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   Table of Contents      
ORIGINAL ARTICLE
Year : 1999  |  Volume : 47  |  Issue : 3  |  Page : 177-180

Subconjunctival cysts following silicone oil injection: A clinicopathological study of five cases


Medical and Vision Research Foundation, Chennai, India

Correspondence Address:
J Biswas
Medical and Vision Research Foundation, Chennai
India
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Source of Support: None, Conflict of Interest: None


PMID: 10858773

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  Abstract 

Purpose: To study the occurrence, risk factors and management of subconjunctival cysts formed following the use of intraocular silicone oil as a tamponade. Methods: We analysed 5 cases of single and multioculated subconjunctival oil cysts between 1986 and 1996.
Results: Cysts were observed 15 days to 4 months following silicone oil injection. Clinically they showed minimal inflammatory signs but histopathology of removed cysts showed emulsified silicone oil globules with chronic inflammatory cellular infiltration. Conclusion: Though silicone oil is considered to be nontoxic, it can cause chronic inflammation when spilled into the subconjunctival space

Keywords: Silicone oil, subconjunctival cyst, silicone globules, oil emulsification, chronic inflammation


How to cite this article:
Biswas J, Bhende P S, Gopal L, Parikh S, Badrinath S S. Subconjunctival cysts following silicone oil injection: A clinicopathological study of five cases. Indian J Ophthalmol 1999;47:177-80

How to cite this URL:
Biswas J, Bhende P S, Gopal L, Parikh S, Badrinath S S. Subconjunctival cysts following silicone oil injection: A clinicopathological study of five cases. Indian J Ophthalmol [serial online] 1999 [cited 2019 Sep 21];47:177-80. Available from: http://www.ijo.in/text.asp?1999/47/3/177/14920

EL IS ENDOLASER; FGE IS FLUID GAS EXCHANGE; LENS IS LENSECTOMY; MP IS MEMBANE PEELING; PVR IS PROLIFERATIVE VITREORETINOPATHY; RD IS RETINAL DETACHMENT; SOI IS SILICONE OIL INJECTION; SB IS SCLERAL BUCKLING; SOR IS SILICONE OIL REMOVAL; VIT IS VITRECTOMY; AND VIT HMG IS VITREOUS HAEMORRAHGE.

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EL IS ENDOLASER; FGE IS FLUID GAS EXCHANGE; LENS IS LENSECTOMY; MP IS MEMBANE PEELING; PVR IS PROLIFERATIVE VITREORETINOPATHY; RD IS RETINAL DETACHMENT; SOI IS SILICONE OIL INJECTION; SB IS SCLERAL BUCKLING; SOR IS SILICONE OIL REMOVAL; VIT IS VITRECTOMY; AND VIT HMG IS VITREOUS HAEMORRAHGE.

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Silicone oil was introduced to ophthalmic surgery by Cibis[1] in the early 1960s in an attempt to treat giant retinal tears and cases of retinal detachment that failed to respond to conventional scleral buckling techniques. Scott[2] modified the technique and popularized it. He injected the silicone oil into a non-vitrectomised eye and basically used the oil as an instrument. In 1976 Haut[3] used silicone oil as an internal tamponade after vitrectomy and Zivojnovic[4] popularized the concept of combined vitreous surgery and silicone oil tamponade. Use of silicone oil is associated with some late complications, the most common of these being silicone oil emulsification, cataract formation, keratopathy, and glaucoma. Presence of silicone oil in the subconjunctival space as a rare complication has been reported in the literature.[5][6][7][8]

We report here clinical and histopathological features of 5 cases of subconjunctival cyst following silicone oil injection as internal tamponade. This article in addition provides a possible explanation of such cyst formation, and discusses the risk factors and prevention of this complication.


  Case Reports Top


Five cases of subconjunctival cyst noticed following silicone oil injection between 1986 to 1996 were the subject of this present study. The cyst was surgically removed in all cases and subsequently subjected to histopathological examination. The clinical features of these cases are presented below.


  Case 1 Top


A 15-year-old boy presented in September 1992 with bilateral retinal detachment with complicated cataract. The right eye had undergone scleral buckling. The left eye underwent lensectomy, vitrectomy, fluid gas exchange, scleral buckling, and trasconjunctival cryopexy in September, 1992. Subsequently the retinal detachment recurred and he underwent re-vitrectomy, fluid gas exchange, endolaser, and silicone oil tamponade. The patient developed secondary glaucoma in his left eye five and half months after the second surgery. There was a small inferior retinal detachment. The patient underwent modified Molteno implant 5 months after the injection of silicone oil. A fornix-based conjunctival flap was made at superior limbus. The conjunctiva was dissected until the encircling band was exposed. A small incision was made in the fibrous capsule over the band at the 1 o' clock position. The levelled cut end of the silicone tube was inserted into the fibrous sac. The other end was introduced into the anterior chamber. Two months after Molteno implant, his visual acuity was 6/36;N18 in the left eye, with normal intraocular pressure (IOP) and attached retina. However, a cystic lesion was noted under the bulbar conjunctiva on the temporal side in the left eye [Figure - 1]. A silicone oil globule was seen in the anterior chamber. The silicone oil was removed and epimacular proliferation was done, along with the excision of the subconjunctival cyst. Both the subconjunctival cyst and the epiretinal membrane were subjected to histopathologic study.


