What Is the Cause of Toxicity of Silicone Oil?

EARLY SILICONE OIL OPACIFICATION IN THE ABSENCE OF EMULSIFICATION IS CAUSED BY AN INCREASED LEVEL OF SILICONE DIOXIDE

BACKGROUND/PURPOSE

In October 2023, other cases with early silicone oil opacification within hours after intraocular implantation in the absence of emulsification occurred. Although multiple, small series of this phenomenon are now documented during the past decade, the cause was never unmasked. In this study, we analyzed explanted patient samples, unused samples of the affected, and a control batch of the same silicone oil.

METHODS

The oils were examined on their optical and viscosimetric properties, interfacial tension, and for the presence of particles. Contamination was investigated using inductively coupled plasma mass spectrometry, thermogravimetric analyses, and Raman spectroscopy. Cytotoxicity examination in ARPE-19 cells was performed. The oil's effect on pH changes of aqueous solutions and the oil's defoaming ability were analyzed.

RESULTS

The affected batch passed all regulatory limits. However, the affected batch showed an elevated turbidity already before implantation. Three thousand-fold magnification revealed dispersed particles only in the affected batch. Contamination analyses revealed the absence of other elements, indicating a silicon-containing contamination. The affected batch showed no in vitro cytotoxicity but altered viscosimetric properties and a lower pH of the hydrophilic phase after inducing emulsification. Both batches did not show relevant defoaming properties.

CONCLUSION

The results obtained combined with information from suppliers and the manufacturer suggest an elevated level of silica particles as the cause of the opacification. Based on these results, the manufacturer and suppliers of the latest affected batch adjusted cutoff values for turbidity measurements and introduced turbidity measurements of the raw material before distillation. Other manufacturers should follow these preventive measures.

Vision loss associated with silicone oil endotamponade in vitreoretinal surgery - a review

PURPOSE

To clarify the definition, prevalence and classification of different types of unexplained vision loss associated with silicone oil (SO) endotamponades (SO in situ (SOIS) or after removal of SO (ROSO)) in vitreoretinal surgery and identifying the most specific clinical findings and suggesting possible causes.

METHODS

Review of the literature regarding randomized clinical trials (RCTs), retrospective case-control, cohort studies and case series evaluating the risk of using SO, published in English between 1994 and 2023, conducting a computer-based search of the following databases: PubMed, Web of Science, Scopus and Embase. The search was supplemented using the Medline option 'Related Articles' and consulting review articles on the topic.

RESULTS

Findings from reported clinical examinations in SOIS and ROSO are analyzed and finally different theories regarding the underlying pathophysiology are described. From the clinical point of view, findings have been found in OCT, OCTA, microperimetry and electrophysiological studies. Other clearly identifiable causes of vision loss related to the use of SO are listed and commented as differential diagnosis. Finally, the different physiopathological theories of the two types of causes of unexplained vision have been analyzed.

CONCLUSION

Unexpected vision loss under or after SO tamponade (SOIS and ROSO) is a significant concern which is probably underestimated because it is not a clearly defined and known entity. The most frequently described changes were in the ganglion cell complex but this unexpected vision loss remains a serious and unexplained concern for vitreoretinal surgeons and should be identified by clinicians, addressed by manufacturers and reported to Health Authorities as a serious incident according to the new regulation.

pO2 reporter composite hydrogel macroencapsulation devices for magnetic resonance imaging oxygen quantification

Hydrogel cell encapsulation devices are a common approach to reduce the need for chronic systemic immunosuppression in allogeneic cell product transplantation. Macroencapsulation approaches are an appealing strategy, as they maximize graft retrievability and cell dosage within a single device; however, macroencapsulation devices face oxygen transport challenges as geometries increase from preclinical to clinical scales. Device design guided by computational approaches can facilitate graft oxygen availability to encapsulated cells in vivo but is limited without accurate measurement of oxygen levels within the transplant site and graft. In this study, we engineer pO2 reporter composite hydrogels (PORCH) to enable spatiotemporal measurement of oxygen tension within macroencapsulation devices using the proton Imaging of siloxanes to map tissue oxygenation levels (PISTOL) magnetic resonance imaging approach. We engineer two methods of incorporating siloxane oximetry reporters within hydrogel devices, an emulsion and microbead-based approach, and evaluate PORCH cytotoxicity on co-encapsulated cells and accuracy in quantifying oxygen tension in vitro. We find that both emulsion and microbead PORCH approaches enable accurate in situ oxygen quantification using PISTOL magnetic resonance oximetry, and that the emulsion-based PORCH approach results in higher spatial resolution.

