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Clinical & Refractive Optometry is pleased to present this continuing education (CE) article by Dr. Tam Nguyen et al entitled Hyperoleon: Complications of Silicone Oil in Reparative Retinal Surgery . In order to obtain a 1-hour Council of Optometric Practitioner Education (COPE) approved CE credit, please refer to page 152 for complete instructions.

Hyperoleon: Complications of Silicone Oil Many advances have further expanded the repertoire of in Reparative Retinal Surgery treatment modalities such as the introduction of vitreous 1 Tam Nguyen, OD, MS, FAAO; Nancy N. Wong, OD, PhD, FAAO; substitutes as long-acting gases and the use of silicone oil 2 Terry Luk, OD, FAAO; David M. Galeoto, OD, FAAO; in vitreous surgery. In particular, silicone oil has been 2,3 Karen Wadhams, OD, FAAO used with increasing frequency. However, the adminis - tration of silicone oil is not devoid of side effects or the potential for complications. Moreover, complications ABSTRACT have been well-documented in the literature and include Silicone oil injection is associated with many post- elevated intraocular pressure, refractive change, operative complications in the eye. The emulsification formation, 4 emulsification of oil, silicone oil keratopathy, and forward migration of silicone oil into the anterior peri-oil fibrosis, 4 re-detachment of the 4 as well as chamber is regarded as an invariable phenomenon that the development of secondary . 5-7 will eventually occur following a given in situ period. Silicone (polymethysiloxane) oil is often used as an Emulsification of silicone oil can manifest as an intraocular retinal tamponade following reparative retinal “inverted hypopyon” or “hyperoleon,” filling up space detachment surgery. For intraocular applications, silicone in the superior portion of the anterior chamber. This oil demonstrates a low density when compared with can cause damage to a variety of structures, posing aqueous. The density disparity easily displaces aqueous potential sight-threatening implications for patients. It downward. Silicone oil has the advantage of being is imperative for the clinician to be familiar with these optically transparent, allowing for visualization of the potential complications so that timely identification posterior segment surgical fields. Often, silicone is selected and proper management can be initiated. over gas for complicated cases because silicone provides Treatment modalities for secondary glaucoma permanent or extended retinal tamponade and is not include conventional topical glaucoma therapies, absorbed by ocular tissues like the long-acting gases. silicone oil removal (SOR), inferior peripheral iridec - Currently, indications for the use of silicone oil in the tomy, and glaucoma surgeries for the control of IOP. eye include: internal tamponade in giant retinal tears, In general, treatment and management is case-specific and risk factors need to be modified according to tamponade in traumatic or complex retinal detachments, individual clinical presentation. dissection of epiretinal membranes with flattening of the retina, macular holes, and closure of breaks which are complicated by proliferative diabetic 4 and INTRODUCTION proliferative vitreoretinopathy. 4 The advent of vitreoretinal surgical techniques in the past The intraocular use of silicone oil may result in 30 years has dramatically altered the management of adverse complications to multiple structures in the eye. At retinal conditions such as macular and retinal holes or the posterior surface, silicone oil migration into subretinal tears, epiretinal membranes and retinal detachments. spaces has been shown to occur in the presence of breaks in the retina. 8 In addition, peri-oil fibrosis can occur at the T. Nguyen — VA Connecticut Healthcare System, West Haven Campus, pre-retinal surface resulting in adherent membranes 4 that West Haven, CT; N.N. Wong — VA Hudson Valley Healthcare System, pose potential threats for . Pupillary Wappingers Falls, NY; T. Luk — James J. Peters VA Medical Center, block or bombé can occur if the silicone oil advances Bronx, NY; D.M. Galeoto — James J. Peters VA Medical Center, Bronx, forward towards the anterior segment. Contact between NY; K. Wadhams — VA Portland Healthcare System, Portland, OR Correspondence to: Dr. Tam Nguyen, VA Connecticut Healthcare System, the oil and the lenticular structures may result in refractive 8 West Haven Campus 950 Campbell Ave. Building 2, Floor 4, West Haven, error shifts and induce cataract formation. Further migra - CT 06516; E-mail: [email protected] and [email protected] tion anteriorly may cause interference with the outflow This article has been peer reviewed. processes of the eye causing elevation in intraocular