  Case 2 Top


A 15-year-old male presented with a detachment of retina with multiple tears, vitreous haemorrhage and cataract following a tennis ball injury to his left eye. He underwent pars plana vitrectomy, and scleral buckling with silicone oil injection in February 1987. Six weeks postoperatively the patient reported with a multinodular cystic swelling under the temporal conjunctiva. The patient also had silicone oil keratopathy. One year later, the silicone oil was removed and the subconjunctival cyst was excised.


  Case 3 Top


A 9-year-old boy presented with traumatic cataract and retinal detachment in his left eye. He underwent vitrectomy with scleral buckling and injection of silicone oil in this eye in February 1986. Fifteen days later, a cystic subconjunctival swelling was noticed in the inferior temporal quadrant. The patient also had recurrent retinal detachment in the inferior periphery. Scleral buckling was done to correct the recurrent retinal detachment and at the same sitting the subconjunctival cyst was excised and sent for histopathologic study.


  Case 4 Top


A 48-year-old male underwent extracapsular cataract extraction in July 1991, transconjunctival cryopexy in August 1991, scleral buckling in March 1996, and vitrectomy, and silicone oil injection in March 1996 for recurrent retinal detachment elsewhere. The retinal detachment subsequently recurred with proliferative vitreoretinopathy (PVR). A firm multinodular swelling was seen in the lower temporal quadrant in the left eye. The patient underwent silicone oil removal, membrane peeling, and repeat silicone oil injection. The subconjunctival mass was removed during surgery and subjected to histopathological study.


  Case 5 Top


A 12-year-old boy presented in November 1994 with a history of blunt injury to the left eye by a tennis ball. He was diagnosed to have retinal detachment with giant retinal tear. Vitrectomy with scleral buckling and silicone oil injection and endolaser was done in December 1994. He developed recurrent retinal detachment with PVR. Subsequently the patient had silicone oil removal, lensectomy, vitrectomy, membrane peeling, and repeat silicone oil injection in March 1995. The postoperative period was uneventful. At the one-month follow-up visit after the second surgery, silicone oil was seen in the anterior chamber. A subconjunctival transluscent cyst was seen in the superior nasal area. The cyst was excised during silicone oil removal and was submitted for histopathologic study.


  Histopathologic Examination Top


Gross examination of the excised cysts revealed white or greyish-brown, translucent unilocular ([Figure - 1], inset) or multilocular cyst. The size of the cysts varied from 2-6 mm in maximum dimension. Microscopic examination of the specimens in general showed clear cysts surrounded by fibrocollagenous tissues infiltrated by chronic inflammatory cells predominantly comprising lymphocytes and few plasma cells. Small, well-defined vacuolated spaces were identified within the cell wall corresponding to engulfed silicone oil droplets. A few Russell bodies were seen in the dense collagenous tissue (Case 1). In Case 3 few foci of pigment-laden histiocytes were also seen. In Case 4 the cystic space was surrounded by dense fibrocollagenous tissue with chronic inflammatory cells. In addition, the wall of the cyst contained multiple silicone oil vacuoles. In Case 5, a large cyst lined by flattened squamous epithelium was seen. Within the wall of the cyst, multiple small, well-defined clear spaces suggestive of silicone oil globules ([Figure - 2], inset) were seen. A similar but smaller cyst was seen adjacent to it. Surrounding silicone oil vacuoles, chornic inflammatory cells, few histiocytes and foreign body giant cells were seen [Figure - 2].

The surgical procedures and the intervals between silicone oil injection and subconjunctival cyst formation are presented in the table.


  Discussion Top


Silicone oil tamponade is known to be associated with complications such as emulsification, secondary glaucoma, cataract, corneal oedema, and band keratopathy. [6, 9, 10] Although considered an inert material, silicone oil has been shown to produce inflammatory reaction as noted following silicone prosthetic implant in a breast.[11],[12] Most descriptions of reactions in the eye have concerned oil emulsification, which is known to damage the trabecular meshwork and produce inflammatory membranes on the retina.[6],[10] Perisilicone oil proliferation is mostly seen in PVR cases and may or may not be related to silicone oil itself but more to the disease process.[13]

Silicone oil in the subconjunctival space is a relatively uncommon complication of use of silicone oil.[5][6][7][8] Silicone oil can find its way in to the subconjunctival space either during or after surgery. During surgery, oil that is spilled during injection can be trapped in the orbital spaces. This is more likely to occur when silicone oil injection is combined with scleral buckling procedures. Where limited conjunctival opening is done for 3 sclerotomies, the chances of the silicone oil being trapped are low. Copious irrigation of eye with the balance salt solution before closure of the conjunctiva can reduce this problem to a great extent.

