Programme and Abstract - fluoron

Programme and Abstracts for HEATAM 3 meeting
21st November 2009
1

Programme
Schedule Speaker Title Affiliation Duratio Duration
n of talk of
discussio
n
0900-0903 Session 1: Indications - Chairperson Bernd Kirchhof (Welcome) / Time keeper (David
Wong)
0903-0910 Alexandra
Lappas
Treatment of macular hole with heavy oil Cologne 7 min defer
0910-0917 Peter Stalman Macular Hole Surgery With Inner Limiting
Membrane Peeling, Endodrainage, and Heavy
Silicone Oil Tamponade
Leuven 7 min defer
0917-0924 Barbara Parolini Posterior retinal detachment due to macular
hole in high myopia, 25 cases treated with
densiron and 17 with silicone oil 1000
Negrar-
Verona
0924-0936 Bernd Kirchhof Panel discussion : to summarise rationale, evidence, complications
and justification of macular hole using HSO
7 min defer
12 min
0936-0943 Heinrich Heimann Is Heavy Oil helpful for PVR? Liverpool 7 min defer
0943-0949 K.A. Becker Retrospective analysis of 67 patients with
heavy silicone oil tamponade
Chemnitz 6 min defer
0949-0956 Katerine
Engelmann
Primary vitrectomy using heavy oil Chemnitz 7 min defer
0956-1003 Murat Oncel Long term results of safety and efficacy of
heavy oils
Istanbul 7 min defer
1003-1010 Cesare Forlini HSO as 1st choice in complicated retinal
detachment: checkmate in two moves
Ravenna 7 min defer
1010-1020 Antonia Joussen HSO study an update Dusseldorf 10 min defer
1020-1030 Discussion of above papers 10 min
1030-1100 Coffee Break
1100-1130 Motion of the debate: “There is no need for heavy oil, not now, not ever”
speaking against the motion will be Claus Eckardt and speaking for the
motion will be Norbert Bornfeld
Session 2: Techniques - Chairperson Stanislao Rizzo
30 min
1130-1137 Hon Woon Giant retinal tears without PFCL Leeds 7 min defer
1137-1144 Thomas Theelen “Hydraulic jump to heavy oil in retinal
detachment surgery - no need for heavy
liquids”
Nijmegen 7 min defer
1144-1150 Discussion of above 2 papers 6 min
1150-1155 David Steel Removal of heavy oil combined with cataract
surgery
Sunderland 5 min defer
1155-1200 Xavier
Removal of heavy oil from the limbus under Barcelona 5 min defer
Valldeperas topical anaesthesia
1200-1205 Theodor Stappler Tubeless syphon Liverpool 5 min defer
1205-1210 Mario Romano Removal of Densiron-68 with 23-Gauge
transconjunctival vitrectomy System. How is it
possible?
Milan 5 min defer
1210-1220 Discussion of above papers 10 min
1220-1230 Stefano Zenoni Combination of tamponade Bergamo 5 min 5 min
1230-1245 Andrew Chang The use of PFCL as temporary tamponade Sydney 10 min 5 min
1245-1300 Carlos Mateo The use of Haelon in vitreoretinal surgery Barcelona 10 min 5 min
1300-1400 Lunch
2

1415 Session 3: New Substances : Chairperson Heinrich Heimann
1415-1420 Rachel Williams Theory behind emulsified resistant oils Liverpool 5 min defer
1420-1425 Albert Caramoy Ex vivo testing of emulsification of different oils Cologne
including
Densiron HV
5 min defer
1424-1430 Hakan Kaymak Clinical experience with the Siluron 2000 Sulzbach/
Saar
5 min defer
1430-1435 M Mura Siluron 2000 in the treatment of complex
vitreoretinal detachment using 25 gauge
transconjunctival vitrectomy
Amsterdam 5 min defer
1435-1450 Discussion of above 4 papers 15 min
1450-1455 Norbert Kociok F4H5 Human experience in removing adherent Düsseldorf
oil on Intraocular lenses
5 min defer
1455-1500 Theodor Stappler Can we remove adherent oil completely with
F4H5?
Liverpool 5 min defer
1500-1510 Stanislao Rizzo Experience with F4H5 Pisa 10 min defer
1510-1520 Discussion of above 3 papers 15 min
1520-1530 Peter Szurman New Hydrogel Vitreous Substitute Tuebingen 5 min 5 min
1530-1540 Kugler Wilfried Thermosensitive polymers as vitreous
substitute
Fluoron 5 min 5 min
1540-1545 Mike Garvey An eyeful of sand Liverpool 5 min 5 min
1545-1555 David Wong
1555-1620 Coffee Break
Low Molecular Weight Silicone Infusion Hong Kong 5 min 5 min
Session 4: Dealing with Complications - Chairperson Jan van Meurs
1620-1627 Wison Heriot How to manage subretinal PFCL bubbles Melbourne 7 min defer
1627-1634 Jerzy Mackiewicz " Subretinal PFCL-what to do?" Lublin 7 min defer
1634-1640 Discussion of above 2 papers 6 min
1640-1655 Jan van Meurs The relation of injury site, tamponade used and Rotterdam
the incidence of PVR: Analysis of 250 patients
10 min 5 min
1655-1705 Marc Veckeneer An outbreak of sticky oil Rotterdam 5 min 5 min
3

Abstracts
Table of contents
Heavy Silicone Oil (Densiron-68®) For Persistent Macular Holes....................................................................... 6
A. Lappas, A. Caramoy, A.M.H. Foerster, B. Kirchhof 6
Macular Hole Surgery with Inner Limiting Membrane Peeling, Endodrainage, and Heavy Silicone Oil
Tamponade ............................................................................................................................................................... 7
Annelies Schurams, Joachim van Calster, Peter Stalmans 7
Surgical management of macular retinal detachment due to macular hole in high myopia ........................... 9
Barbara Parolini, MD, Grazia Pertile MD 9
Is Heavy Oil helpful for PVR? ................................................................................................................................ 10
Heinrich Heimann 10
Retrospective analysis of 67 patients with heavy silicone oil tamponade ....................................................... 11
K.A. Becker, K. Engelmann 11
Treatment of GRT without perfluorocarbon liquids............................................................................................ 12
Hong Woon 12
Ex vivo emulsification testing of different oils including Densiron 68 HV ........................................................ 13
Albert Caramoy, Sabine Schröder, Sascha Fauser, and Bernd Kirchhof 13
Siluron 2000 in the treatment of complex vitreoretinal detachment using 25 gauge transconjunctival
vitrectomy. .............................................................................................................................................................. 14
M.Mura 14
Removal of heavy oil from the limbus under topical anaesthesia .................................................................... 16
Xavier Valldeperas 16
Tubeless Siphoning A Guide to the Removal of Heavy Silicone Oil .................................................................. 17
T Stappler, R Williams, SK Gibran, E Liazos, D Wong 17
Removal of Densiron-68 with 23-Gauge transconjunctival vitrectomy System. How is it possible? ............ 18
Romano MR, Heimann H, Groenwald C, Stappler T, Wong D. 18
Increasing the extensional viscosity of Silicone oil reduces the tendency for emulsification ....................... 19
Rachel L Williams, Michael Day, Michael J Garvey, Robert English and David Wong 19
Can we remove adherent oil completely with F4H5? ......................................................................................... 20
Stappler, R. Williams, D. Wong 20
Clinical Experience with Siluron 2000.................................................................................................................. 21
4

