Throwing New Light on Buckling Surgery
Scleral buckling was first performed as a technique to repair rhegmatogenous retinal detachment by Custodis in 1949 and was popularized in the 1950s.1,2 The underlying principle in scleral buckling is approximation of neurosensory retina with the retinal pigment epithelium by compression of the globe wall, thus preventing passage of liquid vitreous into the subretinal space. If the break is properly closed, the retinal pigment epithelium pump actively absorbs subretinal fluid and the retina will spontaneously reattach with no need for subretinal fluid drainage.
Until the introduction of pars plana vitrectomy (PPV) in the early 1970s by Machemer et al,3 scleral buckling was the gold standard technique for management of rhegmatogenous retinal detachment. Soon after its introduction, PPV enhanced the ability to repair retinal detachments, particularly in settings of complex cases,4,5 trauma,6,7 and proliferative vitreoretinopathy (PVR).8-10 The use of PPV has expanded in the repair of retinal detachments, particularly in patients with pseudophakic eyes.11,12
Apart from vitrectomy and scleral buckling, another procedure, pneumoretinopexy, has also been used in specific configurations of retinal detachments with breaks located superiorly. It requires good case selection, however, and also needs significant cooperation of the patient for postprocedure positioning. In phakic eyes, it was associated with a significantly higher reoperation rate than scleral buckling, but resulted in equivalent final visual outcome and reattachment rate after reoperations.13
The type of surgical procedure used for rhegmatogenous retinal detachment, however, still remains an individual surgeon-based decision that is influenced by the preoperative findings, patient characteristics, available tools for surgery, and, above all, the experience and ability of the operating surgeon. What this essentially means is that, for a fresh retinal detachment with a single superior tear, different surgeons would choose any 1 of the 3 procedures mentioned based on their specific training or experience using a certain technique.
In recent years, a shift in the choice of methods can be observed, with a clear trend toward PPV. Improvements in the instrumentation and safety of PPV, along with modern microscopes and wide-angle viewing systems, has enabled intraoperative visualization of retinal breaks,14 accurate closure of all retinal breaks, and retinal reattachment in an easier and faster way. Moreover, transconjunctival sutureless vitrectomy techniques provide faster wound healing, diminished conjunctival scarring, improved patient comfort, decreased postoperative inflammation, and reduced postoperative astigmatic change.15-23 Eliminating suturing also shortens surgical opening and closing times.24,25
Scleral buckling, alternatively, has the advantage of being an extraocular procedure, which, in the case of failure, is more forgiving than vitrectomy because PVR develops more quickly in patients who have undergone vitrectomy as a primary procedure compared with buckling. Although scleral buckling is technically easier, it requires accurate decision-making for appropriate case selection, solid surgical experience, and mentors who are well versed in the procedure to advise in terms of the most effective surgical elements. Scleral buckling also requires practice to visualize and localize the breaks, to place the elements in the correct location with the desired indentation to support the retinal breaks and to drain subretinal fluid without complications. In short, scleral buckling is vastly different from microscope-based ophthalmic surgery and has a significant learning curve.
Because primary vitrectomy is now the procedure of choice for most surgeons, the present generation of fellowship training programs does not provide adequate access to buckling procedures, limiting the experience that is required to achieve sufficient confidence with buckling procedures. The visualization systems and their optical zooming capability in vitrectomy surgery are far superior to that of indirect ophthalmoscopy, and thus it is easy to teach vitrectomy with real-time video transmission facilities. New generation chandelier systems have improved the field and quality of resolution, thus allowing the surgeon an unrestricted view of the extreme periphery when used in conjunction with widefield viewing systems.26,27
Hence, we would like to introduce a concept that would allow us to perform scleral buckling in noncomplex fresh retinal detachments without using an indirect ophthalmoscope; rather, we propose the use of the same visualization systems used for vitrectomy procedures. A similar concept has been reported earlier in the form of using noncontact visualization systems.28,29 In this article, we present a series of cases in which patients underwent scleral buckling under microscope using the HRX Vit SSV lens (Volk) with a single 25-gauge chandelier (Alcon Laboratories, Inc.) for illumination.
Materials and methods
We prospectively assessed 10 eyes (10 patients) undergoing scleral buckling for primary rhegmatogenous retinal detachment with chandelier illumination system for retinal detachment at our institution over a 6-month period. Ethical approval was obtained, and informed consent to participate was gained from participants.
Patients with rhegmatogenous retinal detachment of recent onset having peripheral break or breaks were included in the study. Patients with media opacities, such as vitreous hemorrhage or significant cataract, and any coexisting ocular pathology, such as glaucoma and uveitis, were excluded.
Following enrollment, all patients underwent complete preoperative assessment including Snellen bestcorrected visual acuity. Slit-lamp examination was also performed, including assessment of the anterior segment, type and position of IOL, integrity of the posterior capsule, and intraocular pressure (IOP) measurement. Fundus examination with slit-lamp biomicroscopy and indirect ophthalmoscopy was performed to evaluate the extent of retinal detachment and the presence of any predisposing pathologic features in the peripheral retina. The fundus/slit-lamp exam was also used to grade PVR, to detect signs of myopic degeneration, to locate retinal breaks, and to determine their location, type, and number. Detailed history of coincidental and past systemic and ocular pathologies and procedures was elucidated.
All patients were operated under peribulbar anesthesia. After a 360° limbal peritomy, traction sutures were passed under the rectus muscles. Sclerotomy for chandelier illumination was created with a 25-gauge Edgeplus trocar (Alcon Laboratories, Inc.) at 3.5 and 4 mm posterior to the limbus for pseudophakic and phakic patients respectively in the inferotemporal quadrant (Figure 1).
