Scleral buckling for rhegmatogenous retinal detachment

Scleral Buckling For Rhegmatogenous
Retinal Detachment.
Conventional Or External Retinal Detachment Surgery
Dr. Usman Attique
Retina Resident Hayatabad Medical Complex
Peshawar, Pakistan.

Retinal detachment
• Retinal detachment refers to the detachment of the neurosensory retina from the
underlying retina pigment epithelium (RPE).
• Rhegmatogenous retinal detachment include a retinal break (rhegma = rent or
rupture) and vitreous liquefaction sufficient to allow fluid in the vitreous cavity to
pass through the break(s) into the subretinal space.

History
James Ware, M.D., F.R.S. (1756–1815) an
English eye surgeon, and Fellow of the Royal
Society.
In 1805 he first described retinal detachment ,
also attempted the first surgery for retinal
detachment and suggested the drainage of
subretinal fluid by puncturing the sclera with a
knife.
James Ware

Cont.
Von Graefe (22 May 1828 – 20 July 1870) German
ophthalmologist considered one of the more important
figures in 19th century ophthalmology. His achievements
were method of treating glaucoma and a new surgical
method for cataract.
In 1863 he modified the method of surgery by also
puncturing the retina and creating a second hole for the
drainage of the subretinal fluid into the vitreous cavity.
Von Graefe (22 May 1828 – 20 July 1870)

Cont…
Jules Gonin (10 August 1870 – May 1935) a Professor of
ophthalmology who pioneered the procedure of
ignipuncture(cauterised the retina through the sclera
with a very hot pointed instrument), the first successful
surgery for the treatment of retinal detachments.
He was the one who first described that retinal
detachments was caused by presence of retinal break
and sealing of this breaks to be the prime factor
responsible for successful reattachment of the retina
after surgery.
He conceptualized the idea of mechanical or scar-induced
sealing of the hole in the retina.
Jules Gonin (10 August 1870 – May 1935)

Cont…
Charles Louis Schepens (March 13, 1912 – March 28,
2006) an Belgian (later American) ophthalmologist,
regarded by many in the profession as "The Father Of
Modern Retinal Surgery“.
Schepens invented the BINOCULAR INDIRECT
OPHTHALMOSCOPE (BIO), he also pioneered surgical
technique of scleral buckling , which raised the success of
retinal reattachment surgery from 40% to 90%.
Charles Louis Schepens (March 13, 1912 – March 28, 2006)

Cont..
Harvey A. Lincoff, MD, 1920–2017 founder of modern
retinal detachment surgery, he recommended non-
drainage procedures and changed diathermy to
cryotherapy for retinopexy.
In 1971 , he pioneered an understanding of the patterns
of retinal detachment and defined the important Lincoff
rules how to find the retinal break in a detachment.
Harvey A. Lincoff, MD, 1920–2017

Scleral buckling surgery
• Referred to as CONVENTIONAL OR EXTERNAL RD SURGERY, in which surgical
material (EXPLANT) is sutured onto the sclera to creates an inward indentation.
The term “buckle” refers to deformation of a structure under stress.
• Its purpose is to close retinal breaks by apposing the RPE to sensory retina and to
reduce dynamic vitreoretinal traction.

Buckling principles
• Preoperative and Intraoperative examination with the goal of locating all retinal
breaks.
• Creating a controlled injury to the retinal pigment epithelium (RPE) and retina to
produce a sterile chorio-retinal adhesion surrounding all retinal breaks so that
intravitreal fluid can no longer reach the subretinal space.
• Draining subretinal fluid (SRF) if necessary.
• Employing an appropriate technique such as scleral buckling and/or intravitreal
gas for approximation of neurosensory retina (break) with RP.

Reattachment forces influenced by scleral
buckles
• Several beneficial effects of a scleral buckle.
a) Reduction of vitreoretinal traction by displacing the eye wall and retina
centrally.
b) Displacement of subretinal fluid away from the location of the retinal break
and scleral buckle.
c) Approximation of the retinal break and adjacent vitreous gel.
d) Increase in resistance to fluid flow through the retinal break, with consequent
increase in the relative reattachment forces.
e) Alteration in the concave shape of the eyeball, resulting in a change in the
effect of intraocular currents that encourage liquid vitreous to enter the
subretinal space.

Preoperative management
Eye Patching :
• Both eye should be patched to limit the conjugate movement of eye.
• Patching reduces the inertial force induced by eye movement and prevent
extension of subtotal detachment especially important if macula is threatened.
• Patching may accelerate settling of mild or moderate vitreous hemorrhage
allowing improved visualization of the fundus avoiding vitreous surgery.
• Patching is used only 24–48 hours prior to surgery.

