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Retinal redetachment after silicone oil removal: a risk factor analysis

BMC Ophthalmology volume 24, Article number: 346 (2024) Cite this article

Abstract

Purpose

To report the rate of retinal redetachment after silicone oil removal following rhegmatogenous retinal detachment surgery and to determine potential risk factors.

Methods

Retrospective observational case series of 161 eyes who underwent rhegmatogenous retinal detachment surgery and subsequent silicone oil removal. Pre- and intraoperative risk factors were evaluated using univariate and multivariate logistic regression. We also evaluated the effect of tamponade duration on anatomical outcomes.

Results

The median tamponade duration was 5.9 [4.3;7.6] months. Seventeen (10.6%) eyes underwent silicone oil removal within 3 months of surgery, with a median delay of 2.3 [2.0;2.8] months. The rate of retinal detachment after silicone oil removal was 14.9%. A history of previous unsuccessful surgery was the only significant risk factor for retinal redetachment after silicone oil removal (OR 4.8, 95%CI [1.5;19.0], p = 0.02). The use of 360° laser retinopexy and concomitant air or gas tamponade during silicone oil removal were not found to affect the redetachment rate. Eyes with silicone oil tamponade ≤ 3 months showed an increased, albeit not significant, risk of developing recurrent rhegmatogenous retinal detachment after silicone oil removal (35.3% versus 12.5%, p = 0.06).

Conclusion

A retinal redetachment occurred in 14.9% of eyes undergoing silicone oil removal following rhegmatogenous retinal detachment surgery. Previous failed surgery was associated with a 4.8-fold increased risk of developing recurrent rhegmatogenous retinal detachment after silicone oil removal. Eyes with silicone oil tamponade ≤ 3 months tended to have a higher redetachment rate.

Trial registration number

ID NCT05647928 (12th April 2022)

Peer Review reports

Introduction

Silicone oil (SO) is commonly used as an intraocular tamponade agent for the treatment of complex rhegmatogenous retinal detachments (RRDs) with severe proliferative vitreoretinopathy (PVR) or giant retinal tear [1, 2]. This chemically inert substance with high surface tension and viscosity provides very good structural support to keep the retina attached for a long time [3]. However, the use of SO is mostly temporary because of anterior segment complications that can result from prolonged tamponade, including oil emulsification, cataract, elevated intraocular pressure with potential secondary glaucoma and band keratopathy [3,4,5]. SO is, hence, typically removed within 3–6 months after the initial surgery to reduce these complications [6,7,8].

Removal of SO (ROSO) is, however, followed by a redetachment in up to 34% of cases, mainly because of reproliferation and subsequent traction on the retina [9,10,11,12,13,14]. The prognosis of this complication is poor with a final anatomical failure rate of 20–35% and a visual acuity less than 0.02 in nearly 50% of cases [9, 13, 15, 16]. It seems therefore important to identify pre- and intraoperative factors that may predispose to retinal detachment following ROSO. Several risk factors have been identified in the literature including previous failed surgery, aphakia, high myopia, giant retinal tears and initial proliferative vitreoretinopathy [13, 17,18,19,20]. Some authors suggested that 360° laser retinopexy might reduce the incidence of redetachment but this protective effect was not confirmed in a recent retrospective study [18, 21,22,23,24,25]. There is also some controversy regarding the timing for ROSO and its possible influence on the surgical success rate. Some series found that eyes with shorter SO tamponade were more likely to develop recurrent RRD while others did not find any association between the tamponade duration and the rate of redetachment [10, 13, 17, 19, 20, 22, 25,26,27]. Thus, it is still not clear whether or not encircling laser retinopexy and/or prolonged tamponade may result in improved anatomical and visual outcomes.

The aim of this study was to determine the rate of retinal redetachment after ROSO and potential pre- and intraoperative risk factors, as well as to investigate the effect of tamponade duration on surgical outcomes.

Methods

Patients and study design

We conducted a single-center observational retrospective cohort study. Three hundred and seven consecutive patients who underwent pars plana vitrectomy (PPV) with SO tamponade at the Nancy University Hospital, from January 2015 to January 2022, were retrospectively reviewed. All patients received complete information on the surgical risks and benefits and gave their written consent before surgery. The study adhered to the tenets of the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of the Nancy Hospital.

Inclusion criteria were as follows: (1) patients with successfully repaired RRD and subsequent ROSO, (2) a minimum follow-up period of 6 months after ROSO. Exclusion criteria were as follows: (1) SO tamponade for indications other than RRD, (2) retinal redetachment during SO tamponade and (3) prior history of SO tamponade.