The fiberoptic was connected to either a Constellation (xenon) or Accurus (halogen) vitrectomy system (Alcon Laboratories, Inc.). The Trocar Fixation Plate (ASICO) was used to stabilize the globe while making the biplanar incision. Initially, the blade was inserted obliquely into the sclera at an angle of about 30º to 45º up to the cannula mark. The direction of the blade was then adjusted perpendicular to the sclera as it was inserted into the vitreous cavity. Once the chandelier was inserted, the widefield viewing contact lens was placed on the corneal surface with viscoelastic interface (Figure 2). Once visualization was achieved, the image was reinverted using the invertor attached on the microscope. Detailed assessment of the fundus was done using indentation, and the break or breaks were localized (Figures 3 and 4). Cryopexy of the breaks and all the suspicious areas was performed (Figure 5 and 6). A 5-mm silicone sponge (type 506; Labtician Ophthalmics, Inc.) was passed beneath the rectus muscles and fixed with a polyester 5-0 suture placed in the sclera so that the buckle indented the site of the break and sat at 1 clock hour on either side, 3 mm posterior and 2 to 3 mm anterior (Figure 7). The decision to use a segmental buckle was made according to the size and location of the retinal tear. Subretinal fluid was externally drained through a sclerotomy with a 24-gauge needle after diathermy to the sclerotomy site (Figure 8). Full drainage was achieved in all cases and was visually confirmed with a microscope. At this stage, the fundus was checked to confirm retinal flattening along with the desired indentation effect (Figure 9). The remaining sutures were removed externally, and the chandelier light cannula was plugged (Figure 10) and eventually removed. The sclerotomy was sutured with 8-0 polyglactin. A drop of povidone-iodine was then instilled followed by conjunctival closure with 8-0 polyglactin and subconjunctival antibiotic injection.
Patients were examined postoperatively on days 1, 30, 90, and 180. During each visit, a detailed ophthalmic examination was carried out. Anatomic and functional status of the retina were assessed and IOPs were checked on all visits.
All patients were followed up for a minimum duration of 6 months. Nine out of 10 patients had fully attached retinas at all follow-ups with visual improvement. One patient who was stable on first postoperative day presented with redetachment at 1-month follow-up. The horseshoe tear seemed to be on the buckle, but there was a significant collection of fluid, and so we performed vitrectomy. We found a macular hole that was responsible for this fluid. The patient had myopia with tessellated fundus and staphylomatous changes, which may have been the reason that the macular hole was not detected at the time of the first surgery. Alternatively, the macular hole may have occurred secondarily during the follow-up period. The vitrectomy resulted in stabilization of the eye in this patient.
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Scleral buckling surgery is on the decline due to the lack of training for this procedure, which requires experience in technique and decision-making. Most fellowship programs train surgeons in vitrectomy techniques as primary procedures, even though many cases would be successfully treated with buckling alone. This is particularly true for younger and phakic patients, who may benefit because the vitreous is frequently only partially detached, with attachment around the edges of the lattice degeneration. Although PPV can be used in these cases, often the vitreous cannot be effectively removed from the periphery or around these areas of lattice degeneration. The vitreous can be shaved close to the surface of the retina, but postoperative contraction of remaining vitreous is common. The adhesive force of the laser scar may not overcome the contractile force of fibrous proliferation. Also, shaving the vitreous closely in the setting of a retinal detachment often leads to iatrogenic breaks. Multiple reports of PPV alone for rhegmatogenous retinal detachment showed anatomic success rates in the range of 70 to 80%.30-33 Another concern is that the surgeon who avoids scleral buckling for the initial repair is likely to attempt the same approach for repair of redetachment, with a greater dependence on retinectomy and silicone oil tamponade than if a buckle were added.
The disadvantages of PPV vs scleral buckling surgery include the need for postoperative positioning, restriction of air travel, potential for endophthalmitis, possible complications of draining retinotomies, and secondary cataract in phakic patients. Additionally, the incidence of PVR after primary vitrectomy in the treatment of retinal detachment has been reported to be as high as 6% in uncomplicated cases and between 11 and 16% in more complicated cases.34,35 Cost is also an important factor because vitrectomy uses expensive equipment. Scleral buckling, however, is a low-budget procedure.
The results of our pilot study provide the rationale for evaluating scleral buckling in a larger series of patients to practically and more clearly explain our procedure, which is similar to a normal scleral buckling procedure with the exception that a chandelier is inserted and a widefield contact lens is used instead of an indirect ophthalmoscope. The ability to transmit the surgery to an OR monitor to see every step in fine detail is a significant improvement over operating with an indirect ophthalmoscope, and it may help train surgeons in their process of decision-making during a procedure (ie, localization, cryotherapy, external drainage). We believe that our technique should be easily adoptable by most vitreoretinal surgeons who are familiar with using widefield visualization and that it may help to propagate the art of scleral buckling, which provides excellent results in carefully selected cases.
Manish Nagpal, MS, DO, FRCS(UK), is Senior Consultant, Retina & Vitreous Services, at the Retina Foundation & Eye Research Centre in Gujarat, India. He is a Retina Today Editorial Board Member. Dr. Nagpal states that he has no financial relationships to disclose. He may be reached at firstname.lastname@example.org.
Sidharth Bhardwaj, MD, is a Vitreoretinal Fellow at the Retina Foundation & Eye Research Centre in Gujarat, India. Dr. Bhardwaj states that he has no financial relationships to disclose. He may be reached at sidharth_267@yahoo.Co.in.
Navneet Mehrotra, MD, is a Junior Consultant at the Retina Foundation & Eye Research Centre in Gujarat, India. Dr. Mehrotra states that he has no financial relationships relevant to the products or companies discussed in this article. He may be reached at email@example.com.
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