Silicone Oil Removal–Related Vision Loss (SORVL)

SORVL Quiz

Expanded Review based on Survey of Ophthalmology, 2026

🔎 Background & Clinical Context

• Silicone oil (SO) is a cornerstone in vitreoretinal surgery, especially for complex retinal detachments (giant retinal tears, proliferative vitreoretinopathy, trauma, endophthalmitis).
• Its role as a long-term endotamponade is invaluable, but complications are well-documented: emulsification, glaucoma, keratopathy, and retinal toxicity.
• A particularly concerning complication is vision loss after SO removal (SORVL), often unexplained despite normal anatomical outcomes.
• This phenomenon challenges surgeons because it undermines otherwise successful anatomical repairs.

📊 Epidemiology & Risk Profile

• Reported incidence varies widely: 1–33%, reflecting differences in definitions and study designs.
• Large multicenter series: 3.3–5.9% incidence, mean age ~50 years, with male predominance.
• Some retrospective cohorts report higher rates (up to 38%), especially in macula-on detachments and giant retinal tears.
• Risk factors suggested:
  • Macula-on retinal detachment at baseline.
  • Elevated intraocular pressure (IOP) during tamponade.
  • Longer SO retention times (though evidence is mixed).
  • Severe baseline pathology requiring SO use (confounding factor).

⚙️ Pathophysiological Mechanisms

Multiple hypotheses exist, none fully conclusive. Likely multifactorial:

1. Toxic Damage

   • Low molecular weight components (LMWC) in SO may penetrate tissues, exerting long-term toxicity.
   • Dissolution of macular pigments (lutein, zeaxanthin) → increased susceptibility to photo-oxidative damage.

2. Metabolic/Ionic Imbalance

   • SO disrupts buffering of K⁺ and Mg²⁺ in the vitreous.
   • Elevated intracellular K⁺ → excitotoxicity and ganglion cell death.
   • Mg²⁺ deficiency → NMDA receptor overstimulation, retinal toxicity.

3. Phototoxicity

   • During SO removal, the shrinking bubble acts as a magnifying lens.
   • Foveal illuminance increases up to 157%, potentially causing acute photochemical damage.
   • Longer removal times = greater risk.

4. Barometric/Mechanical Factors

   • Acute IOP spikes during aspiration or fluid-air exchanges.
   • Iatrogenic optic nerve trauma.
   • Multiple exchanges leading to unstable pressure dynamics.

🧪 Clinical Features & Diagnostic Findings

• Onset: Usually immediate to within weeks post-removal.
• Symptoms:
  • Sudden drop in BCVA (≥2 Snellen lines).
  • Central scotoma, blurred central vision, color desaturation.
  • Afferent pupillary defect in some cases.
• OCT:
  • Inner retinal thinning, ganglion cell complex loss.
  • Microcystic changes in inner nuclear layer.
  • Occasionally intact outer retina despite profound vision loss.
• Microperimetry:
  • Deep central scotoma, reduced foveal sensitivity.
• Electrophysiology:
  • ERG: reduced amplitudes, macular dysfunction.
  • VEP: delayed responses, optic nerve involvement.

📈 Prognosis & Outcomes

• Frequently irreversible, with vision loss persisting months after removal.
• Some cases show partial recovery (gradual improvement over 3–6 months).
• Prognostic factors remain unclear; recovery may depend on intraoperative conditions and SO composition.

💡 Clinical Pearls

• SORVL is underrecognized — incidence likely underestimated.
• Prevention strategies:
  • Minimize SO retention time (ideally 3–6 months).
  • Control IOP during tamponade and removal.
  • Reduce microscope light exposure during removal.
• Monitoring:
  • OCT and microperimetry for early detection.
  • Careful postoperative follow-up to identify subtle central vision changes.
• Research gaps:
  • Molecular characterization of SO purity.
  • Standardized definitions of vision loss.
  • Prospective trials on intraoperative illumination and fluid dynamics.

✨ Blog Angle for Farabi Retina

This expanded review positions SORVL as a critical but overlooked complication in vitreoretinal practice. For your readership, it emphasizes:

• The need for vigilance in postoperative care.
• The importance of understanding multifactorial mechanisms (toxic, metabolic, phototoxic, mechanical).
• The call for standardized protocols to reduce risk and improve outcomes.

Citation:

Ruggeri, Maria Ludovica, et al. “Silicone oil removal-related vision loss.” Surv. Ophthalmol., vol. 71, no. 1, 1 Jan. 2026, pp. 61-70, doi:10.1016/j.survophthal.2025.08.011.