146 Clinical and Refractive Optometry 27:4, 2016 tensions. 9,10 If silicone oil remains in direct contact with grade 2 relative afferent pupillary defect OS was again noted the trabecular meshwork, ultra-structural damage may on examination. were unrestricted occur 9,10 which may further reduce outflow. Silicone oil in all fields of gaze and cover testing demonstrated contact with the corneal endothelium causes a characteristic orthophoria at distance and a slight at near. On keratopathy 9,11-13 resembling . The use of external examination, there was an OS upper lid silicone oil in the eye may result in multiple iatrogenic which impinged on the visual axis. Palpebral apertures complications which may be sight-threatening. With were 11 mm on the right and 5 mm on the left. Anterior the increased application of silicone oil in retinal repair segment evaluation by slit lamp biomicroscopy was surgeries, recognition of the postoperative complications remarkable for mild endothelial guttatta, stromal scarring represents significant clinical importance in the manage - OD>OS and inferior punctuate epithelial erosions ment of retinal diseases. These complications are unique OD>OS. Temporal endothelial incision scars were visual - to its use and often present a straightforward clinical ized in the peripheral of the left eye. The bulbar profile. In patients with a history of vitreoretinal surgery and palpebral were quiet OD and trace peri- with silicone oil administration, proper assessment of limbal injection was observed in the OS. Further examina - postoperative complications with sight-threatening effects tion of the iris OS demonstrated tiny crystalline-like is important for disease co-management. structures localized to the crypts of the iris furrows. An opaque crystalline-substance occupied the top half CASE REPORT of the anterior chamber. A demarcation line was evident A 51-year-old African-American male presented to the 3.5 mm from the superior-most cornea in the left eye. The Eye Clinic with complaints of a mild, dull, periorbital demarcation line in the anterior chamber separated the ache and pain in the left eye. The pain was graded as a 4 on white crystalline opacity superiorly from the clear aqueous a scale of 10. The intermittent pain had been ongoing for fluid inferiorly. Applanation tonometry was OD: 20 and OS: the past several weeks. The patient also had complaints of 38 mmHg. The anterior chamber appeared clear without subsequent decreased vision in the left eye. He reported cells or flare. In both eyes, angle estimation demonstrated that he felt the reduced vision correlated temporally to grade 4 open angles by Van Herick technique. Gonio- when his antihypertension medications were taken. The scopy of the left eye demonstrated open angles to ciliary patient denied symptoms of , photopsia, body band in all quadrants except the superior portion where headache, and discharge. His last eye exam was approxi - a thick, white, crystalline substance filled the angle. Intra- mately 3 months prior. Moreover, the patient had been ocular pressure (IOP) OS was reduced to 27 mmHg receiving ongoing care over the course of three years and following in-office topical instillation of brimonidine was co-managed by a local, private retina specialist for an 0.2% and timolol maleate 0.5%. inferior retinal detachment secondary to lattice degenera - The dilated fundus examination revealed trace tion. The patient’s ocular history was significant for retinal nuclear sclerotic and cortical in the right eye. reparative surgery including pneumatic retinopexy, The posterior chamber intraocular implant in the left scleral buckling, pars plana with silicone eye was centered and clear of opacities. The vitreous in substitution, phaco-extracapsular cataract extraction, and the right eye was unremarkable. Silicone oil was evident YAG capsulotomy in the left eye. Following reparative in the hyaloid space of the left eye. Fundus assessment retinal surgery, the left eye had developed cystoid macular revealed healthy optic nerves with a cup-to-disc ratio of edema resulting in subsequent poor vision. Despite 0.5 in both eyes. The neuroretinal rim was healthy and prompt treatment, visual acuity was never fully restored to intact in the right eye. Pallor and peripapillary atrophy better than counting fingers. The patient’s medical history was noticed in the left eye. The macula was clear and flat was significant for type 2 diabetes mellitus, hypertension in both eyes. The left eye demonstrated a foveal reflex. All and benign prostrate hypertrophy, all of which were vasculature was normal for course and caliber OU. The controlled with oral medical therapy. The patient’s blood left eye demonstrated an inferior scleral buckle with an pressure measured 115/83 mmHg. Review of laboratory old hilar-shaped demarcation line that terminated 4 disc findings indicated a glycosylated hemoglobin level of diameters from the macula. Extensive overlying retinal 7.8%, and a fasting blood glucose level of 117 mg/dL. The pigment epithelial hyperplasia and disruption were patient denied any history of allergies and was alert and noticed along the demarcation line. The peripheral retina oriented to time, person and place. was flat and intact in both eyes. On clinical examination, the patient’s visual acuity The patient was diagnosed with hyperoleon or emul - was 6/6- (20/20-) and counting fingers at 5 feet with sified silicone migration into the anterior chamber best spectacle correction of -4.50 -1.50 x 077 and -3.00 resulting in subsequent elevation of intraocular pressure -1.50 x 071 for the right and left eyes, respectively. in the left eye. The patient was referred back for retinology The patient’s visual acuity was unchanged with pinhole. A evaluation. Retinology evaluation was elicited to consider