Hakan Kaymak 21
Heavy Silicone Oil versus Standard Silicone Oil in as vitreous tamponade in Inferior PVR (HSO Study): Interim
Analysis of 94 consecutive patients..................................................................................................................... 22
Antonia M. Joussen, Christina Ocklenburg, Bernd Kirchhof, Norbert Schrage, Ralf-Dieter Hilgers, on behalf of
the HSO –Study Group 22
F4H5: Experiences in removing adherent silicon oil on intraocular lenses ..................................................... 23
Norbert Kociok, Yong Liang, Monika Leszczuk, Wilfried Hiebl4, Bastian Theisinger, Anja Lux, and Antonia M.
Joussen 23
Hydrogel as Vitreous Substitute........................................................................................................................... 24
Peter Szurman 24
Management of retained perfluorocarbon liquids. ............................................................................................. 25
Wilson J. Heriot 25
Subretinal PFCL – what to do ? ............................................................................................................................ 26
Jerzy Mackiewicz 26
AN EYEFUL OF SAND – AN ALTERNATIVE HEAVY TAMPONADE..................................................................... 27
M.J,Day, M.J.Garvey, T. Stappler, R.L.Williams and D. Wong 27
Combined Phacoemulsification and heavy oil removal. .................................................................................... 28
David Steel, Sunderland Eye Infirmary, UK 28
Short term tamponade using perfluorcarbon in the treatment of giant retinal tears. .................................... 29
Andrew Chang 29
The use of viscoelastics in vitreoretinal surgery ............................................................................................... 30
Carlos Mateo M.D. 30
An Outbreak of Sticky Oil ..................................................................................................................................... 31
Marc Veckeneer 31
Hydraulic Jump to Heavy Oil – No Need for Heavy Liquids ............................................................................... 32
Thomas Theelen, Maurits A.D. Tilanus, and B. Jeroen Klevering 32
COMBINATION OF TAMPONADE ......................................................................................................................... 33
Stefano Zenoni, Natalia Comi, Piero Fontana 33
Thermosensitive polymers as vitreous substitute.............................................................................................. 34
Wilfried Kugler, Fluoron GmbH, 89077 Ulm, Germany 34
HSO AS 1ST CHOICE IN COMPLICATED RETINAL DETACHMENT: CHECKMATE IN TWO MOVES! ............ 35
Cesare Forlini MD*, Matteo Forlini MD**, Paolo Rossini MD* 35
5

Heavy Silicone Oil (Densiron-68 ® ) For Persistent Macular Holes
A. Lappas, A. Caramoy, A.M.H. Foerster, B. Kirchhof
Dept. of Vitreo-Retinal Surgery
University of Cologne
Purpose: To evaluate the long term results after retreatment of patients with persisting
macular holes with Densiron-68 ® .
Materials and Methods: Twelve consecutive patients presented with persisting macular holes
after conventional macular hole surgery including internal limiting membrane peeling and gas
tamponade with SF6 (sulphur hexafluoride). They were retreated with Densiron-68 ® , that was
removed after 1,5-4 months. Best-corrected visual acuity, slit lamp examination, binocular
fundus examination and optical coherence tomography (OCT) were used for pre- and
postoperative evaluation.
Patients were followed for 12 months.
Results: The mean preoperative diameter of the full thickness macular holes was 502,25 μm
(+/- 129,39 μm). After 12 months eleven out of twelve macular holes were still closed after
treatment with the “heavy silicone oil” tamponade Densiron-68 ® . In one case the macular
hole reopened after removal of Densiron-68 ® . Mean visual acuity improved from 20/250
(1,07 +/- 0,22 logMAR) prior to retreatment with Densiron-68 ® to 20/160 (0,76+/- 0,27
logMAR) 12 months postoperatively.
Conclusion: We observed anatomical closure of persisting macular holes up to 12 months
after retreatment with Densiron-68 ® . In one case, however, the persisting hole could not be
closed, in another case the macular hole reopened. Mean visual acuity improved by 3 lines.
6

Macular Hole Surgery with Inner Limiting Membrane Peeling,
Endodrainage, and Heavy Silicone Oil Tamponade
Annelies Schurams, Joachim van Calster, Peter Stalmans
7

Surgical management of macular retinal detachment due to macular
hole in high myopia
Barbara Parolini, MD, Grazia Pertile MD
Ospedale Sacro Cuore
Negrar Verona Italy
Background. Macular retinal detachment due to macular hole in high myopia is a real surgical
challenge. The rate of recurrence is very high with any surgical strategy available.
The need for an easier and efficient surgery is explored
Methods. Two series of eyes operated with vitrectomy, posterior cortex peeling and ILM
peeling were revised. Seventeen eyes were tamponated with silicone oil 1000 and 24 eyes
were tamponated with Densiron.
Results. The rate of permanent retinal detachment was 24% in the silicone oil group and 40%
in the Denrison group. Eyes reoperated with revision of vitrectomy and Densiron tamponade
failed. Eyes reoperated with Silicone oil tamponade succeded with one or two additional
surgeries.
In the majority of cases the retina finally reattached but the macular hole remained flat and
open.
A new model of macular scleral buckle is also presented in combination of vitrectomy
Conclusions. Densiron is not helpful in diminishing the number of reoperation for macular
retinal detachment in high myopes. We encourage the use of scleral buckle in combination
with vitrectomy to lower the rate of reoperations and to facilitate macular hole closure.
8

Is Heavy Oil helpful for PVR?
Heinrich Heimann
Royal Liverpool University Hospital, UK
heinrich.heimann@gmail.com
Complicated rhegmatogenous retinal detachments (RRD) and redetachments of the inferior
retina are the major indication for the use of heavy silicone oil (HSO) tamponades. Proliferative
vitreoretinopathy (PVR) grade B or C is present in around 70% of such cases [Stappler T et
al., Eye 2008, 22:1360]. Whilst some authors argue that HSO might be helpful in lowering the
rate of postoperative PVR through immediate tamponade of large inferior breaks and retinal
reattachment, there is also an contrary viewpoint that a PVR reaction could be stimulated by
possible pro-inflammatory effects of HSO.
A review of published series of HSO surgery for complicated RRD shows overall
reattachment rates between 33% and 86% with the majority being around 70% primary
success [Heimann H et al., Eye 2008, 22:1342]. Most redetachments were caused by PVR in
the superior periphery. Final success rates varied between 71% and 100% with the majority
being around 90% final success. Postoperative PVR can be seen in around 20% to 30% of
these complicated cases. In contrast to conventional silicone oil tamponades, PVR
redetachments occur mainly in the superior periphery when the HSO tamponade is in situ.
Newer HSO tamponades (Oxane HD and Densiron) do not seem to be associated with
increased rates of intraocular inflammation.
Conclusion: HSO is a useful tool for the treatment of inferior RRD associated with PVR.
Postoperative PVR rates are comparable to conventional silicone oil tamponades. HSO
tamponades seem to shift but not reduce PVR-stimulating factors. On the other hand, there
is no indication that HSO tamponades have an additional PVR-stimulating effect. There is no
published prospective randomized clinical trial as yet to answer the question whether
outcomes and complications of PVR surgery with HSO tamponades are better or worse
compared to conventional silicone oil.
9

