SFT Pupilloplasty Effectively Treats Silicone Oil Glaucoma | Healio

A minimally invasive procedure, single-pass four-throw (SFT) pupilloplasty, offers a swift and cost-effective solution for silicone oil-induced angle-closure glaucoma, a complication that can arise after retinal detachment surgery. The technique, detailed in reporting from Healio, allows surgeons to resolve the condition without necessarily requiring a referral to a glaucoma specialist.

Understanding Silicone Oil Synechiae Glaucoma

Silicone oil is frequently used as a tamponade following retinal detachment surgery to help the retina reattach. Still, in some instances, the pressure exerted by the oil on the structures within the eye can lead to the formation of peripheral anterior synechiae – essentially, adhesions between the iris and other structures. These synechiae can close the angle formed by the iris and cornea, increasing intraocular pressure (IOP) and leading to a specific type of glaucoma known as silicone oil synechiae (SOS) glaucoma.

According to Amar Agarwal, MS, FRCS, FRCOphth, of Dr. Agarwal’s Eye Hospital and Eye Research Centre, SFT pupilloplasty demonstrates a “very well” and “immediate, everlasting effect” in these cases. The SFT pupilloplasty technique was initially described as a refractive procedure for highly aberrated corneas.

Traditional approaches, such as peripheral iridectomy (creating a small hole in the iris) or removing the silicone oil, don’t always resolve the issue. Agarwal emphasizes that simply removing the oil isn’t always sufficient to normalize IOP, and without further intervention, patients risk optic atrophy and blindness. Retinal detachment surgery with silicone oil tamponade can, in some cases, lead to this complication.

Diagnosis with Anterior Segment OCT

Diagnosing SOS glaucoma involves imaging the eye with anterior segment optical coherence tomography (OCT). This imaging allows clinicians to visualize the structures in the front of the eye and determine if the iris is adhered to the cornea, indicating angle closure. Agarwal explains that anterior segment OCT provides a quick assessment: if there’s no angle closure, removing the oil is usually sufficient. However, if high pressure and a closed angle are observed, SFT pupilloplasty should be performed after oil removal.

The SFT Pupilloplasty Procedure

The SFT pupilloplasty procedure itself is relatively straightforward. After removing the silicone oil, two small incisions (paracenteses) are made in the cornea. The iris is then gently grasped to detach the synechiae. A 10-0 Prolene suture is carefully passed through the iris tissue, and a specialized technique involving a second needle and suture loops is used to draw the edges of the iris together. The suture ends are then cut, completing the procedure.

The procedure typically takes between 5 and 10 minutes and is considered safe and easy to perform. The cost to the surgeon is minimal, primarily the cost of the suture. This contrasts with more invasive alternatives like Ahmed valve implantation or trabeculectomy, which are typically reserved for more complex glaucoma cases.

Accessibility and Versatility

A significant advantage of SFT pupilloplasty is its accessibility. It doesn’t require specialized glaucoma training, meaning that retina surgeons can perform the procedure immediately after removing the silicone oil. This eliminates the need for a referral and potentially speeds up treatment. As Agarwal states, “Anybody can do this surgery, whether they are retina, glaucoma, cataract, cornea or refractive surgeons.”

Sunir J. Garg, MD, FACS, FASRS, of Mid Atlantic Retina, Wills Eye Hospital, corroborates this assessment, noting that the technique is simple, fast, and allows retina specialists to manage cases they might otherwise refer to a glaucoma colleague. Glaucoma perception and adherence to medication can impact quality of life.

Garg learned the technique from Agarwal and has consistently used it in his practice. He suggests that surgeons new to the technique practice on simpler cases, such as correcting irregular irises, before tackling SOS glaucoma. He also highlights the potential for the technique to prevent recurrence of angle closure, a common issue with other approaches.

Growing Recognition and Future Directions

Whereas silicone oil-induced secondary glaucoma is becoming less frequent with advancements in surgical techniques, it remains a potential complication. The increasing recognition of SFT pupilloplasty as a simple and effective solution is encouraging. Garg notes that the technique is increasingly discussed among ophthalmologists as a viable option for managing these cases.

For more information, Amar Agarwal can be reached at [email protected] or through his hospital’s website: www.dragarwal.com. Sunir J. Garg can be contacted at [email protected].