Preoperative Activity and Head Positioning
• Bed rest seems to reduce the amount of eye movement, thereby decreasing
vitreoretinal traction.
• When the head is positioned such that the retinal break is in a dependent
location, SRF may pass through the break into the vitreous cavity and vitreous gel
may also be in contact with the break causing functional closure of the break.

Prevention of Infection
• Infectious conjunctivitis or blepharitis is treated medically before retinal
reattachment surgery. Broad spectrum topical antibiotics are used preoperatively
to reduce the bacterial flora on the conjunctiva and lid margins.
• A technique without drainage of SRF may also help to reduce the risk of
endophthalmitis.

Open Angle Glaucoma or Glaucoma Secondary to
Retinal Detachment:
• Eyes with raised pressure are treated to control the intraocular pressure (IOP)
before the surgery. This minimizes the risk of corneal edema, permits more
effective scleral depression and lessens the risk of complications related to
sudden hypotony in cases in which drainage of SRF is necessary.
Cataract
• Cataract surgery can be done prior to buckling or simultaneous cataract and
vitreous surgery chosen.
• If there may be significant posterior capsular opacity compromising visualization.
A large Nd:YAG laser capsulotomy is performed to allow fundus examination in
these cases.

Cont..
Anesthesia:
• Patient’s general medical condition is evaluated before surgery.
 Cardiovascular and Pulmonary systems, Drugs and other allergies should be
assess.
The choice of anesthesia depends upon specific feature of case and also on the
preferences of the surgeon and the patient.
 Majority of scleral buckling procedures are now performed under local
anesthesia.

Cont..
• Advantages of local anesthesia
Shorter operating time.
Quicker postoperative recovery.
Reduced risk of morbidity and mortality.
• Disadvantage of local anesthesia.
 Globe perforation.
Optic nerve damage and injection into the optic nerve dural sheath.
 Inadequate analgesia.

Cont..
• General anesthesia:
General anesthesia provides ideal for younger patients, uncooperative patients,
and for reoperations (when local anesthesia may be less effective).

Preparation of the site
• Patient’s head is positioned to improve exposure of the eye.
• The chin should be elevated slightly.
• Lid margins and periocular skin are prepared with 10% povidone iodine solution
followed by application of 5% povidone iodine solution.
• Pupil should be maximally dilated preoperatively with mydriatic drops to permit
effective indirect ophthalmoscopy.

Surgical steps
A circumferential limbal peritomy with radial
relieving incisions is made. The conjunctiva 3–4
mm behind the limbus is grasped with forceps and
gently lifted creating a radial fold of conjunctiva .
Conjunctival Peritomy
Great care is taken not to tear the conjunctiva.
The extent of the peritomy depends on the size of the
buckle planned.
Conjunctival Peritomy

Slinging Rectus Muscles
The muscle is engaged with a sweeping posterior and
circumferential movement around the globe employing a
specialized muscle hook.
Very posterior “sweeps” risk damage to the vortex veins.
Once a rectus has been successfully hooked, the globe moves
with the hook.
A large braided (e.g., 2-0 silk) bridle suture is passed under the
muscle. The sclera is now inspected for dark ectatic areas ,
suturing and for cryotherapy.

Localization and intraoperative
examination
The surgeon should carefully examine the retina 360° with
binocular indirect ophthalmoscopy and scleral indentation.
• The number and location of retinal breaks.
• The extent of the detachment.
• The amount of elevation.
• Whether the macula is detached.
The position of each retinal break is marked externally on the
sclera. The scleral mark can then be enhanced with a sterile
pen, cautery or both
The locations of other lesions or areas to be supported by the
scleral buckle are also marked on the sclera. e.g lattice
degeneration, atrophic holes and vitreoretinal traction.

Treating the breaks
• Retinal break can be treated to produce the chorio-retinal adhesion.
• Three energy source which are use to treat retinal break are
1. Diathermy.
2. Cryotherapy.
3. Photocoagulation.

Diathermy.
It produced chorio-retinal adhesion by delivering high frequency (MHz) current
through the tissues which generates heat.
Diathermy is now rarely used because of the following reasons :
• Causes immediate shrinkage and subsequent necrosis of the sclera.
• Raises IOP due to shrinkage.
• It causes choroidal and retinal bleeding, and retinal holes.
• Its high intensity application causes rupture sclera, choroidal scaring.

Cryotherapy
Its use in ophthalmology was popularized by Lincoff in later
part of 1960s. It applied through full thickness sclera with
causing significant damage and can be applied to treat
detached retina.
Modern units use nitrous oxide gas to produce cooling up to –
89°C. The temperature effect is confined to the tip of the probe
by an insulating sleeve. A probe of 2.0–2.5 mm in diameter
usually is used for retinal work. The treatment end point is
retinal whitening without ice crystal formation.
Cryotherapy should be applied while observing the fundus with
the ophthalmoscope, using the cryoprobe in place of scleral
depressor.