Emulsification of Silicone Oils: Altering Factors and Possible Complications-A Narrative Review

Background: Endotamponade of the vitreous body with silicone oil is a common procedure, being the basis of many vitreoretinal surgeries. However, emulsification may happen, which is a clinically relevant adverse event of silicone oil use. Methods: This review provides a thorough analysis of the emulsification process. It focuses on describing factors affecting this event as well as its possible subsequent complications. Results: The viscosity of silicone oil, the duration of emulsification, the status of the lens and many other factors have an influence on the onset and intensity of emulsification. This phenomenon carries several risks for operated eyes such as increased intraocular pressure, keratopathy or structural changes to the retina. Conclusions: The use of modern imaging techniques, especially optical coherence tomography, enables faster detection of the emulsification process. This allows for an adequate clinical response and more accurate follow-up of the patient.

A minimum specification dataset for liquid ocular endotamponades: recommendations by a European expert panel

PURPOSE

To propose a minimum specification dataset to characterize liquid ocular endotamponades (OEs), namely silicone oil (SO), heavy SO (HSO), perfluorodecalin (PFD), and perfluoro-octane (PFO), in terms of physicochemical properties, purity and available evidence of safety, in line with ISO16672:2020.

METHODS

An evidence-based consensus using the expert panel technique was conducted. Two facilitators led a committee of 11 European experts. Facilitators prepared a dataset for each compound including the list of specifications relevant for the safety, identified by the group members on the basis of expertise and a comprehensive literature review. Each item was ranked by each member using a 9-point scale from 1 "absolutely to not include" to 9 "absolutely to include" in two rounds followed by discussion. Only items reaching consensus (score ≥ 7 from ≥ 75% of members) were included in the final datasets.

RESULTS

For all OEs, consensus was reached to include manufacturer, density, refractive index, chemical composition, dynamic viscosity, interfacial and surface tension, endotoxins, in vitro cytotoxicity assessment, and any evidence from ex vivo and/or in vivo tests for safety assessment. Additional specifications were added for SO (molecular weight distribution, content of oligosiloxanes with MW ≤ 1000 g/mol, spectral transmittance) and PFD/PFO (% of pure PFD/PFO in the final product, vapor pressure, chemical analyses performed for safety assessment).

CONCLUSION

The proposed evidence-based minimum specification datasets for SO, HSO, PFD, and PFO have the potential to provide surgeons and health service purchasers with an easily available overview of the most relevant information for the safety assessment of OEs.

Effect of silicone oil versus gas tamponade on macular layer microstructure after pars plana vitrectomy for macula on rhegmatogenous retinal detachment

PURPOSE

To analyze structural changes in the macular retinal layers and sub-foveal choroidal thickness (SFCT) in eyes after macula-on rhegmatogenous retinal detachment (RRD) repair by pars plana vitrectomy with either silicone oil (SO) or gas tamponade, and the effect of these changes on visual acuity.

PATIENTS AND METHODS

Retrospective study which included 26 eyes in the SO Group and 32 in the Gas Group. Optical coherence tomography (OCT) scans of the affected eyes were obtained before surgery, and 3 months after PPV in the Gas Group, and during silicone oil in situ and 3 months after SO removal, in the SO Group. Qualitative assessment of photoreceptor layer and foveal contour, along with quantitative assessment of macular retinal thickness and SFCT was performed. Postoperative OCT macular microstructural changes were recorded and correlated to corrected distance visual acuity (CDVA). Intraocular pressure (IOP) was measured preoperative and at 3 months post operative.

RESULTS

There was a 2-line loss (from 20/28 preoperatively to 20/40 at final follow-up) of CDVA in the SO Group (p=0.051), while there was no statistically significant change in CDVA in the Gas Group (p=0.786). There was no significant correlation between CDVA loss and duration of silicon tamponade (r=-0.031, p=0.893). There was a statistically significant increase in IOP from its baseline to final follow-up of 0.7 mmHg in the SO Group (p=0.023) while there was no statistically significant change in IOP in the Gas Group. During silicone oil tamponade, there was approximately 11% and 5% of retinal and sub-foveal choroidal thinning respectively, which was moderately resolved following silicone oil removal. 20% (5/24) of eyes in the SO Group had qualitative flattening of foveal contour during SO tamponade that resolved after SO removal.

CONCLUSION

Thinning of the macula was noticed after macula-on RRD repair with SO tamponade. Such thinning was only partially reversible after the removal of SO.

Contamination Profile of Different Formulations of Silicone Oil Tamponade Before and After Intraocular Permanence for Rhegmatogenous Retinal Detachment

Purpose

The purpose of this study was to search for contaminants in silicone oil tamponades removed from eyes treated for retinal detachment, and to correlate chemical results with some clinical/functional parameters of the considered eyes.

Methods

We examined a sequential cohort of eyes grouped according to the tamponade received: (1) Siluron2000 (S2), (2) RS-OIL ECS5000 (S5), and (3) Densiron Xtra (DX). Samples were collected at the beginning of the scheduled removal and analyzed by untargeted headspace gas-chromatography mass spectrometry (HS-GC-MS). Visual acuity and optic coherence tomography assessments were obtained before and after the tamponade removal.