Hyperoleon: Complications of Silicone Oil in Reparative Retinal Surgery — Nguyen 147 and left eyes, respectively. No silicone oil was evident in the anterior and posterior chamber of the left eye. The patient was instructed to taper the topical steroid drops, and complete the antibiotic and non-steroidal anti-inflammatory drops for a 13-day course. He was maintained on the topical beta-blocker to control IOP. Follow-up #2 A follow-up examination was performed one month following surgical silicone oil removal. The patient reported resolution of the aching sensation in the left eye and maintenance of stable vision. The patient confirmed compliance with timolol maleate 0.5% ophthalmic Fig. 1 Inverted or reverse hypopyon as a result of emulsification into the solution. Visual acuities remained stable at 6/6- (20/20-) anterior chamber. Migration of silicone oil into the anterior chamber and counting fingers at 5 feet, in the right and left eyes, displaces aqueous inferiorly and results in a density gradient demarcation respectively. The intraocular pressures were 19 mmHg line. (This image was originally published in the ASRS Retina Image Bank. OD and 28 mmHg OS. No silicone oil was evident in the Michael Lambert, MD. Inverted Hypopyon – Silicone Oil Complication. Retina Image Bank, 2016, Image Number 24099. © The American anterior or posterior chamber of the left eye. Society of Retina Specialists.) The patient was maintained on timolol maleate 0.5% b.i.d. OS for the control of pressure. Follow-up manage - ment included continued observation of glaucoma status.