Cryotherapy
Small retinal breaks and atrophic retinal holes can be treated
with single freeze centered on the retinal break. Larger breaks
or lesions should be surrounded with 1–2 mm of contiguous
treatment. More then one row may be required anteriorly to
extend the future adhesion into the vitreous base.
Disadvantages of cryopexy include the dispersion of viable
pigment epithelial cells which can cause PVR, choroidal
congestion and hyperemia which may complicate drainage of
SRF through treated areas, breakdown of blood ocular barrier
and development of postoperative cystoid macular edema
(CME) and exudative detachments.
Treated retina with cryotherapy

Photocoagulation
Another means of creating RPE-retinal adhesion is through
laser application. Laser may be delivered through laser indirect
ophthalmoscope or transscleral route. Laser induces an
adhesive effect between the retina and pigment epithelium
within 24 hours, and carries less morbidity.
Confluent treatment around retinal breaks with medium
intensity gray white burns should be applied.
Laser treatment can be delivered with precise location and
intensity. Compared with cryotherapy, laser causes less
inflammation and does not cause dispersion of RPE cells into
the vitreous cavity eventually leading to low incidence of
postoperative PVR.

Methods of buckling
Scleral buckle is prepared to support all retinal breaks and retinal degeneration
The buckling material may be sutured to the surface of the sclera (explant).
be placed beneath scleral flaps after lamellar scleral dissection (implant).
Explant Techniques Popularized by Ernst Custodis in 1953. He described placement
of a polyviol explant that was sutured to the sclera overlying
any retinal break.
• They are easier and quicker to place.
• There is minimal damage to the sclera.
• The configuration and height of the buckling effect can be selected more easily
• The technique can be used in almost all eyes, including those with thin sclera.
• The risk of endophthalmitis is reduced.
• Use of episcleral explants is readily combined with cryotherapy.
Ernst Custodis

Buckling Materials
Solid silicone rubber: Silicone rubber is available as symmetric
or asymmetric tires, bands, strips and wedges of different
shapes and sizes.
Silicone sponge: Sponges have many air filled pockets that give
them great compressibility and elasticity, and also make them
considerably softer.
Hydrogel implant: The MIRA gel implant, a non-biologic
hydrogel, was used until 1996, when the manufacturer stopped
its distribution. It is associated with late onset complications
such as extrusion, fragmentation, limitation of ocular motility,
and intrusion between 7 years and 11 years after implantation.

Choice of Scleral Explant
A detachment with a single elevated equatorial tractional tear.
Example 1
May be closed successfully using a single radial sponge
without drainage of subretinal fluid.

Example2
A detachment due to a series of round retinal holes,
The holes are anterior to the equator at various distances
from the ora.
They may be treated with a circumferential explant. A very
high indent is not required because there is no traction on the
breaks and the fluid is very shallow. As the distance from the
ora varies the broader indentation from a tire can close all the
breaks.

Example 3
A Pseudophakic eye with a total retinal detachment. Good
visualization of the peripheral retina is impeded by peripheral
capsule opacification and limited pupil dilatation. No tears are
seen.
An encircling tire may be used. The buckle may be secured just
behind the rectus muscle insertions to support the anterior
retina where the breaks are likely to be located. The tire
supports the whole area of subretinal fluid (“dry-to-dry”
buckling). The placement of an encircling silicone band in the
groove of the tire maintains the height of the indent so that
undetected retinal breaks remain closed.

Example 4:
Three tractional tears are present.
They can be treated with separate radial sponges or with a
single circumferential buckle.

Example 6:
A retinal dialysis.
3-mm circumferential sponge usually works well.

Scleral Sutures
Once the breaks have been marked, the size and position of the
required buckle should be apparent so that partial-thickness
scleral mattress sutures are placed.
Monofilament nylon and polyester are used to suture explant on
Sclera, due to its properties durability, biocompatibility,
and ease of handling.
The suture bites are oriented parallel to the long axis of the
explant (i.e., radial suture bites for a radial explant,
circumferential bites for a circumferential explant).

Cont..
The distance between the bites is significantly greater than the
width of the explant. This allows the sclera to partially envelop
the explant, creating the indent. For example, when suturing a
5-mm sponge, the bites are placed 8 mm apart.
The sutures need to be placed partial thickness (12–13)
through the sclera. As the sclera is only 1 mm thick, care needs
to be taken to avoid scleral perforation. A spatulated needle
rather than a cutting needle is used. The spatulated needle
profile has a flat top and bottom and cutting lateral edges.