Results

Forty-one samples were analyzed: 22 belonging to the DX group, 13 to the S2 group, and 6 to the S5 group. For each group, a mixture of uninjected commercial preparation was analyzed as the reference. Different siloxanes and fluorinated compounds including perfluorodecalin (PFCL) were the most prevalent chemicals, found in 55% to 100% of the intraocular samples of the 3 groups. Some siloxanes were present also in the control matrices, whereas PFCL was only in the extracted tamponades. In the DX group, the concentration of hexamethylcyclotrisiloxane showed an inverse correlation trend with the duration of its permanence inside the eye (P = 0.054). Different alkanes, propanol, and acetaldehyde were identified only in the control matrices.

Conclusions

Several contaminants including siloxanes were identified in the intraocular samples and in the control matrices. A time-related ocular uptake of some of these is conceivable. PFCL was also highly present but only in intraocular samples.

Translational Relevance

After intraocular permanence silicone oils (SOs) have various unlabeled contaminants with some relevant differences with the commercial formulation chemical profile.

Effect of the Presence of Silicone Oil in the Anterior Chamber After Complicated Retinal Detachment Surgery on Corneal Morphology by In Vivo Confocal Microscopy

PURPOSE

This study evaluated the corneal endothelium, stromal keratocytes, subbasal nerve number and density in patients with silicone oil transferred to the anterior camera after pseudophakic complicated retinal detachment surgery by in vivo laser scanning confocal microscopy (IVLSCM).

METHODS

Sequential measurements were made by IVLSCM between 3-6 months after surgery in two groups of patients: a) with silicon oil migration (Group 1) and without silicone oil migration (Group 2).

RESULTS

A total of 63 cases (Group 1: 32 and Group 2: 31) were examined. The mean ages of patients were 65 ± 12 and 61 ± 11 and M/F ratio was 18/14 and 17/14, respectively. Mean intraocular pressures were 16.60 ± 4.60 and 15.75 ± 5.70 mm Hg, respectively. Changes were detected by IVLSCM mostly on the superior part of the cornea. A significant decrease in endothelial cell density and the number was detected in group 1 (2072 ± 116.2 cells/mm2 vs 2752 ± 512.3 cells/mm2; p < 0.001). Significant increases in posterior keratocyte density and stromal hyperreflective deposits were observed in group 1 (887 ± 45.8 cells/mm2 vs 725 ± 65.8 cells/mm2; p < 0.001). A significant negative correlation was observed between the size of stromal deposits and endothelial cell density (r=-0.758; p < 0.001). The number and density of corneal subbasal nerves were significantly lower in group 1 (1.8 ± 0.8 and 4.8 ± 1.2 vs 420 ± 101 and 701 ± 112 µm/square; p < 0.001).

CONCLUSION

IVLSCM is a useful tool for the early detection of corneal abnormalities caused by silicone oil injection. This study verified silicone oil's detrimental effect on the corneal endothelium and revealed stromal changes in the anterior chamber, which we believe can be also been associated with the presence of silicone oil.

Vitreous Substitutes from Bench to the Operating Room in a Translational Approach: Review and Future Endeavors in Vitreoretinal Surgery

Vitreous substitutes are indispensable tools in vitreoretinal surgery. The two crucial functions of these substitutes are their ability to displace intravitreal fluid from the retinal surface and to allow the retina to adhere to the retinal pigment epithelium. Today, vitreoretinal surgeons can choose among a plethora of vitreous tamponades, and the tamponade of choice might be difficult to determine in the ever-expanding range of possibilities for a favorable outcome. The currently available vitreous substitutes have disadvantages that need to be addressed to improve the surgical outcome achievable today. Herein, the fundamental physical and chemical proprieties of all vitreous substitutes are reported, and their use and clinical applications are described alongside some surgical techniques of intra-operative manipulation. The major upcoming developments in vitreous substitutes are extensively discussed, keeping a translational perspective throughout. Conclusions on future perspectives are derived through an in-depth analysis of what is lacking today in terms of desired outcomes and biomaterials technology.

