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| CASE REPORT |
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| Year : 2023 | Volume
: 16
| Issue : 1 | Page : 110-112 |
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Pupillary block glaucoma due to anterior migration of nonemulsified silicone oil in a phakic patient: A case report and review of literature
Shihab Hilal Al-Habsi1, Mohamed S Al-Abri2
1 Oman Specialty Board, Muscat, Oman
2 Department of Ophthalmology, Sultan Qaboos University Hospital, Muscat, Oman
| Date of Submission | 06-Apr-2022 |
| Date of Decision | 16-Dec-2022 |
| Date of Acceptance | 17-Dec-2022 |
| Date of Web Publication | 21-Feb-2023 |
Correspondence Address:
Shihab Hilal Al-Habsi
Oman Specialty Board, Muscat
Oman
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ojo.ojo_92_22
 Abstract | | |
This report describes a case of acute pupillary block glaucoma related to migration of nonemulsified silicone oil into the anterior chamber (AC) in a young phakic patient. A 24-year-old male diabetic patient underwent uneventful left eye pars plana vitrectomy (PPV) with silicon oil endotamponade for diabetic macula-off tractional retinal detachment. Two weeks after discharge, he presented with severe left eye pain. Examination revealed hand motion vision, high intraocular pressure (IOP) of 67 mmHg with ciliary injection, corneal edema, and two large nonemulsified silicone oil bubbles in the AC at the pupillary margin. Medical management with topical antiglaucoma medications (AGMs) and intravenous acetazolamide and mannitol failed to reduce the IOP. The patient underwent left eye PPV, silicone oil removal, and AC wash. IOP was eventually controlled after the operation without AGM. Pupillary block glaucoma after silicone oil injection is well recognized in aphakic patients, but ophthalmologists should be aware that it can occur in phakic and pseudophakic patients, particularly in complicated cases and patients with a weakness of the iris–lens diaphragm.
Keywords: Anterior migration, glaucoma, phakic, pupillary block, silicon oil
How to cite this article:
Al-Habsi SH, Al-Abri MS. Pupillary block glaucoma due to anterior migration of nonemulsified silicone oil in a phakic patient: A case report and review of literature. Oman J Ophthalmol 2023;16:110-2 |
How to cite this URL:
Al-Habsi SH, Al-Abri MS. Pupillary block glaucoma due to anterior migration of nonemulsified silicone oil in a phakic patient: A case report and review of literature. Oman J Ophthalmol [serial online] 2023 [cited 2023 Mar 26];16:110-2. Available from: https://www.ojoonline.org/text.asp?2023/16/1/110/370066 |
| Introduction | |  |
Silicone oil is widely used in vitreoretinal surgery. It creates an effective endotamponade in patients with complex retinal detachments involving proliferative vitreoretinopathy, advanced diabetic retinopathy, and giant retinal tears.[1] Silicone oil-mediated pupillary blocks were common complications in aphakic eyes until the introduction of inferior peripheral iridotomy (IPI), which is a standard practice in aphakic eyes undergoing vitrectomy with silicone oil injection.[2],[3] Anterior migration of nonemulsified silicone oil in patients with natural crystalline lens is rare. In this report, we demonstrate an acute pupillary block glaucoma related to migration of nonemulsified silicone oil into the anterior chamber (AC) in a phakic patient.
| Case Report | | |
A 24-year-old male diabetic patient underwent uneventful left eye pars plana vitrectomy (PPV) with injection of silicon oil (5000 centistoke) for diabetic macula-off tractional retinal detachment. IPI was not performed since the crystalline lens was clear and not removed. Postoperatively, the AC was deep and there were no signs of pseudoexfoliation (PEX), lens dislocation, zonular defects, or silicone oil migration.