Retrospective analysis of 67 patients with heavy silicone oil
tamponade
Department of ophthalmology, Klinikum Chemnitz gGmbH, Germany
K.A. Becker, K. Engelmann
Purpose: A retrospective analysis of 67 consecutive patients with heavy silicone oil
tamponade (Densiron® 68).
Patients and Methods: 67 patients with different indications underwent vitrectomy with
Densiron® 68 tamponade from March 2006 to July 2009 at the department of
ophthalmology, Klinikum Chemnitz gGmbH, Germany: 65 retinal detachements (thereof 6 due
to diabetic retinopathy, 8 after trauma, 6 after previous intraocular surgery, 3 high myopic
eyes), 1 low grade endophthalmitis and 1 massive subretinal bleeding due to ARMD. 7
patients underwent a second Densiron® tamponade in the same eye.
Results: The mean duration of the tamponade was 80±44 days (22-228d). We observed a
“shift” phenomenon in 12 and significant emulsification in 6 patients. 29 of 67 patients
underwent one or more prior surgeries before the Densiron® tamponade. In 39 patients only
a removal of the heavy tamponade was performed thereafter. In 6 patients it was not possible
to achieve a complete adherent retina. We observed no complications at the removal like
“sticky” silicone oil.
Conclusions: Heavy silicone oil tamponade have a great potential for the surgical treatment
i.e. of complicated retinal detachement or after trauma. Further investigations and trials are
necessary to reduce the rate or improve the treatment of “shift” phenomenon and to
recommend indications.
10

Treatment of GRT without perfluorocarbon liquids
Hong Woon
St James’ Hospital, Leeds UK
We direct injected a heavy silicone oil (Densiron-68TM) into a fluid filled eye in the treatment of
retinal detachments secondary to giant retinal tears (GRT). The technique uses the heavy
silicone oil as a peroperative tool to unroll the GRT and to displace subretinal fluid. The
densiron is then left to provide postoperative tamponade. It is thus a one step technique and
avoids the need to use a perfluorocarbon liquid in the treatment of GRT.
The technique does not rely on the static hydrostatic forces generated by the displacement of
fluid by the oil but on the dynamic forces generated by the injection of oil into the eye. The
expanding oil bubble drives the contact line between oil, retina, and saline to displace
subretinal fluid and flatten the retina. The role played by an advancing contact angle is
discussed.
11

Ex vivo emulsification testing of different oils including Densiron 68 HV
Albert Caramoy, Sabine Schröder, Sascha Fauser, and Bernd Kirchhof
University of Cologne, Center of Ophthalmology, Department of Vitreo-Retinal Surgery, 50924
Cologne, Germany
Corresponding author:
Dr. med. Albert Caramoy
University of Cologne
Center of Ophthalmology
Department of Vitreo-Retinal Surgery
Kerpener Str. 62
50924 Cologne
Germany
Tel: 0049 (0) 221 478-4308
Fax: 0049 (0) 221 478-3526
E-Mail: acaramoy@yahoo.co.uk
ABSTRACT
Purpose: To investigate whether the emulsification of conventional silicone oils can be
reduced by adding small amounts of silicone molecules of very long chain length.
Methods: Siluron 1000, Siluron 2000, Siluron 5000, Acri.Sil-Ol® 5000, Oxane® 5700,
Densiron 68 LV, Densiron 68, and Densiron 68 HV (0.5 ml) were each tested along with either
plasma or serum (0.5 ml) in a glass cuvette. Emulsification was induced by sonication and
documented by photography. The total area of emulsified oil was assessed using the ImageJ
software.
Results: The addition of small amounts of very long-chain silicone molecules significantly
reduced the emulsification rate for 1000 cSt silicone oil (Siluron 2000) and for 1000 cSt
silicone oil with admixture of F6H8 (Densiron 68 HV).
Conclusion: New low-viscosity silicone oils show reduced emulsification similar to 5000 cSt
oils. In future, it may be possible to avoid using 5000 cSt oils. The findings may foster silicone
oil surgery in general and particularly the application of small-incision techniques.
12

Siluron 2000 in the treatment of complex vitreoretinal detachment
using 25 gauge transconjunctival vitrectomy.
M.Mura
Purpose: to determine feasibility, safety, efficacy of the new Siluron 2000, emulsification
resistant silicone oil .
Methods: 30 patients with complex retinal detachment were recruited.
Inclusion criteria: retinal detachment with PVR requiring silicone oil infusion.
Exclusion criteria: previous surgery involving silicone oil.
All the patient underwent 25 gauge transconjunctival vitrectomy, membrane peeling,
endolaser and retinectomy. Silicone oil was kept in the eye for a variable period of time
pending on the indications ( range 15-91 days).
Best corrected visual acuity pre and post operative, intraocular pressure 1 day, 1 week, 1
month and 3 months post op and after oil removal were recorded.
Intraocular inflammation was recorded post operatively and after oil removal according to the
same time scheme.
Silicone oil infusion and removal time were recorded.
The presence and amount of emulsification was graded clinically 1 week, 1 month and 3
months post-op before the oil is removed and 1 week after oil removal.
Surgical outcome was also assessed.
Results: All the patients had multiple inferior breaks with grade C PVR and higher. They all
underwent 25 gauge transconjunctival vitrectomy, membrane peeling, retinectomy, laser and
Siluron 2000 oil infusion. Visual acuity improved from CF (range HM- 0.1) to 0.32 (range
0.12-0.5).
The oil was injected after a full air-fluid exchange, using a 25 gauge high-pressure infusion
cannula ( Synergetics Inc.). The mean injection time was 68 seconds (range 65-70 sec.). 80
to 90% oil fill was clinically seen the day after surgery. No intra or perioperative complications
were encountered.
In these patients the oil was removed after a mean period of 32 days after surgery (range
15-91 days).
Intraocular inflammation was very mild at day 1 ( trace to 1+ cells).
Mean intraocular pressure was 13 mmHg (range 10-18 mmHg).
No signs of emulsification were found on clinical examination with gonioscopy before and
after oil removal.
The oil was removed via 25 gauge transconjunctival cannulas in a passive or active fashion.
None of the 30 patients had subconjunctival oil extrusion. 3 patients developed central PVR
without retinal detachment that was peeled at the same time of the oil removal. 2 patients
redateched and required further surgical procedures.
Conclusions: Siluron 2000 is a safe tamponade agent that can be efficiently used in
association with 25 gauge surgical instruments. No signs of emulsification were found in this
small group of patients.
13