DISCUSSION The term “emulsification” refers to the breaking up of the risks, benefits and alternatives of either partial silicone silicone into small intraocular fragments. The incidence of oil removal from the anterior chamber or complete intra- emulsification into the anterior chamber has been reported ocular silicone oil extraction. The patient was maintained from as low as 0.7% 9 to as high as 56%. 4 Emulsification on timolol maleate 0.5% in the left eye to control intra- and migration of silicone oil into the anterior chamber ocular pressure. displaces aqueous inferiorly and results in a density At the retinal evaluation, the patient was counselled on gradient demarcation line. The characteristic appearance risks and benefits of further surgical procedures for silicone has also been termed “inverted” or “reverse hypopyon” or oil removal. The patient elected to undergo complete “hyperoleon” (Fig. 1). Discrepancies exist in the literature silicone oil removal. Silicone oil removal from the posterior as to whether or not the presence of silicone in the anterior cavity was completed via vacuum pump. The remaining chamber is directly responsible for elevated ocular silicone oil in the anterior chamber was removed by para - tension. The emulsification of silicone with subsequent centesis and sodium hyaluronate. A washout procedure for migration into the anterior chamber is a rare complication the anterior chamber was also performed. The patient under - in phakic or pseudophakic eyes. 2,14-16 The natural or went the operative procedure without complications. pseudophakic lens acts as a barrier to prevent migration 16,17 of the silicone oil into the anterior chamber. The incidence Follow-up #1 of migration is much higher in aphakes. 15 The current case A follow-up examination was performed one day following represents an uncommon complication of emulsification surgical silicone oil removal surgery. The patient reported with migration of silicone into the anterior chamber despite post-surgical soreness but denied pain or photophobia. the presence of a pseudophakic implant. Alternative theories Postoperative medications included: moxifloxacin 0.5% suggest partial zonulysis following extracapsular cataract (Viagamox ®, Alcon Canada, Mississauga, ON), pred - extraction enabling the oil to migrate around the implanted nisolone 1% (Pred Forte ®, Allergan Canada, Unionville, lens. 15,16 In the current case, the surgical history is positive for ON), and ketorolac tromethamine 0.5% (Acular ®, Allergan extracapsular cataract extraction. The resultant disturbance Canada, Unionville, ON). In addition, the patient was of the lens zonules may have contributed to migration of the maintained on timolol maleate 0.5% (Timoptic ®, Merck emulsified silicone oil into the anterior chamber. Canada, Kirkland, QC) in the left eye to control intra- The incidence of emulsification was thought to ocular pressure. Visual acuities remained stable at 6/6- decrease with the development of higher viscosity oils. (20/20-) and counting fingers at 5 feet, in the right and Lower-viscosity oil had a tendency to emulsify more than left eyes, respectively. Slit lamp biomicroscopy was higher viscosity laboratory grade silicone. 9 Despite new significant for trace diffuse injection in the left eye. The innovations in vitreous substitutes, the problem of emulsifi - ocular tensions were 19 mmHg and 30 mmHg in the right cation has not been eliminated. In particular, for cases in