A detailed ophthalmologic examination was obtained for all patients before surgery and at each follow-up visit. It included an assessment of best-corrected visual acuity (BCVA) measured with projected-light Snellen charts, biomicroscopy with anterior segment evaluation and fundus. Axial length measurement using optical biometry (IOL Master; Carl Zeiss Meditec AG, Jena, Germany) was performed before RRD surgery and checked with ultrasound A-scan (OcuScan RxP Ophtalmic Ultrasound System, Alcon Laboratories, Fort Worth, Texas, USA) when there was macula-off RRD or dense vitreous hemorrhage. Fundus findings were documented on an Amsler-Dubois scheme detailing several factors: extent of the RD, number and type of retinal breaks, macular status, presence of vitreous hemorrhage, existence of choroidal detachment and preoperative PVR grading according to Machemer et al. [28].

All patients with completely attached, flat retinas without any retinal traction or proliferation were offered ROSO. The timing for ROSO was left at the surgeons’ appreciation, depending on prior history, condition of the contralateral eye and patient preferences. A comprehensive ophthalmologic examination with macular imaging using the Spectralis HRA-OCT (Heidelberg Engineering, Heidelberg, Germany) was systematically performed during the month preceding ROSO.

Surgical procedure

All surgical procedures consisted of an extensive three-port PPV using 23-gauge instrumentation (EVA phacovitrectomy system, DORC, Dutch Ophthalmic Research Corporation, Zuidland, The Netherlands) followed by removal of any epiretinal membranes (ERM). In eyes with extensive PVR involving the macula, the internal limiting membrane (ILM) peeling was systematically carried out on the posterior pole after Brilliant Blue G staining (ILM-Blue®, DORC, Zuidland, The Nederlands). Relaxing retinotomy/retinectomy was done if required. After fluid-air exchange, retinopexy was performed with endophotocoagulation or cryotherapy, followed by SO injection into the vitreous cavity. The decision to apply 360° laser retinopexy was left to the surgeon’s appreciation. In most cases, three to four rows of circumferential laser spots were placed anteriorly to the equator. In cases with giant retinal tear or relaxing retinotomy/retinectomy, perfluorocarbon liquid (PFCL) was used and directly exchanged with SO. For all patients, SO with viscosity of 1000 centistokes was selected (Purified silicone oil 1000 cSt in syringe, FCI, Besançon, Franche-Comté, France).

Combined phacoemulsification with posterior chamber intraocular implantation was done before the PPV when needed.

SO extraction was carried out through 23-gauge pars plana sclerotomy using active drainage. To remove residual SO droplets, several fluid-air exchanges were then performed. Combined phacoemulsification and ERM peeling were also made if necessary. Additional laser treatment and air or gas tamponade (25% SF6 or 20% C2F6/air mixture) were performed at the surgeon’s discretion.

The post operative treatment after RRD surgery and ROSO included topical anti-inflammatory and antibiotic treatments for 4 weeks for all patients. During the whole period of SO tamponade, IOP-lowering medication (carbonic anhydrase inhibitor/beta blocker combination) was systematically administered.

Macular imaging with SD-OCT

The imaging protocol included two high-resolution horizontal and vertical 6 mm ART5 scans, and a fovea-centered volume scan over a 20° horizontal and vertical area obtained by 25 equally spaced horizontal B-scans.

The built-in Spectralis software was used to measure central macular thickness (CMT). The presence of ERM and cystoid macular edema (CME) was noted. ERM was defined as a hyperreflective line on the surface of the retina, with distortion of the inner retinal layers. CME was defined as the presence of intraretinal hyporeflective cystic spaces in the inner nuclear layer and/or the outer plexiform layer.

All qualitative OCT assessments were carried out independently by two readers (CG and CD). A third investigator was consulted to make the final decision (JBC) in the event of disagreement.

Pre-, intra- and postoperative data

Pre-and intraoperative data consisted of patient age and sex, BCVA, lens status, axial length (AL), RRD characteristics and surgical procedures during RRD surgery and ROSO (combined phacoemulsification, ILM or ERM peeling, 360° laser retinopexy, pneumatic tamponade). We also collected the duration of SO tamponade (within 3 months or more than 3 months after RRD surgery) and SD-OCT findings before ROSO.

Post-ROSO data were initial and final (after two or more procedures) redetachment rate, causes of failure, follow-up duration and BCVA.