Removal of heavy oil from the limbus under topical anaesthesia
Xavier Valldeperas
Barcelona
We present a case of an 89 year-old man who attended our clinic with a macula on retinal
detachment (RD) in his right eye (RE), and total blindness in his left eye (LE) since child. Two
weeks before, the patient had had a complicated cataract extraction in his RE, and the eye
was left aphakic with a non-resolving vitreous haemorrhage.
The patient developed a stroke during preoperative assessment in the anaesthetic
department, and was immediately admitted and started on double antiaggregation with
acetylsalicylic acid (75mg/day) and clopidogrel (100mg/day). Three days later, he underwent
a pars plana vitrectomy (PPV) and heavy silicone oil - Densiron® - for the management of a
macula on RD with an inferior giant retinal tear. The patient had this first PPV under subtenon
anaesthesia and the direct supervision of the neurologist, who understood the need of urgent
surgery in this case.
Two months later, the retina was flat with a good laser scar, but a bubble of Densiron® had
moved into the anterior chamber. We then decided to remove the endotamponade, in order
to avoid corneal damage. The surgery was performed under topical anaesthesia, as the
double antiaggregation was impossible to be stopped.
We present the video of this procedure, when we removed the Densiron® through the limbus
using a 20g paracentesis and an anterior chamber maintainer. The patient experienced no
pain or discomfort at all, and the surgery was easy and safe to perform.
14

Tubeless Siphoning A Guide to the Removal of Heavy Silicone Oil
T Stappler, R Williams, SK Gibran, E Liazos, D Wong
(1) St Pauls Eye Unit, Royal Liverpool University Hospital, Prescot St., Liverpool, L7 8XP, UK
(2) Clinical Engineering and Ophthalmology, School of Clinical Sciences, University of
Liverpool, Liverpool, UK
(3) Eye Institute, LKS Faculty of Medicine, The University of Hong Kong
Purpose: Heavy silicone oil removal can be challenging and differs considerably from
conventional oil. Traditionally, strong active aspiration had to be applied through a long 18G
needle just above the optic disc. We present a novel technique using a much shorter (7.5mm)
and smaller (20G) needle allowing its removal “from a distance”.
Method: Active aspiration on a vacuum of 600mmHg of the “viscous fluid injector” was
applied using the 20G cannula in a polymethylmethacrylate model eye chamber that was
surface-modified to mimic the surface properties of the retina. Measurements were taken
using still photographs.
Results: Under injection the maximum diameter of a silicone oil bubble supported by
interfacial tension alone was 5mm for a steel and 7mm for a polyurethane cannula. Under
suction, the silicone bubble changed shape and became conical thus further increasing the
cannula’s reach. This conical shape illustrated “tubeless siphoning”, which is a physical
property of non-Newtonian fluids.
Discussion: Static forces such as the interfacial tension between the steel or plastic cannula
and the oil, dynamic forces such as the phenomenon of tubeless siphoning inherent in the
viscoelastic property of silicone made it feasible to use a shorter and smaller gauge needles
to remove heavy silicone oil. We recommend the use of the short 20-gauge steel needle
because it works and it reduces the risk of iatrogenic damage such as entry site tears or
postoperative hypotony.
15

Removal of Densiron-68 with 23-Gauge transconjunctival vitrectomy
System. How is it possible?
Romano MR, Heimann H, Groenwald C, Stappler T, Wong D.
Affiliation:
1 Royal Liverpool University Hospital, Liverpool, UK.
2 Istituto Clinico Humanitas, Rozzano, Milan, Italy
Purpose: to report a new approach for removal of Densiron-68 via pars plana
with 23-Gauge transconjunctival sutureless vitrectomy system (TSVS).
Methods: Prospective, interventional case series. Thirty-five eyes (21 phakic, 12
pseudophakic, 2 Aphakic) of 35 patients underwent Densiron-68 (1480 mPas viscosity and
1.06 g/ml specific gravity) removal via pars plana with active suction of 600 mm Hg vacuum
through a short 23-Gauge silicon cannula.
Results: Densiron-68 was completely removed from all eyes. Retinal reattachment was
achieved in all cases. The IOP was 19.8 (SD 3.5) mmHg at baseline, 11.2 (SD 4) mmHg at 1
day postoperatively, and 12.4 (SD 2.9), 13.2 (SD 2.5), 15 (SD 1.8) mmHg after 1 week, 1
month and 3 months, respectively. Seven eyes needed suture of at least one sclerotomy.
Postoperative hypotony (≤ 8 mmHg) was seen in 3 out of 35 eye (5.7%) No additional
postoperative procedure was necessary.
Conclusions: Active removal of Densiron-68 with 23-Gauge short cannula is a simple,
innovative and safe technique that can help reducing surgical trauma.
16

Increasing the extensional viscosity of Silicone oil reduces the
tendency for emulsification
Rachel L Williams, Michael Day, Michael J Garvey, Robert English and David Wong
Background: Emulsification of silicone oil tamponade agents can cause clinical complications. This
study aimed to increase the emulsification resistance of silicone oil 1000 to be at least as resistant as
silicone oil 5000 while maintaining the shear viscosity lower than 5000 mPa s to aid injection and
removal.
Methods: High molecular weight (423 kDa) poly(dimethyl siloxane) was added to silicone oil 1000 at
5% and 10% w/w concentration. The shear and extensional viscosity of 1000, 5000, a 50:50 mixture
of 1000 and 5000 and 5% and 10% w/w additive blends of silicone oil were measured using capillary
break-up extensional, rotational shear and capillary extrusion rheometry. In vitro emulsification was
assessed qualitatively following agitation using Pluronic F68 or a protein solution as the emulsion
stabiliser.
Results: Addition of high molecular weight polymer increased the extensional viscosity of the blends at
high strain rates to levels equal to or greater than silicone oil 5000. In all cases the shear viscosity of
the blends was lower than that of silicone oil 5000. The additive blends were qualitatively as
emulsification resistant as silicone oil 5000.
Conclusion: Addition of low concentrations of very high molecular weight polymers of the same
chemistry as the bulk oil has the potential to increase the emulsification resistance of the tamponade
agents while maintaining ease of injection and removal.
17

