Why scleral buckling is still relevant

Scleral buckling surgery has been around for over 60 years and is more of an art than a technique.[1] It fosters excellent indirect ophthalmoscopic skills and improves hand eye coordination as in localization and cryotherapy, the art of selection of the buckle and its proper placement, and the analytical skills of the surgeon. It also requires the surgeon to be fit with the weight of the indirect ophthalmoscope straining the neck and the need to assume various postures when standing and testing the core muscles. It also requires that the surgeon stand up to perform steps such as cryotherapy and localization, unless he or she prefers performing chandelier-assisted scleral buckling.

However, vitrectomy can be performed comfortably seated for the whole duration of surgery, with no necessity to precisely localize the retinal break, perusing different types of tamponades to temporarily close the break, irrespective of its location.

Younger generation of surgeons are moving away from the art of scleral buckling due to various reasons such as lack of training, better surgical results perceived with vitrectomy techniques, and the ability to complete the surgery without having to get off the surgeon’s chair. A thorough preoperative fundus examination and drawing, a requisite for performing scleral buckling, is not imperative with vitrectomy as well.[1,2]

Despite the limitations and lack of enthusiasm in honing the art of scleral buckling, it offers unmatched advantages over vitrectomy in certain situations.

1. In young patients with an attached vitreous and detached retina, inducing posterior vitreous detachment (PVD) with vitrectomy and its thorough removal can be technically challenging, fraught with the risk of creating iatrogenic retinal breaks. This is particularly relevant in syndromic detachments such as those associated with Stickler’s syndrome, wherein inducing PVD and satisfactory removal of the vitreous can be a nightmare.

   However, scleral buckling obviates this risk. In these patients with formed vitreous gel and the detachment being caused by atrophic retinal holes, just pushing the sclera, choroid, and retinal pigment epithelium toward the break allows the formed gel to tamponade the break and resolve retinal detachment without having to resort to drainage of subretinal fluid (SRF), the dreaded step of scleral buckling surgery.

2. In eyes with long-standing retinal detachment and subretinal gliosis (SRG), vitrectomy does not offer any undue advantage over scleral buckling unless the SRG is beneath the macula, necessitating its removal. In fact, SRF drainage is safer in these patients as one can drain SRF close to SRG, decreasing the risk of iatrogenic retinal incarceration. The anatomic results of scleral buckling in these eyes is as good or even better than vitrectomy, with less-demanding surgical skills.

3. Earlier rehabilitation is possible with scleral buckling surgery as there is no tamponade in the vitreous cavity causing refractive changes that disallow reasonably clear vision. Tamponades cause high refractive changes that induce anisometropia, which disallows the operated eye to be used until the tamponade is removed from the eye. Similarly, with pneumatic retinopexy, the patient cannot see until the gas bubble is absorbed with the added disadvantage of the patient having to maintain a particular posture for prolonged periods of time, which can also cause musculoskeletal problems. There is no need for prolonged postoperative positioning post-scleral buckling, which allows the patient to resume productive activity early in the postoperative period in contrast to vitreous surgery or pneumoretinopexy.

4. Tamponading agents can induce cataract. While cataract can be taken care of easily, it means a second surgery. Retinal detachment is common among myopes, and cataract surgery post-vitreous surgery can not only make the operated eye nearly emmetropic, but also induces anisometropia in these patients with a refractive error in the other eye, making it a challenge to overcome. Often times, the cataract surgeon opts for a residual myopia to decrease anisometropia, or the patient has to wear contact lenses for rehabilitation or undergo refractive cataract surgery in the other eye, which increases the risk of retinal detachment in these predisposed eyes.

5. Recent studies have shown increased metamorphopsia with vitrectomy for retinal detachment compared to pneumatic retinopexy.[3] This has been attributed to forcible reattachment of the retina with fluid air exchange during vitrectomy. The authors have suggested that spontaneous reabsorption of SRF like that happening with pneumatic retinopexy allows better alignment of the photoreceptors, thereby decreasing the risk of metamorphopsia. Nondrainage or partial drainage scleral buckling surgery can achieve the same results, but with the advantage of earlier rehabilitation of the patient.[4]

Scleral buckling is thus preferred in uncomplicated rhegmatogenous retinal detachment, particularly in eyes with formed vitreous, those with atrophic retinal breaks, and in retinal dialysis. It is also preferred in young patients, in eyes with SRG, and in eyes with inferior retinal breaks. In these situations, scleral bucking achieves retinal reattachment with less morbidity, allowing earlier rehabilitation and better success rates with a single surgery.

Hence, scleral buckling remains relevant even today, and the learning curve can be flattened easily with novel techniques that allow easier adaptation of the art of scleral buckling.[5]

About the author

Dr. Mahesh P Shanmugam

Dr. P. Mahesh Shanmugam is head of vitreoretinal services and ocular oncology of Sankara Eye Foundation hospitals and is based in Bengaluru. He has served as associate director of ocular oncology and senior consultant, vitreoretinal services at Sankara Nethralaya, Chennai, associate professor at The Chinese University of Hong Kong, honorary professor, university of Shantou and as visiting consultant, ministry of health and prevention, UAE. He is currently the scientific convenor, vitreoretinal society of India and is the co-founder of retnetindia. He has authored more than 200 peer reviewed publications in the field of vitreoretinal diseases and ocular oncology. He has 32 years of experience in the field of vitreoretinal diseases and surgery and ocular oncology with extensive surgical experience in treating complicated vitreoretinal disorders. He has trained numerous fellows in the field of vitreoretinal diseases. He has numerous national and international awards to his credit and serves as a reviewer to national and international journals and is an editorial board member with the Indian journal of Ophthalmology. He specializes in management of pediatric retinal disorders, intraocular tumors and surgical management of ROP in addition to management of complex adult vitreoretinal disorders.