148 Clinical and Refractive Optometry 27:4, 2016 prevents flow of aqueous into the anterior chamber. Resultant anterior chamber narrowing and elevated intraocular pressure is evident from the misdirection of the aqueous. Pupillary block complications are circum - vented by creation of a peripheral iridectomy (PI) in the inferior position of the iris, which allows for communication between the anterior and posterior chambers (Fig. 2). The incidence of elevated tensions in the aphakic individual immediately following surgery has decreased in patients that have received prophylactic treatment with a PI. Similarly, blockage of the iridectomy by blood, fibrin or oil in the postoperative course may be another mechanism for raised intraocular tensions. In phakic or pseudophakic Fig. 2 Peripheral iridectomy in the inferior position of the iris in order to individuals, the mechanism for acutely elevated IOP is prevent pupillary block. likely to be true overfill with silicone oil. 4 Elevated IOP in such cases typically demonstrates acute onset following surgery. 13 If the intraocular pressure is as a result from true silicone overfill, surgical intervention to remove excess silicone generally has favorable results. 13 which prolonged internal tamponade is desired, 5000 Additionally, raised IOP may be a late-onset complica - centistokes (cs) of highly purified silicone oil is recom - tion. Late-onset elevated pressure is caused by emulsifica - mended. 9 The current patient received 5000 cs silicone tion of silicone, pre-existing glaucoma, steroid induced oil, which is characterized as one of the highest viscosity glaucoma and . 4 Not all patients with a hyperoleon oils currently available for medical use. Despite such have raised IOP. Many risk factors have been identified that precautions, emulsification of silicone still resulted and IOP may predispose the patient to an elevation of IOP following rise was observed. pars plana vitrectomy with silicone oil injection. 5,7,22 In the current case, inverse hypopyon was readily visu - Posner-Schlossman Syndrome generally presents alized when the left was manipulated superiorly. with marked unilateral elevation (40 to 60 mmHg), with However, the emulsification of silicone and the deposition minimal conjunctival injection. This syndrome typically in the anterior chamber can also be subclinical. 4 The droplet presents in young-to-middle-aged patients and is often dimensions are smaller than a wavelength of light, therefore, accompanied with a history of recurrent episodes. In slit lamp biomicroscopy and gonioscopy techniques may addition, this condition is responsive to steroid treatment. not facilitate visualization of the subclinical emulsified A retrobulbar hemorrhage generally appears in patients particles. 4 Ultrasound biomicroscopy, however, has been with an extensive history of recent blunt ocular trauma or shown to be more sensitive than the aforementioned head injury. Accompanying signs on external examination techniques. 18 Emulsification of oil droplets has been would include subconjunctival hemorrhage, occasionally readily identified on ultrasound biomicroscopy as highly chemosis and proptosis of the . In patients with reflective images with a typical morphologic appear - pigmentary glaucoma, a Krukenberg’s spindle may be ance. 15,18,19 Moreover, ultrasound biomicroscopy should be visualized on the cornea, and patients are typically young performed in all cases where emulsification and migration males with intact accommodative systems. With inflam - is suspected and a hyperoleon cannot be visualized. matory open-angle glaucoma, a moderate to severe anterior The incidence of IOP elevation secondary to silicone chamber reaction would be evident on slit lamp bio- oil has been reported to range from 5.9% to 56% of microscopy. Medications can be responsible for inducing treated eyes. 20 The cause of elevated intraocular pressure unilateral elevated intraocular pressures (e.g., steroid, may be either direct blockage of the trabecular meshwork topiramate). If the etiology lies in the structure of the lens, or inflammation and damage to the trabecular meshwork this can easily be visualized on slit lamp biomicroscopy. cells. 21 Elevation in IOP is a common finding following Pupillary block would be evident as a result of a phako- vitreoretinal surgery with silicone oil injection. 15 morphic lens. Choroidal detachments and posterior segment However, elevated IOP should prompt consideration of tumors will be evident on B-scan ultrasonography of the possible surgical complications. In aphakes receiving anterior and posterior segment, respectively (Table I). silicone oil substitutes, elevated ocular tensions can occur The presence of an inverted hypopyon or silicone immediately following the postoperative period as a result droplets are pathognomonic for emulsification and of pupillary block. Pupillary block glaucoma occurs if migration of silicone oil into the anterior chamber. A the silicone oil creates a barrier at the pupillary space and history of retinal detachment repair with silicone injection