Postoperatively, leakage of silicone oil can occur under two different circumstances. One, if there is inadequate or improper closure of sclerotomy. This complication is particularly likely following multiple surgeries, where in the sclera is thin and friable, and sutures tend to cut through the tissues leaving large suture tracks. Case 4, 5 and 6 had multiple surgeries before silicone oil injection which probably compromised the scleral integrity. Gross suture cut through or gape is easily identified during surgery itself and possibly remedied by additional sutures. But small leaks such as those that may occur from enlarged suture tracks due to large gauge sutures and needles (for example, 5-0) in an already thin sclera, (especially in the presence of secondary glaucoma), can lead to unrecognized postoperative ooze of silicone oil that can collect in the subconjunctival space. Use of thin sutures such as 7-0 and 8-0 polygalaction in cases with thin slcera and in reoperations can help reduce this complication to a minimum. The other postoperative cause of subconjunctival collection of silicone oil is an actual wound dehiscence caused by increased IOP. The cases reported by Federman et al[6] belonged this category, wherein the patients complained of pain which was relieved after the leak of silicone oil. This was corrected by re-exploration and suturing of the sclerotomy. In none of our cases was a leak sclerotomy clinically evident during the excision of cysts. No resuturing procedure was required.

All the 5 cases in our series on histopathology showed evidence of chronic inflammation predominantly comprising lymphocytes and a few plasma cells. In one case (Case 5) in addition to the presence of histiocytes, foreign body giant cells were seen, indicating a granulomatous inflammation. None of these cases showed clinically significant inflammation. We feel such chronic inflammation probably resulted in fibrous tissue incorporation around the silicone oil globule(s), resulting in cyst formation.

Hutchinson and co-workers[5] also reported a case of a 57-year-old male who had initially undergone an extracapsular cataract extraction and posterior chamber IOL implant, scleral buckling and vitrectomy, followed by a second vitrectomy, photocoagulation, removal of intraocular lens and silicone oil injection. Two months after the second surgery the patient initially had a diffuse bulbar conjunctival infiltrate which coalesced over a period of several weeks to form a transparent firm subepithelial droplet-like swelling. As in our cases there was no evidence of clinical inflammation, although histopathological examination revealed infiltration of chronic inflammatory cells including foreign body giant cells.

 
  References Top

1.
Cibis PA, Becker B, Okum E. The use of liquid silicone in retinal detachment surgery. Arch Ophthalmol 1962;68:590-99.  Back to cited text no. 1
    
2.
Scott JD. Treatment of the detached immobile retina. Trans Ophthalmol Soc UK 1972;92:351-57.  Back to cited text no. 2
[PUBMED]    
3.
Haut J Ullern M, Boulard ML, Cedah A. Utilisation du silicone intra-oculaire aprés vitrectomie comme traitement des rètractions massive du vitre. Bull Soc Ophthalmol Fr 1978;78:361-65. [In French]  Back to cited text no. 3
    
4.
Zivojnovic R. Silicone Oil in Vitreoretinal Surgery. Dordrecht:Martinus Nijhoff/Dr. W Junk Publishers; 1987. pp 133-40.  Back to cited text no. 4
    
5.
Hutchinson AK, Capone A, Grossiklaus HE. Subconjunctival silicone oil after vitreoretinal surgery. Am J Ophthalmol 1993;115:109-10.  Back to cited text no. 5
    
6.
Federman JL, Schubert HD. Complications associated with the use of silicone oil in 150 eyes after retinovitreous surgery. Ophthalmology 1988;95:870-76.  Back to cited text no. 6
[PUBMED]    
7.
Kasner D Miller, Taylor WH, Sever RJ, Norton EWD. Surgical treatment of amyloidosis of the vitreous. Trans Am Acad Opthalmol Otolaryngol 1968;72:410-16.  Back to cited text no. 7
    
8.
Gonvers M. Temporary silicone oil tamponade in the management of retinal detachment with proliferative vtireoretinopathy. Am J Opthalmol 1985;100:239-45.  Back to cited text no. 8
[PUBMED]    
9.
Leaver PK, Grey RHB, Ganver A. Silicone oil injection in the treatment of massive preretinal retraction II. Late complications in 93 eyes. Br J Ophthalmol 1979;63:361-67.  Back to cited text no. 9
    
10.
Lucke K, Laqua H. Silicone Oil in the Treatment of Complicated Retinal Detachments. Berlin, Germany:Springer-Verlag; 1990.  Back to cited text no. 10
    
11.
Wilfingseder P, Propst A, Mikuz G. Constrictive fibrosis following silicone implants in mammary anizementation. Chir Plast 1974; 2:215-29.  Back to cited text no. 11
    
12.
Wintsch W, Smahel J, Clodius L. Local and regional lymph node response to ruptured silicon filled mammary prostheses. Br J Plast Surg 1978;14:349-52.  Back to cited text no. 12
    
13.
Bornfeld N, El-Hifnawi E-S, Laqua H. Ultrastructural characteristics of preretinal membranes from human eyes filled with silicone oil. Am J Ophthalmol 1987; 103:770-75.  Back to cited text no. 13
    


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