Figure. Gross and histologic photographs. A, Gross photograph of the enucleated globe with a large white mass extending from the posterior sclera. B, Low-magnification histologic photograph of the globe with iatrogenic scleral discontinuity (arrow) and a large silicone oil granuloma extending off the posterior sclera (asterisk) (hematoxylin-eosin, original magnification ×1). C, High-magnification histologic photograph of the posterior epibulbar mass, showing silicone oil with a granulomatous reaction characterized by giant cells (arrow) and associated lymphocytes (hematoxylin-eosin, original magnification ×400).
Couch SM, Harocopos GJ, Holds JB. Orbital Silicone Oil Granuloma Discovered During Enucleation. Arch Ophthalmol. 2012;130(8):1083-1085. doi:10.1001/archophthalmol.2012.287
Author Affiliations: Departments of Ophthalmology and Visual Sciences (Drs Couch and Harocopos) and Pathology and Immunology (Dr Harocopos), Washington University, and Departments of Ophthalmology (Drs Couch and Holds) and Otolaryngology–Head and Neck Surgery (Dr Holds), Saint Louis University, St Louis, Missouri.
Silicone oil tamponade is commonly used in surgical repair of recalcitrant retinal detachments. Complications of intraocular silicone oil include corneal decompensation, cataract formation, and glaucoma.1 Silicone oil has been reported to migrate through the optic nerve into the brain.2 Free silicone oil within tissues can cause a chronic granulomatous inflammatory reaction, which, depending on the location, can result in impairment of involved structures.3,4 Silicone oil has been reported to cause granulomatous anterior episcleral nodules following transscleral migration through vitrectomy sites.4 We have found no cases of posterior orbital silicone oil granulomas incidentally discovered during enucleation.
A 44-year-old highly myopic (approximately 20 diopters) woman had an outpatient surgical consultation for a blind, painful left eye. A decade prior, she was struck in the left eye, causing a retinal detachment. Four vitreoretinal operations were performed and no encircling band was placed. During the most recent retinal surgery, 5 years prior to her consultation, silicone oil tamponade was performed. Her visual acuity had been no light perception since surgery. She did not start developing severe pain until 2 years prior to her consultation with us. She described her discomfort as a nearly constant ache in the orbit and brow that worsened with eye movement.
Anterior segment examination showed a closed angle without inflammation and a well-centered posterior chamber intraocular lens implant. The posterior segment showed approximately 70% silicone oil fill over a flat retina. The intraocular pressure was 55 mm Hg.
An enucleation was carried out in the standard fashion. As the enucleation scissors were passed to sever the optic nerve, a hard mass was felt posterior to the globe. Dissection was carried out posterior to the Tenon fascia, and a retrobulbar mass was discovered. The entirety of the granulomatous mass was removed, remaining attached to the posterior aspect of the globe (Figure, A). The orbital tissues were rinsed and wiping debridement of any silicone oil remnants was performed. An implant was placed and the remainder of the procedure was completed as per our usual technique.
Histopathologic evaluation of the globe showed thinning of the posterior sclera consistent with a myopic staphyloma. The axial length was 29 mm. There was neovascularization of the iris and angle, with peripheral anterior synechiae, correlating with angle-closure glaucoma noted clinically. The retina exhibited extensive degeneration as well as silicone oil spaces without any associated inflammation. A large posterior episcleral mass was evident, consisting primarily of silicone oil droplets, some with associated foreign body giant cell reaction (Figure, B and C). No foreign body giant cell reaction was seen intraocularly.
At follow-up visits, the patient described resolution of all pain.
Pain in the blind eye can be secondary to many reasons, including elevated intraocular pressure and development of phthisis bulbi. Extraocular masses can also lead to discomfort especially if associated with inflammation. In our patient, it is difficult to determine whether her pain was only secondary to the elevated intraocular pressure or the chronically inflamed orbital mass.
Pathologic myopia is characterized by an excessively long globe and commonly has thinned or dehiscent layers of the ocular side wall. The silicone oil nidus for the inflammatory reaction may have escaped through dehiscent scleral channels. The several years between the silicone oil placement and onset of discomfort may be explained by long-term, slow leakage of silicone oil through the sclera.
Free silicone oil within the extracellular matrix commonly causes a chronic granulomatous reaction that may lead to inflammation or functional impairment. Our patient described late development of ocular and orbital pain in a blind eye treated with silicone oil. Enucleation and orbital granuloma removal resolved the pain. It is important to consider extrascleral silicone oil granulomas in patients with ocular and orbital pain following treatment with silicone oil tamponade.
Correspondence: Dr Couch, 12990 Manchester Rd, Ste 103, Des Peres, MO 63131 (firstname.lastname@example.org).
Financial Disclosure: None reported.
Funding/Support: This work was supported by Heed Ophthalmic Research Foundation and Research to Prevent Blindness.