Silicone oil migration into the anterior chamber in a phakic eye: A novel management strategy

Abdullah S Al-Kharashi; Abdulrahman F AlBloushi

doi:10.4103/ijo.IJO_3020_21

CASE REPORT

Year : 2022 | Volume : 2 | Issue : 3 | Page : 711-713

Silicone oil migration into the anterior chamber in a phakic eye: A novel management strategy

Abdullah S Al-Kharashi, Abdulrahman F AlBloushi
Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Saudi Arabia

Date of Submission	02-Dec-2021
Date of Acceptance	01-Mar-2022
Date of Web Publication	16-Jul-2022

Correspondence Address:
Dr. Abdulrahman F AlBloushi
Department of Ophthalmology, College of Medicine, King Saud University, Riyadh - 11411
Saudi Arabia

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_3020_21

Abstract

We describe a novel technique to manage silicone oil (SO) migration into the anterior chamber (AC) in a phakic eye. A 57-year-old female patient underwent right lens-sparing pars plana vitrectomy for diabetic tractional retinal detachment with SO tamponade. Postoperatively, a large bubble of SO was detected in the AC. The case was managed with the intraoperative displacement of the SO bubble using an ophthalmic viscoelastic device, phacoemulsification, and insertion of a capsular tension ring with an opening directed toward 6 o'clock position. The insertion of the capsular tension ring in this particular position prevented further migration of SO into the AC.

Keywords: Anterior Chamber, capsular tension ring, phacoemulsification, silicone oil

How to cite this article:
Al-Kharashi AS, AlBloushi AF. Silicone oil migration into the anterior chamber in a phakic eye: A novel management strategy. Indian J Ophthalmol Case Rep 2022;2:711-3

How to cite this URL:
Al-Kharashi AS, AlBloushi AF. Silicone oil migration into the anterior chamber in a phakic eye: A novel management strategy. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2023 Jun 9];2:711-3. Available from: https://www.ijoreports.in/text.asp?2022/2/3/711/351166

Silicone oil (SO) installation provides a long-term endotamponade after complex retinal detachment surgeries. The integrity of the zonular–capsular bag complex, in addition to the high surface tension of SO, prevents its migration into the anterior chamber (AC).^[1] Occasionally, the SO can migrate into the AC, especially in cases of aphakia, pseudophakia, and rarely in phakia due to inadequate capsular–zonular support. Several complications may occur after SO migrates into the AC, including pupillary block glaucoma, trabecular meshwork damage, corneal endothelial dysfunction, and cataract formation.^[2]

In this report, we present a novel technique to manage a rare case of the migration of SO into the AC in the phakic eye after a complex retinal surgery with SO tamponade.

Case Report

A 57-year-old female patient with a history of diabetes mellitus presented with a history of progressive decrease in vision in the right eye over 1 month. On examination, her best-corrected visual acuity (BCVA) was hand movement in the right eye and 20/40 in the left eye. Intraocular pressure (IOP) was 12 mmHg in both eyes. Slit-lamp examination showed bilateral nuclear sclerotic cataracts. Fundus examination showed right advanced diabetic tractional retinal detachment involving the macula and left proliferative diabetic retinopathy. The patient underwent left panretinal photocoagulation and right pars plana vitrectomy and SO tamponade. On the first postoperative day, her right eye BCVA improved to 20/400. Surprisingly, her right eye examination showed a large bubble of SO that filled most of the AC; IOP was 50 mmHg, and the retina was attached under SO [Figure 1]a and [Figure 1]b.

Figure 1: (a) Slit-lamp photo of the right eye on the first day post right pars plana vitrectomy with silicone oil tamponade showing a large silicone oil bubble in the anterior chamber. (b) Ultrawide field fundus photograph of the right eye showing the attached retina under silicone oil after retinal surgery for advanced diabetic tractional retinal detachment

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The patient was started on systemic acetazolamide in addition to timolol and brimonidine eye drops, and on the next day, she underwent right phacoemulsification with implantation of a capsular tension ring (CTR) and a foldable intraocular lens (IOL).