Subretinal fluid drainage
Drainage of subretinal fluid is a useful step to aid in the repair
of retinal detachment during scleral buckling surgery.
The rationale for drainage of SRF is to diminish intraocular
volume so as to achieve good buckle height without causing
elevated IOP and to reduce SRF, enabling approximation of the
retinal breaks to the RPE over the buckle, facilitating closure of
the breaks.
SUBRETINAL FLUID DRAINAGE

Indications for SRF Drainage
• Bullous detachments.
• Chronic detachments.
• Highly myopic and aphakic or pseudophakic detachments.
• Inferior breaks.
• Poor retinal pigment epithelium function.
• Eyes with known glaucoma.
• Eyes in which no apparent retinal break is found.
• Eyes needing more extensive buckling of multiple breaks.

Technique of Drainage
Selection of the Drainage Site:
• Drainage should be performed in an area where there is sufficient SRF to enter
the subretinal space safely.
• It should be avoided in areas treated with cryotherapy, because choroidal
congestion induced by cryotherapy may predispose to hemorrhage.
• The long ciliary neurovascular complexes run at 3 and 9 o’clock, and these sites
should be avoided, as should the area around the vortex veins. Sites adjacent to
(but not under) the horizontal recti are optimal from the perspective of avoiding
choroidal vasculature.

Cont..
• Where feasible, nasal quadrants are preferred because if subretinal bleeding
complicates drainage, it would be less likely to track under the macula.
• It is best to drain in the bed of the buckle because any inadvertent retinal
perforation or incarceration will automatically be supported without the need for
additional buckling or revision of the buckle.
• The site for drainage is usually selected as far away from the retinal break(s) as
possible, to minimize the chance of liquid vitreous passing from the vitreous
cavity through the break and into the subretinal space.

Drainage Techniques
Cut Down Techniques.
A scleral incision 3 mm in length is made in the sclera,
repeatedly spreading the edges, then incising the base of the
resulting groove. The choroid becomes increasingly visible in
the base of the incision. Finally, a small knuckle of bare choroid
protrudes slightly.
The choroidotomy can be made with a needle.
Thermal choroidotomy may be used to reduce
the risk of bleeding with this technique. A
diathermy needle may be used to coagulate
the choroidal vessels and a diathermy needle
used to perforate the choroid.
Cut Down Techniques

Cont..
Single-Stage Techniques
A technique using a 25-gauge hypodermic needle attached to
an open syringe under ophthalmoscopic visualization. The
needle enters the globe anteriorly and is passed under the
buckle and obliquely posteriorly in the subretinal space.
Retinal incarceration is extremely unlikely, and any retinal
breaks created will be in the bed of the buckle and therefore
supported. An increased risk of intraocular bleeding has been
reported however. This may be averted by increasing the
intraocular pressure to close the choroidal vascular bed, for
example, by tightening an encircling band prior to drainage.
Single-Stage Techniques

Adjusting Intraocular Volume
• If excessive drainage results in hypotony, IOP may be restored by tightening the
buckle or by injection of air, gas or balanced salt solution (BSS) through the pars
plana.
• Gas is injected with moderate rapidity in one movement to obtain a single large
bubble, and prevent many small bubbles that would interfere with visualization
of the fundus.
• Air is used most commonly for intraocular injection, although expandable longer
acting gases are sometimes used, such as sulfur hexafluoride (SF6) or a
perfluorocarbon gas such as C3F8. The intraocular tamponade effect of the
bubble is usually needed for only 24–48 hours to temporarily flatten the retinal
break against the scleral buckle and/or to functionally close the retinal break by
physically obstructing the break while the SRF is absorbed.

Assuring perfusion of central retinal artery
• It can be difficult to tell whether the central retinal artery is patent. If pulsations
of the central retinal artery are observed, perfusion is marginally sufficient.
• If pulsations are not visualized and perfusion is questioned, additional digital
pressure should be applied to the globe to elicit pulsations. If these do not occur,
the arterial flow into the eye has probably ceased, and IOP must be reduced if
pulsations do not begin soon.
• IOP can be reduced by drainage of SRF, paracentesis, aspiration of fluid vitreous,
reduction in circumferential contraction of the buckle, or relaxation of sutures
causing indentation of the buckle.

Nondrainage procedure
• The primary advantage of a nondrainage procedure is avoidance of the possible
complications associated with drainage.
• Nondrainage procedures have been shown to reattach the retina with success
rates comparable with those of drainage procedure.
• The selection of patients for drainage or nondrainage is usually a matter of
surgeon’s preference.
• Most nondrainage procedures are effective if the crest of the buckle is within 3
mm of the respective retinal break.

Indication of non-drainage procedure
• Superior retinal breaks when the surrounding retina was close enough to the
pigment epithelium to be frozen by the cryo applications.
• Retinal breaks located anterior to the equator associated with low retinal
detachment.
• Significant preoperative absorption of SRF after bed rest and bilateral patching.
• Nondrainage procedure often requires lowering the IOP by either medical or
surgical means. A 27–30-gauge needle can be used to remove 0.3–0.4 mL of
aqueous at one time intraoperatively.

