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Is there a role for silicone oil in the repair of macular hole?
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A limited role for silicone oil
 Mitchell S. Fineman |
I do not think there is any question that gas is more effective than silicone oil at achieving macular hole closure. Notably, Lai and colleagues reported in Ophthalmology in 2003 a 65% macular hole closure rate after surgery with silicone oil compared with a 91% rate with gas tamponade. Gas accomplishes its intended purposes and is easily absorbed without the need for a second surgery, which is another drawback of silicone oil.
Recently, it has been suggested that silicone oil may be beneficial for patients who cannot or will not adhere to face-down positioning after surgery. Silicone oil, because it fills the entire vitreous cavity and remains the same size until it is removed, may not be as dependent on postoperative positioning as gas. Finally, silicone oil may have a role in reoperation of a macular hole when the prior surgery failed due to inadequate positioning.
However, I do not believe that silicone oil has a real role in primary repair of macular holes. It has been my experience that face-down positioning may not be necessary if the internal limiting membrane is peeled and long-acting gas is used. In patients who can position, I normally use SF6, a gas with a shorter duration. This improves the patient’s postoperative experience because once the hole is closed, visual improvement can be achieved more quickly. In patients who cannot or will not position, I use C3F8, which takes longer to absorb, but still achieves anatomical closure in more than 90% of cases.
Mitchell S. Fineman, MD, is an ophthalmologist at Mid Atlantic Retina and Wills Eye Institute in Philadelphia.
Gas is usually preferred
Although tamponade with either non-expansive SF6 (20%) or C3F8 (14%) is the standard for the repair of both traumatic and age-related macular holes, silicone oil tamponade has been suggested as a means to overcome suspected limitations of gas. Namely, use of gas requires prolonged face-down positioning by the patient in the postoperative period, and vision is reduced by the presence of the gas.
 Eugene de Juan |
In practice, however, silicone oil has not achieved wide use because of reduced long-term results both in primary closure rates and vision. Also, it requires a secondary procedure to remove it. The reason why silicone oil is not as effective is not obvious but may relate to the reduced “drying” effect around the hole because of the buoyancy of the oil vs. gas.
Silicone oil does play a role in selected cases of macular hole. Myopic macular holes with more extensive surrounding subretinal fluid may need chronic or very long-term tamponade due to reduced healing of the posterior retinal pigment epithelium and choroidal “suction.” It can be useful in patients who are unable or unwilling to position as required with gas, such as elderly, children or those with physical limitations. But stage and size of the hole, along with surgical technique, affect the results in macular hole surgery more than the selection of the tamponade agent, making gas preferred in most cases.
Eugene de Juan, MD, is an OSN Retina/Vitreous Board Member.