Scleral Buckle for Retinal Detachment: Three Surgical Approaches

This video series is intended to be useful for trainees at various levels. From early students observing a surgery for the first time to specialized fellows looking to hone their skills, these videos can help.

Instead of providing one perspective on one way to do a scleral buckle, this collection of videos shows a variety of approaches to the same procedure. Common steps are labeled, variations are highlighted in the videos, and the accompanying commentary provides more in-depth insights.

These videos can be used to understand and to prepare for the operating room. As background, they reiterate key steps and goals of the surgery. For those already with surgical experience, these videos can help clarify the nuances of the procedure. This can help in preparation for an upcoming surgery or in reflecting on a recent experience.

— John Hinkle, MD, CovalentCareers | Ophthalmology Clinical Editor

Nikolas JS London, MD, FACS

1. Peritomy: 1:04 - 1:10
2. Tenon's dissection: 1:11 - 1:16
3. Isolating rectus muscles: 1:17 - 1:30
4. Cryo to the retinal break: 1:31 - 1:33
5. Placement of Scleral Buckle: 1:34 - 2:00
6. External drainage: 2:01 - 2:12
7. Suturing the Scleral Buckle: 2:13 - 2:55
8. Tightening the buckle: 2:56 - 3:20
9. Closing: 3:21

Retinal detachment repair is perhaps the quintessential skill of the vitreoretinal surgeon. Imagine being the patient, visiting an unfamiliar doctor as an emergency add-on, not sure why you are losing vision and terrified that the doctor will tell you there is nothing that can be done. Fortunately, they are wrong, and nothing feels better than telling that scared patient that everything is going to be ok. In fact, we have three effective treatment options for repairing retinal detachment: pneumatic retinopexy, scleral buckling, and pars plana vitrectomy. This video and accompanying commentary focuses on the oldest option, the scleral buckle. Developed and refined over the first half of the 20th century, scleral buckling involves the surgical attachment of an exoplant to the external surface of the eye in order to provide a tamponade over a retinal break. Most often, including in the case of this video, the exoplant is a 1x4mm silicone band that encircles the eye, providing 360-degrees of support.

While an elegant surgery, scleral buckling can be intimidating to young surgeons where vitrectomy dominates the surgical arena. Moreover, as vitrectomy has gained in popularity over the past few decades, exposure to scleral buckling has diminished in training programs, to the point where some graduates of retina fellowships have performed few, if any, of the procedures. This is unfortunate as scleral buckling is the best option in many cases, and can enhance vitrectomy in cases of complicated detachment. Hopefully this video will serve as a platform for young surgeons to learn the technique.

The easiest way for me to learn a new surgical technique is to watch it being performed by as many different surgeons as possible, then to write out the steps in cookbook fashion to go through one-by-one as many times as possible. Keep in mind that there are multiple techniques, and that you will need to find out which is best suited to you. Moreover, there is much more that goes into this than just these steps, and this should absolutely not be attempted by anyone other than a trained surgeon or trainee under direct supervision.

Steps of scleral buckling with cryotherapy:

1. 360-degree conjunctival peritomy
2. Isolate the four rectus muscles with 1-0 silk ties
3. Dissect Tenon’s capsule and other adhesions with blunt scissors
4. Apply cryotherapy to areas of retinal defects
5. Pass the silicone band under the muscles, being sure to leave the ends in the appropriate quadrant
6. Attach the ends of the band together using a silicone sleeve
7. Suture the buckle to the eye at the appropriate location based on the retinal breaks
8. Drain subretinal fluid (if applicable)
9. Tighten the buckle to the appropriate height
10. Trim the buckle
11. Close the conjunctiva

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Gowtham Jonna, MD

1. Peritomy (0:01-0:15)
2. Tenon's dissection (0:16-0:22)
3. Isolating rectus muscles (0:23-1:11)
4. Placement of Scleral Buckle (1:21-2:35)
5. Suturing the Scleral Buckle(2:36 - 3:23)
6. External drainage (3:24 - 4:03)
7. Tightening the buckle (4:04-4:44)
8. Closing (4:55 - 5:03)

Scleral buckling is a mainstay of rhegmatogenous retinal detachment repair. It can be performed as a primary procedure or combined with pars plana vitrectomy for retinal detachment repair. Primary scleral buckling is an excellent option for the young, phakic patient with attached vitreous. It is particularly useful in cases of retinal dialysis, inferior retinal detachment, high myopia or myopic degeneration, extensive lattice degeneration, numerous retinal breaks, peripheral traction, proliferative vitreoretinopathy, and trauma. Scleral buckle should be strongly considered in cases of prior failed repair with vitrectomy alone and in patients with chronic retinal detachment.

Steps of Primary Scleral Buckle:

1. Conjunctival peritomy
2. Blunt dissection in sub-Tenon’s space
3. Isolation of recti muscles
4. Funduscopic examination and location of retinal breaks
5. Marking of retinal breaks
6. Retinopexy
7. Placement of scleral buckle explant
8. +/- Drainage of subretinal fluid
9. Fastening of scleral buckle
10. +/- Intravitreal injection of air or gas
11. Closure of conjunctiva

Techniques vary but ultimately, the goal should be to reattach the retina in the most efficient and effective manner to achieve the best anatomic and functional outcomes. One’s experience and comfort level will dictate how certain steps are carried out. Choosing to create sutureless scleral tunnels or “belt loops” versus suturing the buckle to the sclera is based on surgeon preference. In my hands, suturing the buckle provides the greatest control and efficiency with possible lower risk of major perforation or hemorrhage. Choice of suture material is another individual surgeon-dependent decision. Choice of segmental or encircling buckle and type of element will depend on pathology to be supported. Most do well with a 41 or 42 encircling band.