Main outcome measures

The primary outcome of this study was the rate of retinal redetachment after ROSO, as well as associated pre- and intraoperative risk factors. The effect of tamponade duration on anatomical success rate was analysed and the final retinal reattachment rate and BCVA were investigated.

Statistical analysis

Snellen visual acuity was converted to the logarithm of the minimum angle of resolution (logMAR) units for analysis. Continuous variables were expressed as median and interquartile ranges, and categorical variables were expressed as numbers and percentages. The normality of the distribution was investigated using the Shapiro–Wilk test.

A bivariate logistic regression was used to estimate the relationship between the potential influencing pre- and intraoperative factors and retinal redetachment. Variables with p < 0.20 in bivariate logistic regression were included in the final multivariate logistic regression model.

Comparisons of BCVA were performed using the Mann–Whitney–Wilcoxon test. The threshold for statistical significance was set at p < 0.05. Statistical analysis was performed using R version 4.2.1 (2022-06-23).

Results

From January 2015 to January 2022, 307 eyes underwent PPV with SO tamponade. One hundred and forty-six of these were excluded for the following reasons: retinal redetachment during SO tamponade (n = 58), indications other than RRD (n = 37), no subsequent ROSO (n = 28), follow-up period of less than 6 months (n = 14) and prior history of SO tamponade (n = 9). Hence, 161 eyes of 160 patients were included in the study.

Baseline characteristics, pre- and intraoperative data

Baseline characteristics, pre- and intra-operative data are shown in Table 1.

Table 1 Baseline characteristics, pre- and intraoperative data of patients who underwent removal of silicone oil after rhegmatogenous retinal detachment surgery
Full size table

. Most eyes 97 (60.3%) received PPV with SO tamponade as the first operation in the treatment of RRD. The rest had either undergone one (30.4%) or two or more (9.3%) unsuccessful RRD procedures in the past before SO injection. The main indications for the use of SO were advanced PVR (59,6%), giant retinal tear (13.7%), choroidal detachment (7.5%) and ocular trauma (6.8%). The remaining eyes received SO because of redetachments without PVR or because of surgeon or patient preferences.

The median tamponade duration was 5.9 [4.3;7.6] months. SO was removed within 3 months following RRD surgery in 17 (10.6%) eyes because of surgeon or patient preferences (n = 10), uncontrolled intraocular pressure (n = 3), ERM (n = 2) and SO emulsification (n = 2). The median tamponade duration in this subgroup was 2.3 [2.0;2.8] months, compared with 6.2 [4.9;8.1] months in the other subgroup.

Seventy-four (46.0%) eyes received 360° laser retinopexy during RRD surgery or SO extraction. ERM or ILM peeling was performed in 86 (53.4%) eyes.

Rate of retinal redetachment and associated risk factors

A retinal redetachment occurred in 24 (14.9%) eyes with a median delay of 4.3 [2.6;11.2] weeks. Eighteen (75.0%) eyes developed a recurrent PVR-related RRD while the others presented with redetachment due to new retinal breaks or reopening of pre-existing breaks without PVR.

In the bivariate analyses, history of RRD surgery (p < 0.05), PVR grade (p = 0.03) and tamponade duration (p = 0.02) were associated with the anatomic failure rate after ROSO. Encircling laser retinopexy (p = 0.99) and concomitant air or gas tamponade during ROSO (p = 0.46) were not found to affect the redetachment rate (Table 2).

Table 2 Predictive factors of retinal redetachment after ROSO: Bi- and multivariate regression analyses
Full size table

Multivariate logistic regression analysis demonstrated that previous unsuccessful RRD surgery was the only risk factor for retinal redetachment after ROSO (OR 4.8, 95%CI [1.5;19.0], p = 0.02) (Table 2). The risk of recurrence did not increase with the number of previous procedures (p = 0.10). Eyes with shorter tamponade (≤ 3 months) tended to have an increased risk of developing recurrent RRD after ROSO (p = 0.06).

Final anatomical and functional outcomes

The final retinal reattachment rate was 98.1% (158/161 eyes) after one or two surgeries, 20 (12.4%) eyes had SO remaining in situ at the last follow-up visit. The final median BCVA was 0.7 [0.4;1.3] logMAR. The final BCVA was significantly lower in eyes who developed recurrent RRD compared to those who did not, after adjusting for baseline values (1.3 [0.9;2.1] logMAR versus 0.7 [0.3;1.2] logMAR, p < 0.01). Only 9 (37.5%) eyes reached a final BCVA better than or equal to 0.1 (1.0 logMAR).

