with PDR which correlated with the inflammatory cascade. Levels of inflammatory markers such as interleukin (IL)-6, IL-8, vascular endothelial growth factor, tissue factor pathway inhibitor and tumor necrosis factor alpha (TNF-α), are found to be higher in vitreous of patients with PDR.^[8],[9] This might have contributed to localized intense inflammation with dense exudation around RCF in case described by Kumar et al.^[6]On the other hand, RRD of recent onset needs surgery within hours to days. Hence, immune system pathways get less time to activate each other in the eyes undergoing PPV for RRD.^[8]
Amount of fibers (fiber load) in vitreous cavity. These were lower in our series. Lack of inflammation has been described for an isolated RCF following intravitreal injection of bevacizumab.^[10]

In our case series, location of retained cotton fibers was peculiar in relation to silicone oil bubble. In first two cases, they were noticed retrolentally in a thin space between the posterior capsule and oil bubble, while in the third case over preretinal surface beneath the bubble. These might have been associated with fibers inadvertently entering the port after and before silicone oil injection, respectively.

Conclusion

Cotton fibers are likely to enter vitreous cavity during surgery following frequent instrument exchanges. This can be prevented by meticulous cleaning of surgical instruments using lint free wipes and use of plastic for draping of eye and trolley.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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