POSTOPERATIVE MANAGEMENT
Medications:
• Systemic analgesic and anti-inflammatory medication (NSAIDs), is given to reduce
pain and inflammation.
• Frequent applications of steroid and antibiotic eye drops.
• A topical mydriatic/cycloplegic medication is used routinely to dilate the pupil.
This regimen reduces inflammation and lowers the chance of developing
posterior synechiae. It also allows examination of the retina.

Postoperative Examination
• Early postoperative examination is usually brief, but it must be complete enough
to determine the status of the retina and to detect significant complications.
• Cornea is examined for epithelial defects.
• The anterior chamber is examined for cells and protein flare. A few cells and mild
flare are common as a result of postoperative iritis. A severe cell and flare
reaction may indicate endophthalmitis and anterior segment ischemia.
• IOP is measured daily until it is normal and stable.

Cont.
• The optic nerve head is examined to be certain that the central retinal artery is
open and that retinal perfusion is adequate.
• The macula is examined to determine whether it is reattached and whether
there are visible abnormalities such as subretinal hemorrhage or pigment.
• The retinal breaks are examined to determine whether they are flat against the
pigment epithelium.
• In uncomplicated cases, the patient is scheduled to return for additional follow-
up after about 1 week. If there are no problems, subsequent follow-up
examinations are completed at 4 weeks, 3 months, 6 months and yearly
thereafter.

Cont..
• If gas has been injected, the patient will require specific instructions regarding
head position and restriction from air travel. Air travel or ascent to high altitude
may cause rapid expansion of the bubble and dangerously high elevation of IOP.
• Patients are often told not to engage in exertional manual labor or heavy lifting
for at least 4 weeks.
• Patients are instructed not to work in a dirty or dusty environment for 2–3
weeks, until the conjunctival incision has fully healed.

DO WE STILL NEED BUCKLE IN
THE
VITRECTOMY ERA ?

I believe
the answer is “yes,” but only if ophthalmologists continue to
perform and teach these procedures.
If we do not, perform scleral buckling procedures it will pass
into
history.

Cont..
A PubMed search revealed the following:
• In 1956, 2745 articles have been published on scleral buckling; in 1970, 12 341
articles have been published on PPV; since 1972, 1073 articles have been
published on scleral buckling plus PPV. In the past 5 years, the difference is even
more pronounced, with 395 articles on scleral buckling, 3126 on PPV, and 234 on
both procedures.
• Medical research in US also reflect this trend. From 2000 to 2011, use of the PPV
code has more than doubled, from about 15 000 annual procedures to about 32
000. Meanwhile, the use of scleral buckling has declined, from 6000 to 2000
procedures per year.

Cont..
Several factors may be responsible for these changes.
• The availability of small-gauge instrumentation, wide-angle viewing systems,
high-speed cutters, and better illumination have made PPV much easier. Surgeons
may also lack confidence in their skills with indirect ophthalmoscopy, and there is
less time spent on scleral buckling by mentors and training programs. Economic
and time factors play a role. In addition, there is no industry support of scleral
buckling at this point.
• “The average cost of a buckling procedure in Pakistan is around 10,000-15,000
PKR , while the average cost of a 20-gauge vitrectomy is around 50,000-60,000
PKR” .

Cont..
• Scleral buckling is a low-budget procedure, while vitrectomy uses expensive
equipment. It is obvious that industries push toward using, studying, spreading
and publicizing vitrectomy,”
• On the other hand, the lower cost of buckling should be an incentive to keep it
alive and use it more.
• Buckling is an elegant form of surgery with many variations, and the more of
them one surgeon knows, the more options he or she will have to reattach the
retina.

MISCONCEPTIONS
Success rates: The success rate with scleral buckling is lower than that with PPV.
Reviewing the published results or retrospective and prospective comparative case
series from 2000 to the present, success and failure of the primary procedure in the
treatment of 7678 rhegmatogenous RDs by 176 surgeons on 5 continents. Final
success rate in phakic eyes was higher with scleral buckling than with PPV (99.5% vs
98.7%; P = .028).
• The study authors concluded that, in the treatment of uncomplicated phakic RD,
repair using scleral buckling is at least equivalent to PPV.
Adelman RA, Parnes AJ, Ducournau D; European Vitreo-Retinal
Society (EVRS) Retinal Detachment Study Group. Strategy for
the management of uncomplicated retinal detachments: the
European vitreo-retinal society retinal detachment study report
.Ophthalmology. 2013;120(9):1804 180

Cont..
• High complication rate. Scleral buckling has a high incidence of
complications. In literature from the late 1990s, fairly high rates of diplopia
(10–24%), strabismus (4–8%), and buckle extrusion (3–8%) were reported after
SBP. Most of these reports of intractable strabismus and other complications
were related to hydrogel buckling elements that are no longer used.
• Study published in 2010 shows that the rate of diplopia and strabismus was not
statistically significantly different between scleral buckling (5.2%) and PPV (3.6%;
P = .29). It is true that there is a risk of complications with scleral buckling, as with
any surgery. But the rates of diplopia, migration, and other complications are low.
Shah GK, Almony A, Blinder KJ. Postoperative complications of
retinal detachment repair with scleral buckles. Paper presented
at: Retina Subspecialty Day, Annual Meeting of the American
Academy of Ophthalmology; October 16, 2010.

