Periorbital Subcutaneous Perfluoron Is Well Tolerated Following Intravitreal Surgery

Abstract

Purpose:

Perfluorocarbon liquids (PFCLs) are well tolerated in intraocular surgery, but chronic exposure can cause inflammation. PFCL leakage into the orbit without significant sequelae has been reported, but PFCL leakage into the preseptal subcutaneous tissues has not been described.

Methods:

A case report is presented.

Results:

A 46-year-old man presented with hand motion vision from a ruptured globe and retained intraocular foreign body. Intraoperatively, the foreign body could not be removed, and PFCL extravasated from the posterior globe rupture. Postoperative imaging revealed hyperdense material in the orbit, lids, and superficial adnexal tissues. The patient tolerated the retained PFCL, and imaging 10 months later demonstrated interval resorption. The patient eventually developed ocular siderosis and underwent transconjunctival orbitotomy with foreign body extraction. Two years following the initial injury, his vision remained stable at 20/40 without further sequelae.

Conclusions:

PFCL is well tolerated in the extraocular space and may resorb with conservative management.

Introduction

Perfluorocarbon liquids (PFCLs) are clear, low-viscosity, high-density substances that are widely used in intravitreal surgery. ¹ These properties make PFCLs optimal surgical adjuncts in stabilizing the retina, shifting subretinal fluid, and supporting the removal of an intraocular foreign body. Multiple studies have demonstrated the safety of temporary use of PFCLs during intravitreal surgery. ^{2 -4} Chronic exposure, typically documented as weeks of contact, has been shown to induce inflammation in animal and human studies. ^2,5 In addition to intraocular inflammation, retained PFCL can lead to corneal toxicity and secondary open-angle glaucoma. ^{1,6 -8} Rarely, PFCL is retained in the extraocular space, with only 3 prior cases describing PFCL leakage into the orbit. ^{9 -11} We report the first documented case to our knowledge of PFCL leakage into the extraorbital subcutaneous tissues.

Methods

Case

A 46-year-old man presented to the emergency department after a piece of steel cable flew into his right eye. On presentation, his vision was hand motion. There was an obvious anterior sclerocorneal entry wound with active aqueous extravasation. Computed tomography (CT) imaging revealed a metallic foreign body extending from the vitreous cavity into the orbit. B-scan ultrasonography demonstrated a hyperreflective band protruding through the posterior pole.

The patient underwent emergent corneoscleral repair followed by 25-gauge pars plana vitrectomy. The foreign body with a surrounding retinal detachment was visible superonasal to the optic nerve, but it could not be extracted because of substantial resistance between the sclera and the crimped end of the cable (Figure 1). Perfluoron (Alcon) was injected to stabilize the retina. During the air-fluid exchange, it was noted that Perfluoron was leaking into the orbit through a posterior globe rupture. The remaining Perfluoron was aspirated and 14% C₃F₈ (perfluoropropane) was injected. The sclerotomies were sutured and no gas leak was noted.

Figure 1.

Wide-angle fundus photograph reveals a large, perforating, metallic intraocular foreign body superonasal to the optic nerve.

Postoperative orbital CT showed the foreign body extending from the posterior globe (Figure 2A). It also demonstrated hyperdense material in the posterior and lateral orbit, preseptal upper and lower lids, and superficial tissues overlying the temporal fossa, which was consistent with retained PFCL.

Figure 2.

(A) Noncontrast orbital computed tomography (CT) immediately after surgical repair demonstrates a retained metallic intraocular foreign body (solid arrow), intravitreal gas tamponade, and hyperdense lobular material in the postseptal orbit (asterisk), preseptal eyelid (arrowheads), and temporal fossa (dashed arrow). (B) Repeat noncontrast CT 10 months after initial presentation illustrates retention of the foreign body, residual postseptal hyperdensity, and interval decrease in preseptal and temporal fossa hyperdense material.

Results

Given the patient’s active illicit drug use and contraindication to general anesthesia, a decision was made to forego further attempts at foreign body removal. In the ensuing months, his periorbital tissue edema gradually resolved. A second orbital CT 10 months later demonstrated an interval decrease in hyperdense material (Figure 2B).

The patient eventually developed signs concerning for ocular siderosis and underwent transconjunctival orbitotomy to extract the foreign body (Figure 3). Two years following the initial injury, his vision remained stable at Snellen 20/40 with no further sequelae and a stable peripapillary scar (Figure 4).

Figure 3.

Intraoperative photograph of the superonasal approach to retrobulbar removal of a metallic intraocular foreign body.

Figure 4.

Wide-angle fundus photograph 2 years after initial repair demonstrates interval removal of an intraocular foreign body with superonasal peripapillary chorioretinal scarring.

Conclusions

PFCLs gained widespread attention in 1966 when Leland Clark and Frank Gollan demonstrated liquid ventilation in mice using an oxygen-saturated PFCL. ¹² In addition to their high diffusion capacity, PFCLs’ ability to fill the alveoli and displace edema led to their use as an inhaled drug-delivery system. ^13,14 PFCLs have also been used as a blood substitute for patients in hemorrhagic shock or suffering from a variety of ischemic diseases. ¹⁵ When Stanley Chang reported the first ocular use of PFCLs for retinal detachment repair in 1987, these substances had been extensively studied and shown to be well tolerated with minimal inflammatory reactions elsewhere in the body. ¹⁶

To the best of our knowledge, there are 3 prior cases of retained PFCL in the orbit. In each case, hyperdense material was noted on orbital CT imaging, consistent with the present case. However, none of the prior cases reported follow-up imaging to demonstrate whether reabsorption was occurring. Although the difference is subtle, there is an obvious decrease in the amount of retained PFCL over a 10-month time period. The mechanism of reabsorption likely occurs through macrophage phagocytosis as previously demonstrated in pathologic studies. ¹⁷ Retained PFCL is known to cause inflammation, but it seems that extraocular PFCL is well tolerated. In the present case there was no evidence of orbital or subcutaneous inflammation. Of the other reported cases, 1 patient developed transient scleritis 2 weeks after surgery that was successfully treated with oral steroids. ⁹ In the other 2 cases, there was no evidence of orbital inflammation. ^10,11

Orbital PFCL typically arises from a posterior globe rupture from a penetrating trauma. ^1,8 Iatrogenic posterior globe rupture from retrobulbar anesthesia has also been reported as the likely entry site for orbital PFCL. ⁹ It is unclear in this case how the PFCLs migrated from the postseptal orbit into the preseptal soft tissue and temporal fossa. One explanation is anterior ocular leakage from the entry wound, although this seems improbable given the wound was repaired before intravitreal PFCL injection. More likely there was a traumatic break in the orbital septum, allowing for extravasation of the PFCLs into the eyelids and ultimately the temporal fossa.

Our patient tolerated the intraorbital and soft-tissue PFCLs well, with resolution of edema and radiologically confirmed decrease in high-density material. This report is the first to our knowledge to describe retained PFCL in extraorbital subcutaneous tissues. It also reconfirms that PFCL is likely well tolerated in the extraocular space and slowly absorbed over time. Although intraocular PFCL retention warrants surgical evacuation, patients with leakage into the orbit and surrounding soft tissues may be observed with repeated examination and imaging.