Informed consent was obtained from the patient for the anonymous use and publication of data and images.

Surgical Technique

The AC was filled with an ophthalmic viscoelastic device (OVD) through the side port, and the SO bubble was displaced through the main wound. A routine cataract procedure was performed. Throughout the procedure, positive pressure was maintained in the AC. After cataract removal, a preloaded CTR (JETRING 11 ACB; Medicontur Medical Engineering Ltd) was inserted into the bag with the opening of the ring directed toward the 6 o'clock position. A single-piece IOL was inserted into the bag [Figure 2]a and [Figure 2]b. No SO was added at the conclusion of the surgery.

Figure 2: (a) Line diagram demonstrating silicone oil migration through an area of zonular weakness in phakic eye filled with silicone oil. (b) Line diagram demonstrating the concept of managing silicone oil from the anterior chamber in the phakic eye. This can be accomplished by displacing silicone oil from the anterior chamber, cataract removal, and insertion of capsular tension ring with the opening directed toward 6 o'clock. This technique prevents further silicone oil migration into the anterior chamber

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Four weeks later, her right eye examination revealed BCVA of 20/200, IOP 14 mmHg, and the retina was attached with SO in situ [Figure 3]. The patient was followed up for 6 months without any further displacement of SO into the AC.

Figure 3: Slit-lamp photo of the right eye 4 weeks after right phacoemulsification with the insertion of a capsular tension ring and an intraocular lens. Note the absence of silicone oil in the anterior chamber

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Discussion

Since SO has lower specific gravity than the aqueous humor, it tends to float upward and fill AC from the superior aspect.^[1] In phakic eyes, SO can rarely migrate into the AC. This is because the zonular–lens complex acts as a barrier that prevents the migration of SO from the posterior chamber into the AC. Our case was challenging because the SO had migrated early into the AC despite apparently intact posterior capsular–zonular support. However, there were no signs of pseudoexfoliation, and the patient denied any previous history of ocular trauma.

The complete removal of SO with or without SO refill increases the risk of retinal re-detachment, especially if it occurs early in the postoperative period.^[3] On the other hand, partly removing SO from the AC is a promising alternative, and several techniques have been previously proposed.^{[3],[4],[5],[6]} The direct aspiration of SO through a large pore cannula is not always successful as this leads to more SO migration into the AC.^[4] Furthermore, the displacement of SO using an OVD through a side port at the 12 o'clock position may be performed as an outpatient procedure. However, the retained OVD may cause inflammation and increase IOP, and SO can migrate again once the OVD gets absorbed.^[3],[5] Finally, the use of high-pressure air infusion through an AC maintainer and active aspiration to remove SO is a safe and effective method to restore the AC; however, there is always a risk that SO will migrate again.^[6]

Previous studies have demonstrated that weak zonular support in the upper part of the zonule–lens barrier is the only pathological change that allows the migration of SO from the posterior chamber into the AC in phakic eyes.^[4] Therefore, we decided to displace SO from the AC using OVD and to insert a CTR during phacoemulsification surgery, with the opening of the CTR directed toward the 6 o'clock position to provide maximum support to the high-risk areas. This idea is in agreement with the concept of performing inferior peripheral iridotomy to prevent pupillary block in aphakic eye filled with SO. To the best of our knowledge, the management of SO migration in the phakic eye by the insertion of a CTR during phacoemulsification has not been previously reported.

A report showed that the rate of SO migration into the AC after phacoemulsification in eyes filled with SO was 5.6%.^[7] Conversely, another report showed that none of the eyes that had a CTR inserted during phacoemulsification developed SO migration into the AC in the postoperative period.^[8] This can be explained by the presence of a subclinical form of zonular dehiscence in the eyes following vitrectomy.^[8] Therefore, it is always recommended to use a CTR routinely during phacoemulsification in eyes filled with SO.^[8],[9]

Conclusion

In conclusion, SO migration into the AC in phakic eyes can be safely managed by inserting a CTR during phacoemulsification. Moreover, using a CTR provides a long-term benefit and prevents remigration of SO by supporting the area of subclinical zonular dehiscence.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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