Two weeks after discharge, the patient presented to the emergency department with severe left eye pain associated with headache, nausea, and vomiting. Left eye examination showed Hand motion vision, a high intraocular pressure (IOP) of 67 mmHg with ciliary injection, corneal edema, two large nonemulsified silicone oil bubbles in the AC at the pupillary margin [Figure 1], a mid-dilated nonreactive pupil, and a clear crystalline lens but no fundus view. Medical management with topical antiglaucoma medications and intravenous acetazolamide and mannitol failed to reduce the IOP. Nd: YAG laser peripheral iridotomy (PI) could not be done as the patient had diabetic ketoacidosis at the time of presentation due to excessive vomiting and could not be seated for YAG laser. The patient was taken to the operation room for left eye PPV, silicone oil removal, and AC wash. Day one postoperation, the patient had no pain, cornea was clear, IOP was 9 mmHg, vision was unchanged, and the retina was attached. IOP continued to be controlled for 2 months; however, the patient developed neovascular glaucoma due to uncontrolled diabetes and his vision eventually dropped to no light perception. | Figure 1: Anterior segment photo of left eye showing two nonemulsified silicone oil bubbles in the AC at the pupillary margin. AC: Anterior chamber
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| Discussion | | |
Silicone oil biocompatibility relies on aqueous occupying the AC, preventing corneal endothelial toxicity and glaucoma. The integrity of the zonular/capsular bag complex and high surface tension of silicone oil prevents its anterior migration, independent of posture.[4]
Glaucoma can develop after intravitreal injection of silicon oil secondary to pupillary block, inflammation, synechial angle closure, rubeosis iridis, or migration of emulsified or nonemulsified silicone oil into the AC.[2] Silicone oil-mediated pupillary block is a rare complication in aphakic eyes since Ando introduced the IPI.[3] The incidence of pupillary block glaucoma is reported to occur in 0.9% in all silicone oil-filled eyes.[5],[6],[7] In phakic eyes, an IPI is usually not necessary, because the zonule–lens barrier does not allow silicone oil migration from the posterior into the AC inducing a pupillary block. The first published case of a pupillary block glaucoma in a phakic eye with silicone oil implantation was due to zonulysis.[4] Such changes are usually seen after trauma, previous surgeries, or PEX. Jackson et al. reported silicon-mediated pupillary block glaucoma in seven phakic patients.[8] In this case series, the observed abnormality of the lens–zonule complex were; phacodenesis, zonulysis, ocular trauma, stickler syndrome and forward displacement of cataractous lens. Four patients treated with Nd:YAG PI and all of the seven patients end up with silicon oil removal.
The potential cause of oil migration in our patient is subclinically weak zonules since he did not have any of the risk factors stated above.
Immediate medical reduction of IOP with systemic and topical IOP-lowering medications is required. Face-down posturing may be attempted to repatriate dependent aqueous into the AC but cannot be sustained. Definitive management involves inferior laser PI, surgical iridectomy, or silicone oil removal.[9]
In summary, pupillary block glaucoma after silicone oil injection is well recognized in aphakic patients, but ophthalmologists should be aware that it can occur in phakic and pseudophakic patients, particularly in complicated cases with possible weakness of the iris–lens diaphragm. Inferior laser PI should be attempted as initial management steps as soon as the patient is stable enough to such procedure. Prophylactic surgical PI at the time of PPV and use of silicon oil is recommended for all aphakic eyes and some pseudophakic eyes with capsular defects or disrupted lens–zonules.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Beekhuis WH, Ando F, Zivojnović R, Mertens DA, Peperkamp E. Basal iridectomy at 6 o'clock in the aphakic eye treated with silicone oil: Prevention of keratopathy and secondary glaucoma. Br J Ophthalmol 1987;71:197-200.  |
| 2. | Gedde SJ. Management of glaucoma after retinal detachment surgery. Curr Opin Ophthalmol 2002;13:103-9. |
| 3. | Ando F. Intraocular hypertension resulting from pupillary block by silicone oil. Am J Ophthalmol 1985;99:87-8. |
| 4. | Zborowski-Gutman L, Treister G, Naveh N, Chen V, Blumenthal M. Acute glaucoma following vitrectomy and silicone oil injection. Br J Ophthalmol 1987;71:903-6. |
| 5. | Han DP, Lewis H, Lambrou FH Jr., Mieler WF, Hartz A. Mechanisms of intraocular pressure elevation after pars plana vitrectomy. Ophthalmology 1989;96:1357-62. |
| 6. | Branisteanu DC, Moraru AD, Maranduca MA, Branisteanu DE, Stoleriu G, Branisteanu CI, et al. Intraocular pressure changes during and after silicone oil endotamponade (Review). Exp Ther Med 2020;20:204. |
| 7. | Bhoot M, Agarwal A, Dubey S, Pegu J, Gandhi M. Silicone oil induced glaucoma. The Official Scientific Journal of Delhi Ophthalmological Society 2018;29:9-13. |
| 8. | Jackson TL, Thiagarajan M, Murthy R, Snead MP, Wong D, Williamson TH. Pupil block glaucoma in phakic and pseudophakic patients after vitrectomy with silicone oil injection. Am J Ophthalmol 2001;132:414-6. |
| 9. | Yusuf IH, Fung TH, Salmon JF, Patel CK. Silicone oil pupil block glaucoma in a pseudophakic eye. BMJ Case Rep 2014;2014:bcr-2014-205018. |
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