Hyperoleon: Complications of Silicone Oil in Reparative Retinal Surgery — Nguyen 149 Table I The differential diagnosis in unilateral elevated intraocular tensions pathogenesis remains obscure but generally, the hyperoleon is thought to be a contributor to or • Glaucomatocyclitic crisis (Posner-Schlossman Syndrome) glaucoma in some patients. 13-15,26 In patients with emulsifica - • Retrobulbar hemorrhage • Pigmentary glaucoma tion and raised intraocular pressure, removal of the oil is • Inflammatory open-angle glaucoma recommended. Some investigators have showed minimal 27 • Medication-induced effect on IOP following silicone oil removal. Other inves - • Lens-induced tigators have demonstrated that removal affords for better • Choroidal detachment control of ocular tensions. 6 In general, secondary glaucoma • Posterior segment tumor is one of the most serious complications for patients with emulsification of silicone and increased IOP. Individuals with such indications should be followed closely for the is further supportive of the etiology of increased IOP. development of secondary . Isolation of the particular mechanism responsible for the postoperative rise in ocular tensions facilitates timely CONCLUSION treatment and management. The causes of hyperoleon and The use of silicone oil in the eye is becoming more pre- unilateral elevated intraocular pressure in the immediate valent with more advances in vitreoretinal surgery. postoperative period include pupillary block and silicone Silicone oil in the eye can lead to serious complications overfill. Pupillary block generally appears in the aphakic that have a specific clinical profile. Recognition of specific individual and may be accompanied by a mid-dilated . An overlying exudative membrane in pupillary vitreous substitutes in retinal surgery allow for prompt block may be evident in patients with existing PI’s. A lack diagnosis. Isolation of the mechanism for IOP-rise facilitate of an oil/aqueous interface in the pupillary plane is evident, targeted treatment and management. In general, treatment as well as an absence of flare in the anterior chamber. and management is case-specific so risk factors need to be Silicone overfill generally appears in the pseudophake or balanced and subsequently modified according to individual phakic patient. The condition may be accompanied by clinical presentation. J signs of shallowing in the anterior chamber, as well as the presence of herniation of oil between the pupil and lens. REFERENCES The causes of hypopyon and unilateral elevated 1. Stern WH, Blumenkranz MS. Fluid-gas exchange after intraocular pressure during the late postoperative period vitrectomy. Am J Ophthalmol 1983; 96: 400-401. include steroid-induced glaucoma, pre-existing glaucoma, 2. Lucke KH, Foster MH, Laqua H. Long-term results of uveitis and emulsification of silicone. Topical steroids are vitrectomy and silicone in 500 cases of complicated retinal frequently given following surgical intervention. In the detachments. Am J Ophthalmol 1987; 104: 624-633. present case, the patient was placed on a topical steroid 3. Scott JD. A rationale for the use of liquid silicone. Trans but the steroid response elevation in IOP will often resolve Ophthalmol Soc UK 1977; 97: 235-237. following discontinuation of therapy. This mechanism is a 4. Chignell AH, Wong D. Management of vitreo-retinal diagnosis of exclusion. Pre-existing glaucoma may disease: a surgical approach. London: Singer Press, 1999. aggravate in IOP following re-attachment of the retina 5. Honavar SG, Goyal M, Majji AB, Sen PK, Naduvilath T, because repair reduces the uveal-scleral outflow afforded Dandona L. Glaucoma after pars plana vitrectomy and by the retinal detachment. Elevated intraocular pressure silicone oil injection for complicated retinal detachments. has also been shown to occur secondary to complex 1999; 106: 169-176; discussion 177. vitreal detachments. The condition is evidenced by the pres - 6. Nguyen QH. Lloyd MA, Heuer DK, et al. Incidence and ence of cells and flare in the anterior chamber but such management of glaucoma after intravitreal silicone oil injection for complicated retinal detachment. Ophthal- constituents should not be mistaken for fine silicone mology 1992; 99: 1520-1526. droplets which may mimic the clinical entity. Finally, the 7. Henderer JD, Budenz DL, Flynn HW, et al. Elevated intra- presence of silicone in the anterior chamber leads to the ocular pressure and hypotony following silicone oil retinal diagnosis of emulsification, as described in the current case. tamponade for complex retinal detachment: incidence and risk factors. Arch Ophthalmol 1999; 117: 189-195. Elevated Intraocular Tension and 8. Leaver PK, Grey RH, Garner A. Silicone oil injection in the Considerations for Glaucoma treatment of massive preretinal retraction: late complica - Silicone oil use has been associated with emulsification of tions in 93 eyes. Br J Ophthalmol 1979; 63: 361-367. oil into the anterior chamber, subsequent elevated intra- 9. Scott JD. Surgery for Retinal and Vitreous Disease. Oxford: ocular pressure, and secondary glaucoma. 23-25 Silicone oil Butterworth Heinemann. 1998. emulsification and glaucoma often are coexisting entities; 10. McCuen BW, de Juan E Jr, Landers MB 3rd, Machemer R. however patients with emulsified silicone may never Silicone oil in vitreoretinal surgery. Part 2: Results and develop glaucoma, even after long term testing. 8,14 The complications. Retina 1985; 5: 195-205.