Cont..
• Higher amount of myopia. There is a significantly higher amount of
myopia after scleral buckling compared with PPV. It is also true that
scleral buckling can induce significant myopia. With proper tensioning of the
band or buckling element, however, this is often much less than many assume.
• In a randomized single-center study, the mean change in refractive error was 1.38
D after scleral buckling and 0.85 after PPV.
Sharma YR, Karunanithi S, Azad RV, Vohra R, Pal N, Singh DV,
Chandra P. Functional and anatomic outcome of scleral
buckling versus primary vitrectomy in pseudophakic retinal
detachment. Acta Ophthalmol Scand. 2005;83(3):293-297

Cont..
• Higher rate of PVR: Rates of proliferative vitreoretinopathy (PVR) are
• higher after scleral buckling than after PPV. Several of the prospective
and retrospective studies are looked for rates of PVR after scleral buckling and
PPV.
• But research shows no statistically significant differences after scleral buckling
and PPV in the rates of re-detachment secondary to PVR (4.3% vs 6.4%,
respectively) or of PVR without detachment (0.7% vs 1.4%, respectively).
Shah GK, Almony A, Blinder KJ. Postoperative complications of
retinal detachment repair with scleral buckles. Paper presented
at: Retina Subspecialty Day, Annual Meeting of the American
Academy of Ophthalmology; October 16, 2010;

Advantages of Scleral Buckling
Scleral buckling offer some advantages over PPV.
• In young patients, the crystalline lens—and therefore accommodation—is
preserved. In older patients, the vitreous is preserved.
• For patients with extensive lattice degeneration or an abnormal vitreoretinal
interface, scleral buckling provides 360° support of the vitreous base and
peripheral retina.
• Scleral buckling is an extraocular surgery, unless drainage of subretinal fluid is
required, and thus lessens the risk of complications related to entering the eye,
such as endophthalmitis.

Cont..
• The equipment and personnel costs are lower with scleral buckling. A comparison
of the costs of scleral buckling and PPV for RD repair found that, considering all
costs, including eventual cataract surgery, scleral buckling procedures were 10.7%
less expensive than PPV for RD repair in phakic patients.

Surgical pearls
• “Basically, scleral buckling is indirect ophthalmoscopy,”
• “Nowadays, people don’t learn it and look at the retina with the slit lamp.
However, only classic indirect ophthalmoscopy allows you to go far out in the
periphery of the retina. It’s a lot more difficult, and you have to learn it over a
long period of time, but if you don’t learn it in the first place, there is no way you
can perform scleral buckling.”
• Localizing all retinal breaks before surgery is a important first step.
• “Surgeons who are not confident with indirect ophthalmoscopy feel that
vitrectomy should be done for internal search of the breaks, which is not such a
great idea,”

COMPLICATIONS OF SCLERAL BUCKLING

COMPLICATIONS OF SCLERAL BUCKLING
• Complications in retinal reattachment surgery can make the operation more
difficult and reduce the anatomic success rate or the final visual result.
Most failures are due to:
• Inability to detect all retinal breaks.
• Errors in surgical judgment or technique.
• Biologic complications, chiefly PVR.

INTRAOPERATIVE COMPLICATIONS
Complications Associated with Anesthesia:
• Ocular damage can occur from compression with a mask during induction of
general anesthesia.
• Retrobulbar hemorrhage or damage to the globe or optic nerve can happen if a
retrobulbar injection is given. It occurs most frequently in myopic eyes, and
additional risk factors include poor patient cooperation and injection by non-
ophthalmologists.

Cont..
Complications During Exposure:
• A vortex vein can be torn when a muscle hook is used to engage the recti. This is
avoided by keeping the hook anterior to the equator.
• Exposure of the sclera and extraocular muscles is more difficult and hazardous in
reoperations and scleral rupture is the most important complication during this
dissection.
• Thin conjunctiva in older individuals and adherent conjunctiva from previous
surgery may lead to irregular tearing and difficult subsequent closure.

Cont..
Rectus Muscle Rupture:
• This occurs occasionally, being common during reoperations. The ends of the
ruptured muscle are immediately identified and sutured together. If a muscle is
lost, attempt is made to locate it by following the intermuscular septum. Medial
rectus is prone to retract when it occur and may be difficult to trace.