Discussion

In this study, the rate of retinal redetachment after ROSO was 14.9%. This rate is consistent with that previously reported in series focusing on eyes operated on for RRD (6–34%) [9, 15, 17, 19,20,21,22, 24, 25, 29]. It is difficult, however, to make comparisons across studies given the wide variations in inclusion criteria, characteristics of RRD and indications for SO tamponade. Despite a final anatomical success rate of 98.1%, almost two-thirds of eyes with recurrent RRD had severe vision loss. This finding is in line with earlier studies which found that RRD post-ROSO was associated with poor functional prognosis and underlines the importance of identifying the subgroup of patients who carry a greater risk of retinal redetachment [9, 13, 16].

Consistent with the literature, multivariate analysis revealed that previous failed RRD surgery was an independent risk factor for recurrent RRD after ROSO [13, 17, 18, 20, 21]. Several authors have reported that the number of preceding operations determines the anatomical success following ROSO [13, 17, 20]. Hence, in the retrospective trial conducted by Lam et al., each unsuccessful RRD surgery was associated with a 61% reduction in the anatomical success rate [20]. This study failed to demonstrate a significant association between the number of operations and the occurrence of retinal redetachment, despite a trend (p = 0.10). However, the number of patients with ≥ 2 surgeries was low (n = 15) and probably inadequate to yield a statistical difference. Previous RRD and repeated surgeries have been suggested to activate cellular and fibrosis proliferation and to promote the development of postoperative PVR [17, 18, 21]. This is evidenced in the present series by the high proportion of recurrent PVR-related RRDs.

Other proposed mechanisms for redetachment following ROSO include progression of occult detachment, reopening of pre-existing breaks and formation of new breaks due to residual traction that had been counteracted by the SO before its removal [30]. These mechanisms may explain the rapidity of redetachment in some cases. Scholda et al. and Ünlü et al. thus reported that almost half of the RRD were diagnosed within 2–3 days after ROSO [11, 13]. In contrast, other authors noted that most recurrent RRD occurred within the first 2 months with a mean delay of 1.3–2.1 months [19, 20, 31]. Our results concur with these data and likely reflect the time course of PVR development, which typically appears within 3 months of surgery [32, 33].

The application of 360° laser retinopexy has been proposed as a potential mean of reducing the incidence of RRD after ROSO [18, 21,22,23,24]. This study did not find any benefit, possibly because of the high rate of PVR redetachment. Indeed, although such treatment may close unseen breaks or limit the posterior extension of a localized anterior RRD, it may not be sufficient to prevent the progression of PVR-related RRDs, which remain the main cause of recurrence following ROSO [10, 11, 13]. Avitabile et al., in a prospective randomized trial thus observed that, despite a significant reduction in the incidence of RRD post-ROSO, a RRD still occurred in 8.6% of laser-treated eyes, because of PVR in 75% of cases [21]. It should also be noted that, in this retrospective series, the laser treatment pattern was left to the surgeon’s discretion. It was generally performed by applying 3 to 4 rows of adjacent laser spots anteriorly to the equator. A recent retrospective comparative case series has suggested that extended vitreous base laser prophylaxis treatment (from the ora serrata to the equator) is associated with lower rates of subsequent RRD in patients with Stickler syndrome [34]. Future studies should explore whether this technique may effectively reduce the incidence of redetachment following ROSO.

Other possible surgical adjuncts include the use of a supplemental scleral buckle (SB) and ILM peeling [17, 19, 35]. Jonas et al. and Teke et al. found that the lack of intraoperative SB was a significant risk factor for recurrent RRD after ROSO [17, 19]. In the present study, none of the patients underwent combined PPV with SB. This may be considered as a limitation but recent meta-analyses have demonstrated that adding SB to vitrectomy do not confer an additional anatomical or visual benefit for RRD patients [36,37,38].

In contrast, the ILM was systematically peeled off the posterior pole beyond the arcade vessels in eyes with extensive PVR involving the macula. Many studies have advocated the benefits of posterior ILM peeling in PVR-associated RRDs [35, 39,40,41]. It creates a cleavage plane underlying the PVR membranes that facilitates its complete removal and increases retinal compliance, aiding adjacent areas to relax better [35, 39, 40]. It also prevents the formation of postoperative ERM and subsequent posterior surface PVR, thereby reducing the need for a second surgery for redetachment or macular pucker [42,43,44].

