Principles Of

Vitreoretinal Surgery
– Scleral Buckle
Dr. Sumit Kumar Mishra
 PRESENTATION
LAYOUT
• Introduction
• Mechanics
• Indication
• Contraindication
• Surgical techniques
• Complications
 Introduction
Scleral buckling
ophthalmic surgical technique that has been successfully
employed to repair RRD for over 60 years.
 Introduction
In the past two decades, pneumatic retinopexy and vitrectomy
have been added to the retina surgeons' reattachment
armamentarium

When used to treat uncomplicated RD, literature search of

peer‑reviewed publications show that there is not much to
choose between SB and PPV with respect to anatomic and
visual outcomes.
 Introduction
Both retrospective studies and prospective randomized data have
not been very conclusive in this regard.

Regarding cost to the patient, SB is significantly cheaper when

compared to internal procedures in an eye with a clear lens.
 Scleral Buckling:
Physical Forces at Work
Factors promoting retinal break
and eventually RD

 Centripetal vitreous traction

 fluid currents caused by rotary
eye movements
 Scleral Buckling:
Physical Forces at Work
Factors promoting retinal
adhesion

 active RPE pump,

 centrifugally acting hydrostatic
pressure from the vitreous,
 oncotic pressure gradient between
the choroid
and subretinal space,
 viscous mucopolysaccharide
substance between the RPE and the
photoreceptors
Scleral Buckle works via :
1- close retinal breaks by apposing the RPE to the sensory retina
 this displaces the existing subretinal fluid (SRF) away from the site of
break
 fluid from the vitreous does not find easy passage into the subretinal space as
the potential space immediately behind the break is reduced
Scleral Buckle works via :

2- reduces centripetal vitreoretinal traction

 By shortening the diameter and circumference of the vitreous base.
 Indications for scleral buckling.
 Rhegmatogenous retinal detachment, especially in phakic eyes
 Inferior retinal breaks
 Retinal dialysis
 Young patients with
attached posterior hyaloid
 Contraindications
 Breaks significantly posterior to the equator

 Opaque media

 In patients with significant vitreoretinal traction (proliferative

vitreoretinopathy and diabetic neovascularization )

 Vaso-occlusive disease, such as sickle cell anemia and, to a

lesser extent, severe diabetic retinopathy.
 Surgical Technique
1- Peritomy & isolation of muscles.
2- Localization of breaks.
3- Treatment of retinal breaks.
4- Scleral buckling.
5- ±Drainage of SRF ±air injection.

DACE technique
(Drainage-Air- Cryotherapy-Explant )
peritomy & isolation of
muscles
 localization of breaks
Precise localization of retinal breaks on the
sclera is crucial for accurate placement of the
buckle on the sclera.

Indirect ophthalmoscope & scleral localizer.

• For small flap tears or atrophic
holes, a single mark on the
posterior edge of the break is
sufficient.

• Larger flap tears require

localization of both the anterior
and posterior extent of the break 
•  In areas with multiple, closely
spaced tears, it is not necessary
to mark each break.

• Marking the most posterior

extent and the circumferential
extent of the breaks is adequate
• This approach is also sufficient
for marking a retinal dialysis.

• The circumferential extent of the

dialysis is marked anteriorly at
the edges of the dialysis, and then
the most posterior extent is
marked
 Treatment of retinal
breaks
Rationale for treatment : is to form an adhesion
between the RPE & retina.

Methods :
1- cryotherapy
2- diathermy
3- photocoagulation
Cryotherapy
Mechanism
 Expansion of a high pressure gas (nitrous oxide) at the
tip of a probe generating temperature down to -89°C.

The temp. effect is confined to the tip of the probe by

insulating sleeve
Goal of treatment :
 to surround all retinal
breaks with 1 to 2 mm of
contiguous treatment.

 The treatment end point is retinal whitening without ice crystal.

 Care is taken not to freeze bare RPE in the bed of the retinal break where there is
no overlying retinal tissue.
 Scleral Buckling
Purpose : to close retinal breaks & relieve
vitreoretinal traction.

Methods of buckling
1-explant→ the buckling material is
sutured to the surface of the sclera.
2-implant → the buckling material is
placed beneath scleral flaps after
lamellar scleral dissection
Buckling materials
1- solid silicone rubber → straight, symmetric tire, and
asymmetric tire.

2- silicone sponge
 Buckle Placement :

1- Circumferential 2 - Radial
 Segmental
 Encircling
Segmental –
 single break or multiple breaks located in 1-2 quadrants,
 anterior breaks
 wide breaks such as dialysis

Encircling –
 multiple breaks ( >2 quadrants )
 extensive lattice degeneration
 aphakia ,
 pseudophakia,
 myopia ,
 PVR grade B or more
 extensive RD without detectable breaks
Radial –
 posterior breaks
 large horseshoe tears
 Buckle size
The buckle must be of sufficient width to leave a safety margin
of 1 mm of retina between the break and the edge of the
buckle
Buckle sutures

 The sutures are arranged in mattress fashion.

 1/2 to 2/3 of the scleral thickness.
 Intrasclearal course 4-5 mm long.
 Parallel to the long axis of buckle.
 The tip of the needle should be visualized at all times as it
is passed through the sclera.
 Drainage of subretinal
fluid (SRF)
Rationale
1-To diminish the intraocular
volume so as to allow elevation
of the buckle without elevation
of IOP.