Complications reducing Visualization.
Corneal Clouding:
• Damage to the epithelium from solutions used to clean the operative field.
• Direct mechanical trauma by lid speculum or other instruments during the
procedure.
• Epithelial edema due to raised pressure because of traction on the rectus muscle
sutures or because of indentation of sclera during scleral depression or
cryotherapy.
Management : Drying of the epithelium is avoided by intermittent wetting of the
cornea through the operation. Viscoelastic or a sterile gelatin sponge can be placed
over the cornea while scleral dissection or episcleral maneuvers are being
performed and fundus examination is not necessary. Extensive edema usually
requires debridement with a scleral blade.

Cont..
Miosis :
• Hypotony at the time of drainage or paracentesis.
• Excessive cryo-induced inflammation.
• Prolonged surgery.
• Injection of gas in aphakic patients.
Management : Miosis can usually be avoided by frequent preoperative use of
topical mydriatic drops. However, if pupillary constriction occurs intraoperatively,
additional mydriatic drops should be instilled to dilate the pupil. intracameral
administration of 0.1 mL of epinephrine (1:10,000) may be considered.

Cont..
Hyphema:
• Hyphema is a rare intraoperative complication. Etiology includes hypotony,
rubeosis iridis, previous uveitis, anterior chamber IOL or injury from needle
during paracentesis.
Management
• A clear view can be regained by pushing the blood into the chamber periphery
by means of an intracameral injection of sodium hyaluronate.

Cont..
• Intravitreal Gas Injection:
• Multiple tiny bubbles (fish-eggs) can result from improper intravitreal gas
injection and can completely obscure visualization.
Management. This is best avoided by injecting the gas rapidly and positioning the
needle tip so that it stays within the expanding bubble.

Cont..
Complications of Scleral sutures:
• Scleral perforation : is potentially the most serious complication of scleral suture
placement. Perforation with suture needles occurs in about 5% of cases, usually
in myopic eyes with thin sclera for which nondrainage procedures are planned.
• The needle or suture should not be withdrawn rapidly if perforation is suspected.
The fundus should be examined immediately to determine the depth of
perforation.
• If the perforation is limited to the choroid or subretinal space without evidence of
bleeding or continuing SRF drainage, or retinal damage, nothing additional needs
to be done.

Cont..
• If a retinal break or incarceration has resulted, it should be treated by
cryotherapy and supported by extending the buckle more posteriorly. If bleeding
occurs, immediate pressure should be applied to the site of perforation to
tamponade the bleeding, and the eye should be positioned to prevent migration
of a blood beneath the fovea.
• Insufficient suture depth : can cause sutures to cut through during tightening. This
requires replacing the suture more posterior to the previous track.
• It becomes important to pass the suture at the correct depth and for the correct
distance in the sclera.

Complications during Subretinal Fluid
Drainage.
Serious complications are more frequently associated with drainage of SRF than
any other step in the operation. Complications of drainage can be minimized by
proper selection of a perforation site and careful technique, but complications
cannot be completely avoided.
Intraocular and Choroidal Hemorrhage :
• Minor bleeding from the choroid at the perforation site is the most common
complication of draining SRF, Bleeding is usually minimal and is visible internally
as a small red spot in the subretinal space at the sclerotomy site. However, more
extensive subretinal hemorrhage can occur and extend into the macula. Severe
choroidal hemorrhage is perhaps the most feared complication of SRF drainage.

Cont..
• Management. Drainage site should be closed immediately with either a
preplaced buckle or a suture and the IOP elevated by compression.
• The eye should be positioned to place the drainage site as inferiorly as possible
in order to prevent migration of blood beneath the fovea. If massive bleeding
occurs, or substantial bleed accumulates beneath the fovea, vitrectomy with
internal drainage of blood should be considered.

Cont..
• Retinal Perforation : Perforation may occur if the needle strikes the retina
because of shallow SRF or excessive entry of the needle.
Management: If the drainage site is in the bed of the buckle, usually no treatment
is required except retinopexy to this area.
• If the perforation occurs outside the bed of the buckle, a new, unsupported
retinal break has been created, and this requires cryotherapy and adjustment of
the buckle for adequate support of this area.

Cont..
• Retinal Incarceration: The retina may get incarcerated at the drainage site in
2–3% of cases. Incarceration occurs most commonly if IOP is elevated when the
choroid is penetrated, and especially if a large opening is made in the choroid.
• Incarceration occurs most commonly if IOP is elevated when the choroid is
penetrated, and especially if a large opening is made in the choroid.
• Management: A retinal incarceration should be supported on a buckle.