Can we remove adherent oil completely with F4H5?
T. Stappler, R. Williams, D. Wong
1St Paul’s Eye Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom;
2Clinical Engineering and Ophthalmology, University of Liverpool, Liverpool, United Kingdom;
3Eye Institute, The University of Hong Kong, Hong Kong.
Abstract
Purpose
Adherent silicone oil on intraocular lenses (IOLs) following retinal detachment surgery induces
large and irregular refractive errors, multiple images and gives rise to glare, distorted and
often poor vision. Its removal remains challenging often requiring mechanical wiping or
explantation. F4H5 is a new semifluorinated alkane into which silicone oil is readily soluble.
We aim to establish the effectiveness of F4H5 in removing silicone oil from three different
types of IOL in vitro.
Method
Silicone lenses (PHARMACIA TECNIS ZM900), hydrophobic acrylic lenses (ALCON MA60)
and PMMA lenses (OCULARVISION PMMA) were firstly immersed in phosphate buffered
saline, secondly in silicone oil, then in F4H5 for 10 min and lastly vigorously agitated in F4H5
for 1 minute. They were weighed at each stage using scales accurate to 0.0001g to measure
the weight of the adherent oil. Dynamic contact angle analysis was used to assess their
surface properties.
Results
Immersion in F4H5 alone removed 96.1%(±1.23) by weight of silicone oil from the
hydrophobic acrylic lenses, 91.4%(±1.58) from the silicone and 95.6%(±1.44) from the
PMMA IOLs. Immersion combined with 1 minute of agitation increased the removal to 98.8%
(±0.46) from the acrylic IOLs, to 93.7%(±0.48) from the silicone IOLs and to 100% (within
±0.0001g) from every PMMA IOL. After treatment with F4H5 all IOL were optically clear.
Dynamic contact angle hysteresis curves remained permanently altered. All measurements
were highly reproducible.
Conclusion
F4H5 was highly effective at removing the bulk of the silicone oil from all three groups of IOL.
The dynamic contact angle measurements suggested that their surface properties were
permanently modified.
18

Clinical Experience with Siluron 2000
Hakan Kaymak
Purpose: The objective of this study was to test the applicability of the new silicone oil,
Siluron 2000 in comparison with standard silicone oils, Siluron 1000 and Siluron 5000, with
respect to small gauge surgery.
Setting: Siluron 2000 is a Siluron 1000 / high molecular weight additive (2.500.000 mPas)
blend with a viscosity of about 2000 mPas.
Methods: To determine and compare the flow rates of silicone oil tamponades with different
viscosities, the oils were pushed through cannulas of different size (20 Gauge, 20 G Kirchhof
cannula, 23 Gauge, 25 Gauge) using a Geuder Megatron S3. In addition, different pressures
were applied (1,5 bar, 3 bar, 6 bar). The amount of silicone oil was determined after 30
seconds running time by weighing of the components. Every test was repeated ten times.
Results: The flow rates of the various silicone oils tested were different depending on the
cannula type. Interestingly, the flow rates showed a nonlinear course depending on the
viscosity. In detail, Siluron 2000 is applicable through a 20 G cannula without any problems.
This new silicone oil could also be utilized in a reasonable way through a 23 G and 25 G
needle, however at a pressure of 6 bar. In comparison, the application of Siluron 1000 was
easily done regardless of the conditions used. The applicability of Siluron 5000, however,
even at 6 bar, decreases rapidly with decreasing cannula size.
Conclusion: Siluron 2000 could be easily applied throught a 20 gauge needle. Importantly, its
application through the smaller 23 and 25 gauge cannulas is much easier to perform
compared to Siluron 5000.
In addition, first clinical results with Siluron in 20 patients will also be presented.
19

Heavy Silicone Oil versus Standard Silicone Oil in as vitreous
tamponade in Inferior PVR (HSO Study): Interim Analysis of 94
consecutive patients
Antonia M. Joussen, Christina Ocklenburg, Bernd Kirchhof, Norbert Schrage, Ralf-Dieter
Hilgers, on behalf of the HSO –Study Group
1 Department of Ophthalmology, University of Düsseldorf, Germany
2 Department of Medical Statistics, RWTH Aachen, Germany
3 Department of Vitreoretinal Surgery, Center of Ophthalmology, University of Cologne,
Germany
4 Augenklinik Köln-Merheim, Köln, Germany
Objective: The Heavy Silicone Oil versus Standard Silicone Oil Study (HSO-study) is
designed to answer the question, whether a heavier than water tamponade improves the
prognosis of eyes with PVR of the lower retina.
Design: The HSO Study is a multicentre, randomized, prospective controlled clinical trial
stratified by surgeon comparing two endotamponades within a two arm parallel group
design.
Patients: Patients with inferiorly and posteriorly located PVR grade C-A6 were randomized to
either heavy silicone oil or standard silicone oil as a tamponading agent.
Main Outcome Measures: The main endpoint criteria are complete retinal attachment at
twelve months and change of VA twelve months postoperatively as compared to the
preoperative VA.
Results: 46 patients treated with heavy silicone oil were compared to 47 patients treated
with standard silicone oil. There was no difference among the groups regarding baseline data.
Three patients in the HSO and 5 patients in the standard silicone oil group fulfilled
intraoperative exclusion criteria. There was no significant difference between both groups
regarding anatomical success. Neither non-inferiority nor superiority was shown with regard
to final acuity.
Conclusions: The HSO Study is the first randomised prospective clinical trial to compare
heavy and standard silicone oil in patients with PVR of the lower retina. The interim results
failed to demonstrate a superiority of a heavy tamponade.
Clinical Trial
Multicenter Study
Randomized Controlled Trial
20

F4H5: Experiences in removing adherent silicon oil on intraocular
lenses
Norbert Kociok, Yong Liang, Monika Leszczuk, Wilfried Hiebl4, Bastian Theisinger, Anja
Lux, and Antonia M. Joussen
1 Department of Ophthalmology, University of Düsseldorf, Germany
2 Department of Ophthalmology, Peking University, People’s Hospital, PR China
3 Department of Ophthalmology, University of Lublin, Poland
4 Fluoron GmbH, Neu-Ulm, Germany
Abstract
Purpose:
We compared the efficacy of perfluorobutylpentane (F4H5) and perfluorohexyloctane (F6H8)
in dissolving silicone oil from the surface of silicone intraocular lenses.
Methods:
Droplets of stained silicone oil applied to an object slide either lying flat or tilted by 30° was
mixed with H2O, F4H5, or F6H8 and documented by a digital camera. Droplets of silicone oil
were applied to silicone lenses and washed off by repeated rinsing with F4H5 or F6H8. A
total of 11 patients with silicone lenses and silicone oil remnants on the posterior IOL surface
were rinsed intraoperatively with F4H5 during removal surgery.
Results:
Only F4H5 was able to mix with silicone oil and to remove it form the surface of a glass object
slides. Rinsing with 25 µl F4H5 reduced the amount of silicone oil 1000 mPas or 5000 mPas
attached on a silicone lens to 15 % and 28%, respectively. A hanging droplet of silicone oil
5000 beneath a silicone lens was completely removed from below by F4H5. In all patients a
sufficient IOL cleaning was possible using F4H5. There was no significant postoperative
inflammation in the vitreous or anterior chamber.
Conclusion:
Silicon oil dissolves effectively in F4H5 due to its lipophilic chemical structure. A much smaller
volume of F4H5 than F6H8 is able to completely remove silicone oil from silicone lenses
without applying intense mechanical forces. Intraocular use of F4H5 is safe and first clinical
data underlines the effectiveness as a cleaning agent after contact of silicone lenses with
silicone oil.
Norbert Kociok, PhD
Department of Ophthalmology
University of Düsseldorf
Moorenstr. 5
40225 Düsseldorf
Phone: +49 211 8104561
Fax: +49 211 8117963
Norbert.Kociok@uni-duesseldorf.de
21