150 Clinical and Refractive Optometry 27:4, 2016 11. Cockerham WD. Schepens CL, Freeman HM. Silicone 19. Azzolini C. Pierro L. Codenotti M, et al. Ultrasound injection in retinal detachment. Arch Ophthalmol 1970; 83: biomicroscopy following the intraocular use of silicone oil. 704-712. Int Ophthalmol 1995; 19: 191-195. 12. Grey RH, Leaver PK. Results of silicone oil injection in the 20. Gedde SJ. Management of glaucoma after retinal detachment treatment of massive preretinal retraction. Trans surgery. Curr Opin Opthalmol 2002; 13: 103-109. Ophthalmol Soc U K 1977; 97: 238-241. 21. Champion R, Faulborn J, Bowald S, Erb P. Peritoneal 13. Kim RW, Baumal C. Anterior segment complications reaction to liquid silicone: an experimental study. Graefes related to vitreous substitutes. Ophthalmol Clin North Am Arch Clin Exp Ophthalmol 1987; 225: 141-145. 2004; 17: 569-576. 22. Budenz DL, Taba KE, Feuer WJ, et al. Surgical management 14. Federman JL, Schubert HD. Complications associated with of secondary glaucoma after pars plan vitrectomy and silicone the use of silicone oil in 150 eyes after retina-vitreous oil injection for complex retinal detachment. Ophthalmology surgery. Ophthalmology 1988; 85: 870-876. 2001; 108: 1628-1632. 15. Avitabile T, Bonfiglio V, Circero A, et al. Correlation 23. Chan C, Okun E. The question of ocular tolerance to intra- between quantity of silicone oil emulsified in the anterior vitreal liquid silicone: a long term analysis. Ophthalmology chamber and high pressure in vitrectomized eyes. Retina 1986; 93: 651-660. 2002; 22: 443-448. 24. Nakamura K, Refojo MF, Crabtree DV. Factors contributing 16. Riedel KG, Gabel VP, Neubauer L, et al. Intravitreal to the emulsification of intraocular silicone and fluorosilicone silicone oil injection: complications and treatment in 415 oils. Invest Ophthalmol Vis Sci 1990; 31: 647-656. consecutive patients. Graefes Arch Clin Exp Ophthalmol 25. Valone J Jr, McCarthy M. Emulsified anterior chamber silicone 1990; 228: 19-23. oil and glaucoma. Ophthalmology 1994; 101: 1908-1912. 17. Ardjomand N, El-Shabrawi Y. Pupillary block after silicone 26. Gao RL, Neubauer L, Tang S, Kampik A. Silicone oil in the implantation in a phakic eye. Eye 2001; 15: 331. anterior chamber. Graefes Arch Clin Exp Ophthalmol 1989; 18. Genovesi-Ebert F, Rizzo S, Chiellini S, et al. Ultrasound 227: 106-109. biomicroscopy in the assessment of secondary glaucoma 27. Moisseiev J, Barak A, Manaim T, Treister G. Removal of sil - after vitreoretinal surgery and silicone oil injection. icone in the management of glaucoma in eyes with Ophthalmologica 1998; 212: 4-5. emulsified silicone. Retina 1993; 13: 290-295.

S FR U EE S BS W Management of Ocular Emergencies EE C I RI TH PA PT 6th Revised Edition GE IO ISBN 978-1-896825-33-5 1 N 25 6 chapters 96 pages 53 color plates 16 figures 12 tables 13 Appendices and a Subject Index

This Book Contains: Descriptions, Workups and Treatment Options for Managing the Following Ocular Emergencies: Nontraumatic Traumatic Red Eye Decreased Vision Pre-Septal Cellulitis Corneal Abrasions in a White Eye (cont’d) Contact Lenses Cortical Blindness Acute Ultraviolet Understanding Glaucoma: Chemical Injuries An Overview Dry Eye Corneal Foreign Bodies Allergic Intraocular Foreign Bodies Adenoviral Conjunctivitis Blow-Out Fracture Third Nerve Palsy Bacterial Conjunctivitis Chlamydia Blunt Trauma Injury Herpes Simplex Lacerations and Perforations Myasthenia Gravis Herpes Zoster Orbital Disease Toxic Conjunctivitis Decreased Vision Recurrent Corneal Erosions in a White Eye Contributors Raymond Stein, MD, FRCSC Subconjunctival Hemorrhage Vein Occlusion Associate Professor, University of Toronto Phlyctenule Artery Occlusion Retinal Detachment Harold Stein, MD, FRCSC Maculopathy Professor, University of Toronto Corneal Ulcers Vitreous Hemorrhage Iritis Rebecca Stein, MD Ophthalmology Residency Program, University of Toronto Acute Angle Closure Glaucoma Ischemic