Cont..
• Dry Tap : A dry tap usually indicates incomplete penetration of the choroid. It is
avoided by steadily advancing the needle until fluid is present around the needle.
Inspecting the retina just before drainage can minimize the possibility of shifting
of SRF

Anterior Segment Ischemia
• Anterior segment ischemia is a well-described but uncommon complication
following retinal detachment surgery. Reduced blood flow to the eye can result in
damage to the anterior segment.
Predisposing factors for anterior segment ischemia include
• Damage to the anterior segment blood supply from surgical maneuvers.
• Interruption of blood flow in the anterior ciliary arteries by temporary
disinsertion of rectus muscles, particularly when more than one rectus muscle is
disinserted.
• Diathermy or cryotherapy to the long posterior ciliary arteries.
• Use of an encircling scleral buckle.

Cont..
Management: Mild cases respond to medical treatment with topical or systemic
steroids.
• In cases with intraoperative over constriction of the band, it is necessary to cut
the encirclage.
• Elevated pressure is treated with antiglaucoma treatment which in turn may also
improve the anterior segment perfusion.
• with the current trend to use smaller buckles, anterior segment ischemia is rarely
seen.

Failure to Reattach
The most significant complication after retinal buckling surgery is persistent or
recurrent SRF due to open retinal breaks and occurs after 9–25% of primary scleral
buckling operations.
Causes of surgical failure : Ineffective closure of treated breaks at the time of
surgery due to inadequate buckle effect. Most failures from incorrect placement of
a scleral buckle are due to anterior leakage.
• Untreated retinal breaks that were not detected.
• New breaks occurring intraor postoperatively.
• Proliferative vitreoretinopathy accounting for 90% of all permanent surgical
failures.

Proliferative Vitreoretinopathy
Proliferative vitreoretinopathy is the most common cause of failure of retinal
detachment surgery.
• Detachment greater than two quadrants.
• Large break (greater than 3DD) multiple retinal breaks (as extensive treatment is
required).
• Excessive cryopexy; cryo treatment to the bed of the break, indentation of the
cryo treated areas with the probe.
• Inflammation and breakdown of blood retinal barrier.
• Intraocular hemorrhage.

Infection and Extrusion
• Various implants and sutures used in buckling surgery are foreign bodies and can
migrate or become foci of infection.
• The incidence of explant infections and extrusion with modern techniques is
about 1%.
Risk factors for buckle infection :
• Multiple elements: When multiple silicone sponges are used, the incidence of
late infection doubles.
• Silicone sponge: Postoperative infection with exposure is more common with
silicone sponge explants than with solid silicone explants.

Cont..
• Resurgery: Higher rate of infection also occurs after reoperations.
Management: Recent data indicates that soaking the buckle in antibiotic solution
before use may decrease extrusion and infection incidence in scleral buckling
surgery when both accurate surgical technique and disinfection prophylaxis are
performed.
• Extrusion alone without signs of infection usually requires removal of the
offending buckle element.
• Management of infected scleral buckle almost invariably involves removal of the
material.
• Because of the risk of re-detachment after removal of scleral buckling material,
placement of photocoagulation around retinal breaks or sites of vitreoretinal
traction 2 weeks before removal.

Motility Disturbances and Strabismus
• Extraocular muscle dysfunction occurs in up to 50% of eyes after retinal
reattachment surgery.
• However, these abnormalities are often temporary and the incidence of
permanent postoperative diplopia is approximately 4%.
• Factors associated with postoperative muscle imbalance include placement of a
buckle beneath a muscle and reoperation.

Changes in Refractive Error
• Changes in the axial length of the globe and corneal curvature and displacement
of the lens iris diaphragm contribute to postoperative refractive errors.
• Encirclage procedures induce the significant myopic shifts by alterations in the
axial length.
• An average increase in axial length of 0.99 mm and an average-induced myopia
of 2.75 diopters.
• low to moderate buckle height resulted in –1.56 to –2.24 diopters of change in
phakic eyes and –0.74 to –1.14 diopters of change in aphakic eyes.
• Changes in refractive error after scleral buckling usually stabilize within 2–3
months after surgery.

MCQS
A 21-year-old with -11D of myopia presented with superior
temporal retinal detachment and a single large tear
secondary to lattice degeneration. How will you
manage this case ?
a) Pars plana vitrectomy with silicon oil tamponed.
b) Radial buckle with cryotherapy
c) 360 degree band (encircling silicon band) with cryotherapy
d) Segmental buckle with cryotherapy.
e) only laser around tear
Correct answer B

2.
A 24-year-old professional basketball player presented to you
with traumatic retinal detachment secondary to a retinal
dialysis after he was stuck in an eye by an elbow from player.
How will you manage this case ?
Correct answer D

3.
A 60-year-old male presented to you with retinal detachment,
after he operated for cataract surgery. How will you manage
this case?
Correct answer C

Scleral buckling for rhegmatogenous retinal detachment

Scleral buckling for rhegmatogenous retinal detachment

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Scleral buckling for rhegmatogenous retinal detachment

Similar to Scleral buckling for rhegmatogenous retinal detachment (20)

Recently uploaded

Recently uploaded (20)

Scleral buckling for rhegmatogenous retinal detachment