Hydrogel as Vitreous Substitute
Peter Szurman
Department of Ophthalmology, Eberhard-Karls University Tübingen, Germany
The natural vitreous is a highly hydrated fibrillary composite with unique biophysical
properties. Since more than 100 years considerable efforts have been made to develop an
artificial vitreous substitute. But since today no ideal tamponade material has been available
yet. The main desired properties comprise a sufficient tamponade effect without buoyancy,
advantageous rheological parameters in view of viscosity, pseudoplasticity, cohesiveness,
transparency and refraction stability, a good biocompatibility and biodegradability, shock
absorption, no proliferation scaffold and potentially serving as a slow release system for
antiproliferative drugs.
Current tamponade materials fulfill these demands only in part by following a different
strategy compared to the effect of the natural vitreous. They rather act by surface tension and
buoyancy. One should take into account that both properties do not represent the
biomechanical action of the natural vitreous. Current research strategies rather follow the
concept to mimic the properties of the natural vitreous by developing hydrogel polymers as
vitreous substitute. The first prototypes of these hydrogels have been tested in animal
experiments and seem to achieve these desired properties indicating that this might be a
future strategy in retinal detachment surgery.
22

Management of retained perfluorocarbon liquids.
Wilson J. Heriot
Retained perfluoro-carbon liquid droplets remain a frustrating post-operative complication in
a small group of patients.
Management of this complication is dependent on the location of the droplets: only subfoveal
droplets are visually significant and should be removed.
A study of the risk factors for retained PFCL (1) assessed 72 cases and found submacular
droplets in 11.1% of eyes. There was no difference between perfluorodecalin and perfluoro
n-octane. The most significantly associated risk factor was the presence of a large peripheral
retinotomy (all cases had retinotomy of 120° or larger). Subretinal PFCL was found in 40% of
eyes with a 360° retinotomy. Small and medium-sized retinal breaks were not associated with
PFCL retention. BSS rinse during fluid-air exchange correlated significantly with subretinal
PFCL- only 1 of 23 eyes that were rinsed had subretinal PFCL, although many had large
retinotomies. The presence of subretinal PFCL does not seem to affect visual outcome nor
the anatomical success when located outside the macula.
Two main approaches have been reported: aspiration of the droplet or displacement within a
localised detachment. Aspiration of the droplet can be performed directly thru a microcanula
(2) or following BSS injection to create a subretinal fluid bleb. Alternatively, simply creating a
BSS bleb that facilitates inferior displacement of the droplet is also successful.
3 illustrative cases will be discussed.
(1) Garcia-Valenzuela, Ito, Abrams. Retina 2004 24: 746.
(2) Garcia-Arumi et al. BJO 2008 92:1693-4
23

Subretinal PFCL – what to do ?
Jerzy Mackiewicz
Department of Ophthalmology, Medical University of Lublin, Poland
Insufficient release of retinal traction or misdirected injection of preretinal PFCL into a retinal
break can result in intraoperative subretinal PFCL. It is not very rare complication of
vitreoretinal surgery and postoperative retention of subretinal PFCL occurs, according to the
literature, in up to 17% of cases.
Author discussed different cases of subretinal PFCL from his own practice. Small
extramacular bubbles of subretinal PFCL have not been removed and during follow up did
not affect retinal function. In cases of PFCL location very close to the fovea, repeat vitrectomy
with small retinotomy and drainage was performed. Clinical pictures, OCT scans and follow
up will be presented.
24

An Eyeful of Sand - an alternative heavy tamponade
M.J,Day, M.J.Garvey, T. Stappler, R.L.Williams and D. Wong
Silicone oil was first introduced as a possible tamponade agent in 1958. It fulfils many of the
requirements of a tamponade agent. It is highly hydrophobic and therefore forms an interface
with aqueous and the hydrophilic retina. Its specific gravity is slightly lower than water (0.98)
and therefore it floats on top of the remaining aqueous but only low buoyancy forces apply,
and so it is effective for treating retinal tears in the superior section of the vitreous cavity. Its
viscosity can be varied by controlling the molecular weight.
In a number of projects we have closely investigated the behaviour of silicone oil using an in
vitro eye model which has been effective at demonstrating how the specific gravity of
tamponade agents controls their behaviour. This has been instrumental in the development of
a tamponade agent called Densiron which consists of a mixture of silicone oil with higher
density perfluorohexyloctane. There are some concerns, however, over the long term stability
of this tamponade agent and its increased tendency to emulsify in the eye. Hence, a clinical
need exists for an alternative heavy tamponade.
The current project builds on this background expertise. In order to increase the specific
gravity of existing tamponade agents it is necessary to add a material of higher density. Since
the addition of low molecular weight polymers with a different chemistry is undesirable,
colloidal or nanoparticulate silica was identified as an additive which would not only increase
the density but also, if finely dispersed, would not increase the optical turbidity. Alternatively,
to ensure the maintenance of optical clarity the refractive index of the silicone fluid
(polydimethylsiloxane) could be adjusted to match that of the silica by the addition of
polydiphenylsiloxane.
Our current prototype is a dispersion of 11% nanoparticle silica in poly phenylmethylsiloxane
with has a viscosity of 2000 mPa.s and a specific gravity of 1.11. The dispersion is noncytotoxic
and currently undergoing animal testing.
25

Combined Phacoemulsification and heavy oil removal.
David Steel, Sunderland Eye Infirmary, UK
Combined phaco and standard silicone oil removal is a widely adopted and successful
technique avoiding the need and morbidity of sclerostomy creation. Two modifications of the
technique to allow safe and efficient heavy oil removal will be described - one using an
angled cannula with translceral illumination to allow endoviewing during oil removal and one
using a short wide bore cannula without endoviewing. Potential pitfalls and tips for success
will be discussed.
26