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Hyperoleon: Complications of Silicone Oil in Reparative Retinal Surgery Tam Nguyen, OD, MS, FAAO; Nancy N. Wong, OD, PhD, FAAO; Terry Luk, OD, FAAO; David M. Galeoto, OD, FAAO; Karen Wadhams, OD, FAAO

1. In the Case Report presented, what degree of pain did the patient report at initial presentation? K Grade 1 K Grade 2 K Grade 3 K Grade 4

2. All of the following statements are true, EXCEPT: K In the Case Report presented, the patient’s ocular history was significant for scleral buckling K In the Case Report presented, the patient’s visual acuity was fully restored to better than counting fingers K For intraocular applications, silicone oil has a low density when compared with aqueous K The use of silicone oil in the eye may result in complications which may be sight-threatening

3. In the Case Report presented, what was the patient’s initial visual acuity? K 6/6- (20/20-)

COPE-APPROVED CE CREDIT APPLICATION FORM COPE-APPROVED CE CREDIT APPLICATION K 6/7.5- (20/25-) K 6/9- (20/30-) K 27:4, 16 27:4, 6/12- (20/40-)

152 Clinical and Refractive Optometry 27:4, 2016 4. All of the following statements describe the patient at follow-up #1, EXCEPT : K He denied photophobia K Visual acuities remained stable at 6/6- (20/20-) K He reported Grade 2 pain M K Ocular tensions were 19 mmHg and 30 mmHg in the right and left eyes, respectively R 5. What is the reported incidence of IOP elevation secondary to silicone oil? O K 2.4% to 56% of treated eyes F K

3.9% to 56% of treated eyes K 4.8% to 56% of treated eyes N K 5.9% to 56% of treated eyes O

I 6. All of the following statements accurately describe Posner-Schlossman Syndrome, EXCEPT :

T K It typically presents in elderly women K It is often accompanied with a history of recurrent episodes A K It responds to steroid treatment

C K A retrobulbar hemorrhage generally appears in patients with an extensive history of recent I ocular trauma or head injury L

P 7. In the Case Report presented, all of the following clinical signs describe the patient

P at initial presentation, EXCEPT : K The patient’s visual acuity was unchanged with pinhole A K Extraocular muscles were restricted in some fields of gaze K On external examination, there was an OS upper lid ptosis which impinged on the visual axis T

I K The bulbar and palpebral conjunctiva were quiet OD

D 8. All of the following statements about use of silicone oil are true, EXCEPT : E K Its use has been associated with secondary glaucoma K

R Silicone oil emulsification and glaucoma often are coexisting entities K The majority of patients with emulsified silicone develop glaucoma C K

Hyperoleon is thought to be a contributor to ocular hypertension in some patients

E 9. In the Case Report presented, following in-office topical instillation of brimonidine 0.2%

C and timolol maleate 0.5%, the patient’s IOP OS was reduced to which of the following? K 22 mmHg

D K 25 mmHg K 26 mmHg E K 27 mmHg V

O 10. All of the following statements about the incidence of IOP elevation following vitreoretinal surgery with silicone oil injection are false, EXCEPT : R K It’s rare

P K It rises with increased age K

P It’s common K Steroid response elevation in IOP typically continues despite discontinuation of therapy A - E P O C 6 1

4 : 7 2

Hyperoleon: Complications of Silicone Oil in Reparative Retinal Surgery — Nguyen 153