Fibrinogen Deposition on Silicone Oil-Infused Silver-Releasing Urinary Catheters Compromises Antibiofilm and Anti-Encrustation Properties

Slippery silicone-oil-infused (SOI) surfaces have recently emerged as a promising alternative to conventional anti-infection coatings for urinary catheters to combat biofilm and encrustation formation. Benefiting from the ultralow low hysteresis and slippery behavior, the liquid-like SOI coatings have been found to effectively reduce bacterial adhesion under both static and flow conditions. However, in real clinical settings, the use of catheters may also trigger local inflammation, leading to release of host-secreted proteins, such as fibrinogen (Fgn) that deposits on the catheter surfaces, creating a niche that can be exploited by uropathogens to cause infections. In this work, we report on the fabrication of a silicone oil-infused silver-releasing catheter which exhibited superior durability and robust antibacterial activity in aqueous conditions, reducing biofilm formation of two key uropathogens Escherichia coli and Proteus mirabilis by ∼99%, when compared with commercial all-silicone catheters after 7 days while remaining noncytotoxic toward L929 mouse fibroblasts. After exposure to Fgn, the oil-infused surfaces induced conformational changes in the protein which accelerated adsorption onto the surfaces. The deposited Fgn blocked the interaction of silver with the bacteria and served as a scaffold, which promoted bacterial colonization, resulting in a compromised antibiofilm activity. Fgn binding also facilitated the migration of Proteus mirabilis over the catheter surfaces and accelerated the deposition and spread of crystalline biofilm. Our findings suggest that the use of silicone oil-infused silver-releasing urinary catheters may not be a feasible strategy to combat infections and associated complications arising from severe inflammation.

Assessment of Silicone Oil Emulsification: A Comparison of Currently Applied Methods

Purpose

To compare ultrasound biomicroscopy (UBM), Coulter counter, and B-scan ultrasonography in the evaluation of silicone oil (SO) emulsification.

Methods

Patients who underwent primary pars plana vitrectomy with SO tamponade for rhegmatogenous retinal detachment and SO removal were included. UBM images were acquired before the SO removal, and B-scan images were taken after removal. The number of droplets in the first and last 2 mL of washout fluid was analyzed using a Coulter counter. The correlations between these measurements were analyzed.

Results

Thirty-four eyes received both UBM and Coulter counter analysis for the first 2 mL of washout fluid, and 34 underwent B-scan and Coulter counter analysis of the last 2 mL washout fluid. The mean UBM grading was 26.41 ± 9.71 (range: 1-36); the mean SO index obtained with B-scan was 5.25 ± 5.00% (range: 0.10-16.49%), and the mean number of SO droplets was 1.26 ± 2.45 × 10⁷/mL and 3.34 ± 4.22 × 10⁶/mL in the first and last 2 mL of washout fluid, respectively. There were significant correlations between UBM grading and SO droplets in the first 2 mL and between B-scan grading and SO droplets in the last 2 mL (all P < 0.05).

Conclusions

UBM, Coulter counter, and B-scan ultrasonography could all be used in the evaluation of SO emulsification, and their findings were comparable.

[Exogenously induced retinopathies]

Exogenously induced retinopathies can be caused by consumation of stimulating substances, systemic or ocular medications, vaccinations, light or irradiation. Some of the effects are transient, whereas other effects induce irreversible toxic reactions. Retinal damage may develop either acutely with obvious relation to the damaging cause, but often may take a long duration of repeated use of a substance or medication. External stimulants (e.g. nicotine, alcohol, poppers, methanol) are the most frequent cause of exogenously induced retinal damage. Side effects from systemic drugs (e.g. hydroxychloroquine, ethambutol, MEK-, ERK-, FLT3-, checkpoint inhibitors, didanosin, pentosanpolysulfat sodium) or intravitreally applied drugs (e.g. antibiotics, VEGF-inhibitors) are less frequent. Ocular side effects associated with vaccinations are rare. Ambient light sources induce no damaging effects on the retina. Incorrect use of technical or medical light sources (e.g. laser pointers) without adherence to safety recommendations or unshielded observation of the sun might induce permanent retinal damage. Local or external irradiation might induce retinal vascular damage resulting in radiation retinopathy.

Exogen bedingte Retinopathien

Exogen bedingte Retinopathien werden am häufigsten durch externe Stimulanzien, seltener durch unerwünschte Arzneimittelwirkungen systemisch oder intravitreal eingesetzter Medikamente und noch seltener durch Impfungen oder die Einwirkung von Lichtstrahlung verursacht. Die Kenntnis exogener Ursachen und ihre mögliche Symptomatik ist zur Prophylaxe oder zur Früherkennung schädigender Wirkungen und zur adäquaten Beratung der Patienten wichtig.

Retinal and Corneal Changes Associated with Intraocular Silicone Oil Tamponade

Silicone oils (SO) are used as long-term intraocular tamponades and have an irreplaceable role in vitreoretinal surgery. They can, however, be associated with multiple and potentially severe complications, involving different ocular tissues, in particular retina and cornea. Recent advances in ophthalmic imaging have allowed the precise characterization of retinal and corneal microstructural changes, at a subclinical level. This detailed analysis of SO-related retinal and corneal changes has improved our understanding of their pathogenesis and offer the potential for optimized monitoring and management of patients with SO-filled eyes. This review aims to provide clinicians and ophthalmic scientists with an updated and comprehensive overview of the corneal and retinal changes associated with SO tamponade.