Short term tamponade using perfluorcarbon in the treatment of giant
retinal tears.
Andrew Chang
PhD FRANZCO FRACS
Vitreoretinal Unit
Sydney Eye Hospital
This paper will report and describe our experience with short term heavy liquid tamponade in
the treatment of giant retinal tears. At the Sydney Eye Hospital, the standard technique for
the repair of these detachments involves short term heavy liquid tamponade.
A retrospective series of 62 eyes is presented.
Aim: To determine the efficacy and safety of perfluorocarbon liquid as a short term
postoperative tamponade in patients with retinal detachment from giant retinal tears. Method:
A retrospective consecutive case series of patients with retinal detachment from giant retinal
tears who underwent vitrectomy using perfluorocarbon liquid as a short term postoperative
internal tamponade. The perfluorocarbon liquid was removed 5–14 days (mean 7.5 days)
later and replaced by gas or silicone oil. Scleral buckling was performed in some cases with
proliferative vitreoretinopathy. The crystalline lens was removed if there was interference with
the surgical view or if it was subluxated. The success rate of retinal reattachment, visual
outcome, and postoperative complications were assessed.
Results: A total of 62 eyes of 61 patients with a follow up of 8–69 months (mean 24.5
months) were included. All retinas were attached intraoperatively. 14 eyes (22.6%) developed
re-detachment and additional operations were performed in 13 eyes. At final visit, 58 eyes
(93.5%) had retinas that remained attached with visual acuity 6/12 or better in 27 eyes
(46.5%). The visual acuity improved in 34 eyes (54.8%) with 28 eyes (45.2%) improving at
least two Snellen lines, it was unchanged in 20 eyes (32.3%), and was worse in eight eyes
(12.9%). Three patients developed glaucoma that was controlled medically. There was no
retained perfluorocarbon liquid in any eyes.
Conclusion: Perfluorocarbon liquid appears safe and effective to use as a short term
postoperative tamponade in management of retinal detachment from giant retinal tears.
However In the past 12 months we have encountered a more intense inflammatory reaction
in 2 patients. Keratic precipitates and preretinal deposits developed over the period in which
the heavy liquid is retained in the eye. Following removal of the heavy liquid the inflammatory
reaction rapidly resolved.
27

The use of viscoelastics in vitreoretinal surgery
Carlos Mateo M.D.
Perfluorocarbon liquids were described for its ophthalmological use as a manipulator during
vitreoretinal surgery in nineteen eighty seven by Stanley Chang .
The main characteristics of these Newtonian compounds are
Low viscosity :from 0.8 to 8 Centistokes at 25° C
They are clear
Specific gravity higher than saline
In early seventies Balazs suggested Sodium Hyaluronate as a substitute for vitreous .This
compound has been commonly used in the anterior segment surgery , and also to manage
the anterior chamber during vitreoretinal surgery ,to open and maintain the pupil ...or for
example to help to stabilize a strange foreign body in the anterior chamber....
Sodium hyaluronate (1%; Healon) has the most favorable viscoelastic properties.
Its molecular weight is nearly 4 million daltons
These compounds are Non Newtonian fluids with pseudoplasticity
Shearing occurs when fluid is made to flow. At zero shear rate (steady state) they exhibit high
viscocity , 400.000Cks whereas at high shear rates their viscocity decreases near to 110
centistokes.
This behaviour allows the material to be injected through small gauge cannula and yet
ensures that the material will regain its shape , and they are cohessive , maintain spaces and
permit easy aspiration .
All these differences make viscoelastics , the material of choice to “open the Retinal
Balloon”in severe traumatized eyes where the funnel shape of the retinal detachment
prevents enough visualization of the posterior retina and in some special PVR cases with
posterior breaks.
In this presentation we show how to deal with these severe cases using viscoelastics..
28

An Outbreak of Sticky Oil
Marc Veckeneer
"The laws of physics predict that removal of a silicone oil bubble form inside a water filled
sphere with a hydrophilic surface should be straightforward.
However, upset and mayhem can occur when the SiO turns into glue. Interactions with
perfluorocabon liquids and other surface modifying agents can alter the surface energy of the
bubble thereby increasing adherence to the retina and resistance to aspiration."
29

Hydraulic Jump to Heavy Oil – No Need for Heavy Liquids
Thomas Theelen, Maurits A.D. Tilanus, and B. Jeroen Klevering
Background
Perfluorocarbon liquids (PFCL) are frequently used to reattach the retina in vitrectomy for
retinal detachment (RD). However, retained PFCL bubbles may cause visual disturbance and
can be the source of permanent visual loss if displaced subfoveal. Hydraulic jump is a
physical phenomenon causing fluid movement against gravity by sudden change of fluid
speed, which can be used to remove subretinal fluid.
Patients and Methods
Consecutive RD cases treated with heavy silicone oil (HSO; Densiron 68®) tamponade for
inferior retinal tears, retinotomy, or PVR, between January 2007 and December 2008 were
retrospectively studied. During pars plana vitrectomy the retina was reattached by the
hydraulic jump technique (HYD; study group) or by PFCL (controls).
Results
A total of 237 eyes (64 cases, 173 controls) were studied. Mean duration of tamponade was
9 and 10 weeks in HYD and PFCL, respectively. Mean duration of surgery was 34 minutes in
HYD and 53 minutes in PFCL. There were somewhat more eyes with retinal traction due to
PVR C in the HYD group than in the PFCL group (54.6% vs. 41.0%, respectively).
Accordingly, primary success rates were 53% and 61% in the HYD and PFCL group,
respectively. After a maximum of two surgeries, final reattachment of the retinal was reached
in 86% of the HYD and in 84% of the PFCL group.
Conclusion
Reattaching the retina in complicated RD cases by hydraulic jump appears equal to PFCL
use in terms of surgical success. By this technique, retained PFCL bubbles can be avoided
and surgery may become faster and less expensive without sacrifying safety.
30

COMBINATION OF TAMPONADE
Stefano Zenoni, Natalia Comi, Piero Fontana
Divisione Oculistica
Azienda Ospedaliera “Ospedali Riuniti di Bergamo”
Bergamo- Italy
Introduction: primary and secondary proliferative vitreoretinopathy (PVR) is a dynamic
biological phenomenon for which drugs of sure efficacy do not exist at present. Vitreous
substitutes are used as stabilising substances that should limit the effects of proliferation and
the consequent retinal detachment. Double filling (DF) has been previously experienced with
combinations of silicone oil (PDMS) and perfluorocarbonades (PFCL), PDMS and
fluorosilicone, PDMS and perfluorohexiyloctane (F6H8), PDMS and perfluorooctane (HPF8). In
selected cases of retinal detachment (RD) with high degree PVR we used a mixture of 70%
heavy silicone oil (Densiron) and 30% PDMS as temporary vitreous substitute after pars plana
vitrectomy (PPV). This in order to tamponade inferior and superior retinal breaks for the first
seven days and to fill completely the vitreous cavity, reducing compartimentalisation. The aim
of this presentation is to test the stability of this DF mixture and to evaluate its clinical efficacy.
Methods: two laboratory tests were performed. In the first one we evaluated the properties of
the mixture and the interface presence between the two substances, in the second one we
evaluated the interface persistence between the two tamponades after shaking. For the
laboratory tests, the silicone oil was coloured for better visualisation.
Fifty consecutive eyes of fifty patients affected by complicated RD with retinal breaks of the
superior and inferior quadrants associated with high degree PVR underwent PPV, retinal
reattachment, membrane peeling and a combined internal tamponade with 70% Densiron
and 30% PDMS. The DF was removed after an average of 55 days (range 45