2-To allow the retina to settle on

elevated buckle by removing
fluid from the subretinal space.
Indications

1-bullous RD to place the retinal break in apposition to the

buckle

2-inferior retinal break :

 inferior breaks tend to settle less readily on the buckle
 inferior breaks are less effectively managed postoperatively
with air injection.
Indications

3- chronic RD ( old standing RD & retinoschisis with RD)

viscous SRF→ delayed absorption.
4-poor RPE function as in high myopia → delayed absorption.
5- danger of high IOP
 Open angle glaucoma,
 recent cataract surgery,
 poor ocular perfusion,
 thin sclera
 Selection of drainage site
 Done in an area where there is
sufficient SRF.

 Drainage just above & or below the

horizontal meridian ( to avoid major
choroidal vessels and vortex veins.)

 Drainage is avoided in areas treated

with cryotherapy → because
choroidal congestion induced by cryo
→ predispose to hemorrhage.
 Drainage Technique

1. Incisional sclerotomy technique

2. Modified needle drainage
 subretinal space is directly entered through the sclera with a 26-
gauge needle.
 After successful drainage and closure of the site, the buckle is
positioned with the appropriate preplaced scleral sutures.
 Any suture that overlies a retinal break is tightened first.
 The encircling band, if present, is then adjusted with a silicone
sleeve.
 As the sutures are tightened, they are secured with temporary
ties, as this allows easy adjustment of buckle height and
position, and the optic nerve is inspected for perfusion.
Nondrainage procedures

 can also be used to reattach the retina, with success rates

comparable to those of drainage procedures.

 avoids the potential complications associated with drainage.

Nondrainage procedures

 In eyes with relatively shallow detachments, the eye may

soften enough after scleral depression and cryopexy to allow
placement of the buckle without IOP problems.

 Waiting several minutes between tightening of the scleral

sutures also may soften the eye.

 However, nondrainage techniques often require the IOP to be

lowered by additional medical or surgical means.
 COMPLICATIONS
Intraoperative Complications
 Scleral perforation
 Drainage complications
 retinal incarceration
 choroidal or subretinal hemorrhage.
 Postoperative
Complications
Glaucoma

 variety of secondary glaucomas

 Angle closure after scleral buckling may take place with or
without pupillary block.
 One presumed mechanism of closure is shallow detachment of the
ciliary body, which results in anterior displacement of the ciliary body
and occlusion of the angle
 Anterior segment ischemia also may cause glaucoma
Choroidal effusion

 Accumulation of serous or serosanguineous fluid in the

suprachoroidal space is relatively common after scleral
buckling
 Choroidal effusion is related to the size and extent of the
scleral buckle
Cystoid macular edema and residual subretinal fluid

 Using cryotherapy and explant techniques, the incidence of

CME 4–6 weeks after surgery in phakic eyes is 25–28%,

 typically resolves spontaneously.

 Additional therapies, such as steroids, may be needed for

resolution.
 Macular pucker

 major cause of decreased vision after

scleral buckling,
 incidence ( 3–17%)
 Risk factors
 preoperative PVR of grade B or greater,
 age,
 total retinal detachment,
 vitreous loss during drainage.
Diplopia

 The incidence of postoperative diplopia is low.

 In a series of 750 patients who underwent scleral buckling for
retinal reattachment, 3.3% complained of diplopia
postoperatively.
Changes in refractive error

 Segmental buckles have little effect on refractive error.

 Large radial elements, such as full thickness sponges that

extend anteriorly beyond the ora serrata, may induce an
irregular astigmatism.

 Encircling procedures induce the greatest change in

refractive error,
 greater for phakic than for aphakic eyes, because of the anterior
displacement of the lens, resulting in an increased myopic shift
 Infection and extrusion

 Scleral buckling materials constitute

foreign bodies and therefore carry the
risk of infection and extrusion.

 The incidence of explant infection and

extrusion is about 1%.

 Effective management of infected scleral

buckling material usually requires
removal.
Surgical failure

 Missed breaks.

 Buckle failure
o due to inadequate size, incorrect
positioning or inadequate height;

 Fish-mouthing’
o phenomenon of a tear, typically a large
superior equatorial U-tear in a bullous RD,
to open widely following scleral buckling,
o requiring further operative treatment.
 Surgical failure

 Proliferative vitreoretinopathy
o most common cause of late failure.
o tractional forces associated with PVR can occasionally
open old breaks and create new ones.
o Presentation is typically several weeks postoperatively with
re-detachment.
 OUTCOME
 The anatomical results following scleral buckling are
impressive, with an overall reattachment rate of at least
90%.

 Unfortunately, the visual results after scleral buckling do not

parallel the anatomical results.
o Multiple factors correlate with visual and anatomical prognosis.
o Detachments with the macula attached (macula-on) at the time of
surgery have a significantly better prognosis.
 References
• Retinal Detachment Surgery , Raj Vardhan Azad

• Clinical Ophthalmology, J & J Kanski

• Yanoff and Duker Ophthalmology, 4th Edition

• Various Internet Sources