Although short-term tamponade is usually preferred to minimize SO-related complications including macular edema, outer retinal changes and retinal thinning, the optimal timing for ROSO is still controversial [45,46,47,48,49]. In this study, eyes with SO tamponade ≤ 3 months showed an increased, albeit not significant, risk of developing recurrent RRD after ROSO (p = 0.06). This is consistent with the series done by Huang et al. and Tan et al., which reported lower reattachment rates in eyes with shorter tamponade [25, 27]. Other authors did not find any association between the tamponade period and anatomical outcomes, possibly because of the low number of patients with early ROSO (≤ 3 months). Nevertheless, caution should be taken in interpreting our findings because of the presence of early SO-related complications in some patients. These complications were not considered in the risk factors analysis and further trials are required to clearly determine whether longer tamponade duration is associated with improved anatomical outcomes.

Finally, it is worth nothing that all patients received light SO in this series. Several authors have investigated the use of heavy SO in the treatment of complicated RRDs, with high anatomical success rates [50,51,52,53,54]. Most comparative studies, however, failed to demonstrate superiority of a heavy tamponade [55,56,57]. In the HSO study, a multicentre randomized controlled clinical trial, no significant difference was found between the two types of tamponade regarding retinal reattachment and visual acuity in patients with PVR of the lower retina [55]. Consistent with our study, they observed a redetachment after ROSO in 13% and 17% of patients with heavy and light SO tamponade, respectively [55].

The present study has several limitations, mainly related to its retrospective design. First, the indication for SO tamponade and the timing for ROSO were left to the judgement of the surgeon, which may represent a selection bias. Second, although the sample size was relatively large, it might not be sufficient to detect other significant risk factors, particularly the presence of an ERM on SD-OCT, which has recently been found to be predictive of PVR redetachment after RRD surgery [58].

In summary, a retinal redetachment occurred in 14.9% of eyes undergoing ROSO following RRD surgery. Despite a high final anatomical success rate, the functional prognosis of these eyes was poor with a severe vision loss in most cases. Previous failed surgery was associated with an increased risk of developing recurrent RRD after ROSO. Eyes with SO tamponade ≤ 3 months tended to have a higher redetachment rate. Future prospective studies are required to determine the optimal timing for ROSO and improve the surgical outcomes.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

AL:

Axial length

BCVA:

Best corrected visual acuity

CME:

Cystoid macular edema

CMT:

Central macular thickness

ERM:

Epiretinal membrane

ILM:

Internal limiting membrane

IOP:

Intraocular pressure

LogMAR:

Logarithm of the minimum angle of resolution

OCT:

Optical coherence tomography

PFCL:

Perfluorocarbon liquid

PPV:

Pars plana vitrectomy

PVR:

Proliferative vitreoretinopathy

ROSO:

Removal of silicone oil

RRD:

Rhegmatogenous retinal detachment

SB:

Scleral Buckle

SO:

Silicone oil

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Authors and Affiliations

  1. Department of Ophthalmology, University Hospital of Nancy, Rue du Morvan, Vandoeuvre-les-Nancy, 54500, France

    Clément Gisquet, Chloé Dubroux, Karine Angioi-Duprez, Jean-Paul Berrod & Jean-Baptiste Conart

  2. UMR Inserm U1256 NGERE (Nutrition-Genetics and Exposure to Environmental Risks), Université de Lorraine, Nancy, France

    Ndeye Coumba Ndiaye

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  1. Clément Gisquet
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  3. Chloé Dubroux
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Contributions

Conception and design: JBC. Analysis and interpretation: NCN, CG, JBC. Review of the manuscript: NCN, CD, KAD, JPB. Data collection: CG, CD. Overall responsibility: JBC.

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Correspondence to Clément Gisquet.

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This study adhered to the tenets of the Declaration of Helsinki, and the protocol was reviewed and approved by the Ethics Committee of the Nancy Hospital, approval number 2022PI084-364. This study is registered on ClinicalTrial.gov, registration ID NCT05647928. All of patients were given complete information on the risks and benefits of the surgical procedure and gave their written informed consent before surgery.

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Gisquet, C., Ndiaye, N.C., Dubroux, C. et al. Retinal redetachment after silicone oil removal: a risk factor analysis. BMC Ophthalmol 24, 346 (2024). https://doi.org/10.1186/s12886-024-03618-z

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Keywords

BMC Ophthalmology

ISSN: 1471-2415

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