Thermosensitive polymers as vitreous substitute
Wilfried Kugler, Fluoron GmbH, 89077 Ulm, Germany
For a long time ophthalmologists are searching for a biocompatible and bioactive vitreous
substitute to improve post-operative treatment in vitreoretinal surgery.
Aim of our joint project is the development and preparation of biocompatible, thermosensitive
hydrogels. The hydrogel is liquid at room temperature and can be injected using conventional
needles and syringes. As the hydrogel warms to body temperature it gelatinises and unfolds
its endotamponade effect. By-and-by it is metabolized. In a first approach we want to link
thermo-responsive block co-polymers to a biopolymer, hyaluronic acid. Important material
properties, among others, should be transparency, stability, as well as a suitable surface
tension and transition temperature. Technical challenges to be solved include sterilisability,
im- and explantability as well as the filling process. The main objective of our work is to
demonstrate that hyaluronic acid-based thermosensitive hydrogels can be utilized as vitreous
substitute.
32

HSO As 1ST Choice In Complicated Retinal Detachment: Checkmate
In Two Moves!
Cesare Forlini MD*, Matteo Forlini MD**, Paolo Rossini MD*
(*) Unit of Ophthalmology “S. Maria delle Croci” Hospital, Ravenna - Italy
(*) Eye Clinic, Univeristy of Modena – Italy
INTRODUCTION: Silicone oil is a vitreous substitute used routinely during vitreo-retinal
surgery as a tamponade during retinal detachment (R.D.) treatment, complicated by vitreoretinal
proliferation (PVR). Such substance, due to its specific weight lower than 1, if used in a
aqueous ambient, tends to float over the the water’s surface. This intrinsic property
represents an advantage, in vitreo-retinal surgery, as it allows the silicone bubble to
tamponade the retinal break present in the superior retina, for a large lapse of time, using
therefore silicon oil as an alternative to the shor-medium term tamponading mixture air & gas.
In the other hand, in presence of pathological situations that include central and inferior retinal
sectors, tamponading action with the mentioned agent is notably lower to patients in clino/
orthostatic posture.
In fact, for that purpose it is well known in cases of complicated R.D. (non recent R.D., posttraumatic,
associated to PDR), the risk to develop PVR in the “dead space” is present where
an aqueous film between the silicon oil bubble’s margin and the retinal surface. In this space
accumulate pigmented epithelia cells that trigger from inside the under - epiretinal
proliferation action.
As the use of standard silicone oil (1000-5000 centistokes) demonstrated such phenomena is
generally located at the inferior sectors, because of the above mentioned oil’s own physic
property of “floating” (fig. 1).
Trying to overcome on such inconvenient, there have been used several procedures to obtain
an adequate tamponade action on the inferior retina.
At first only with liquid perfluorocarbon (PFCL, F6H8), later on with double tamponade (PFCL/
F6H8-silicone oil) an finally with the last generation of heavy silicon oil (HSO), to fight back the
proliferation in the inferior sectors, cause of recurrence and therefore surgery’s fail.
Actually we can count on several ways to treat superior retinal breaks (air, gas, silicon oil).
Unfortunately all these having a specific weight C3)
were trated with heavy silicon oil (Densiron 68, Fluoron).
33

Surgical Technique: 23 gauge transconjunctival vitrectomy (Alcon Accurus 2500, Dorc
Associate 2500) with te use of Xenon chandelier light system (Dorc Brightstar, Synergetics
Photon 2) positioned at 12 o’clock or at 6, depending on the case; all phakic patients
become pseudophakic, to be able to access easily to the extreme retinal periphery. Assisted
triamcinolone vitrectomy with accurate shaving of the vitreous base; peeling of eventual
epiretinal and subretinal membranes (if present) with bimanual technique with the help of a
chandelier light illumination source.
For all patients, routinely we perform an ILM peeling, prior staining (in fluid or PFCL) with ICG
or Brilliant Peel; use of endolaser on present break(s) and at 360°; direct PFCL-HSO
exchange or prior air exchange. All scleral-accesses are always sutured at the end of the
operation, with transconjuntival 7/8-0 suture.
HSO is maintained within a period among 60 and 90 days. The removal is performed through
the active aspiration (vacuum 500-600 mmHg) with 20 or 23 gauge transconjuntival system
(fig.4). A very meticulous control to the retinal periphery is done, and epiretinal membrane
peeling if present, always using illumination source with chandelier system.
RESULTS: Recurrence at the superior retina was present in 7 cases (30%) between 9 and 3
o’clock, at the moment of the second procedure performed among 60-90 days from the first
operation. In 3 cases it was used 1000 cs oil, in 4 cases gas mix (C2F6 15%). Of the 3 cases
were tamponade with 1000cs oil 2 cases had to be reoperated with the use of 1000 cs oil.
4 cases are highlighted of essudation in anterior chamber over the anterior and posterior
surface of the IOL, associated to increase of intraocular pressure, all well controlled with
medical therapy.
CONCLUSIONS: The choice of HSO Densiron 68, associated to the ILM routine peeling, has
avoided R.D. recurrence episodes or PVR at inferior sectors and at the posterior pole (in any
case, no macular secondary pucker was encountered). HSO does not oblige the patient to
uncomfortable posing.
All cases of PVR were reallocated to the superior emiretina (9/3 o’clock). In R.D. recurrence
cases, it was possible to operate with diversified solutions with silicone oil and gas mixture,
always on patient’s behalf.
The surgical strategy has allowed to reduce further operations with reallocating critic area to
superior sectors and to manage recurrence more easily (using different tamponade
substances) and interrupting the multiple inferior recurrence chain.
Due to our experience, it is absolutely important to check out some solutions during the
surgical phase of the primary vitrectomy as follows:
allocating service sclerotomies close to horizontal meridians, to facilitate operation at the
superior sectors.
Use an independent chandelier light system to execute bimanual manoeuvre and an accurate
shaving of the vitreous base and peripheral retinopexy.
ILM peeling using vital dyes with the help of PFCL if a R.D. is present
Anterior segment complications observed were always treated with medical therapy and we
never need to remove the HSO before the scheduled time.
Finally, the strategy of using HSO as first choice in case of complicated R.D. allows to ensure
the anatomical and functional success in two passages: checkmate in two moves!
Images.
34

Fig. 1: scheme of the “dead space” localized in the inferior quadrants developed with
standard silicone oil endo-tamponade.
Fig. 2: scheme of the “dead space” localized in the superior quadrants developed with HSO
endo-tamponade.
Fig. 3: HSO active aspiration with 23 gauge cannula.
Fig. 4: epiretinal membrane developed in the superior nasal sector after HSO tamponade in a
post-traumatic case
35