Cryoretinopexy versus laser retinopexy is surgeon-dependent but many tend towards cryoretinopexy in the context of scleral buckling. If extensive retinopexy is required (beyond treatment of dominant break), laser may be less pro-inflammatory and should be considered. Drainage of subretinal fluid is likely the highest-risk step and is not necessary in many cases. Many will choose to drain especially in cases of bullous retinal detachment. Techniques of drainage are varied and surgeon-dependent. Intravitreal air or gas injection may be useful to help support retinal breaks in addition to the buckle, especially with superior retinal breaks. Choosing to fasten the buckle and generate indentation with a sleeve versus placing sutures further apart to create indentation is surgeon-dependent. Ultimately, the scleral buckle will work well by supporting the vitreous base and the retinal breaks as well as by relieving traction.

Mistakes to Avoid:

1. Incomplete isolation of recti muscles – can lead to strabismus and diplopia.
2. Hooking oblique muscles instead of recti muscles – can lead to ocular misalignment with torsion and diplopia. Passage of a superior rectus muscle hook from the temporal side of the muscle reduces the risk of inadvertently hooking the superior oblique.
3. Posterior cryoretinopexy – avoid using shaft of cryotherapy probe and ensure that the tip of the probe is used to create indentation before treating. Using the shaft can inadvertently treat the posterior pole and even the macula.
4. Subretinal hemorrhage or avulsion from inadequate thaw of cryotherapy probe – make sure to allow the probe to thaw adequately; use balanced salt solution to help the thawing process and slowly remove the probe from the sclera after treatment.
5. Scleral perforation and hemorrhage from deep scleral passes – be careful in highly myopic eyes and avoid areas of scleral thinning/scleromalacia.
6. Inadequate support of retinal breaks – avoid “fish-mouthing” of retinal tears by carefully marking and placing the buckle. Parallax error gives the impression of a retinal break being more posterior than it actually is in the context of detachment, especially if bullous.
7. Over-tightening buckle – can lead to anterior segment ischemia, band-related pain, and secondary angle-closure glaucoma (especially if buckle placed too anteriorly).

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David R.P. Almeida, MD, MBA, PhD; Eric K. Chin, MD & R. Rishi Gupta MD, FRCSC

Scleral buckle (SB) placement for rhegmatogenous retinal detachment (RD) repair was first described in 1949 by Ernst Custodies and further popularized by Charles Schepens and Harvey Lincoff in the 1950s. SB technique favorably alters the geometry and physiology of the eye to help close and maintain closure of retinal breaks. Inward indentation of the eye, along with laser photocoagulation or cryotherapy, aid in creating a permanent adhesion between the neurosensory retina and the retinal pigment epithelium (RPE). SB is advantageous as it treats existing retinal breaks, supports the vitreous base, minimizes the likelihood of new retinal tears developing and confers a lower incidence of cataract formation compared to vitrectomy. In some cases, internal gas or silicone oil tamponade may not be necessary and therefore positioning may not be necessary in primary SB RD repair.

Who should get a scleral buckle?

SB surgery should be strongly considered in the following:

1. Young, phakic patients with no posterior vitreous detachment (especially high myopes)
2. Retinal dialysis (SB allows better support of the anterior location)
3. Patients with extensive lattice degeneration or multiple retinal breaks (SB with an encircling segment provides 360-degrees of support to the vitreous base and peripheral retina thereby reducing the likelihood of new subsequent retinal tears)
4. Patients with predominantly inferior and/or anterior pathology, for which face down positioning may also be difficult
5. Patients who live at high altitudes who may not be able to tolerate gas tamponade agents and who prefer not having to undergo a second surgery to remove silicone oil if used.

What type of buckle should be used?

Fundamentally, primary principles of SB involve closing all retinal breaks by apposing the RPE to the neurosensory retina and reducing the dynamic vitreoretinal traction at sites of vitreoretinal adhesion. To accomplish this, most SB procedures fall into one of three categories: encircling circumferential buckle placed parallel to the limbus (i.e., 360-degree buckle; cases with retinal breaks in three or more quadrants, diffuse retinal pathology like lattice degeneration, possible unidentified retinal breaks), segmental circumferential buckle placed parallel to the limbus (cases where retinal breaks span less than 6 clock hours) and radial buckle perpendicular to the limbus (cases with a single posterior retinal break in an easily accessible location).

Pearls of scleral buckle placement technique

SB surgical technique can be summarized as follows:

1. Conjunctival peritomy
2. Isolation of the rectus muscles
3. External localization of all retinal breaks using indirect ophthalmoscopy to mark each break on the external sclera (this can include external drainage of subretinal fluid). In some cases, chandelier endoillumination can alternatively be used.
4. Treatment of retinal breaks with cryotherapy and/or photocoagulation
5. Placement of the SB components
6. Optional external drainage of subretinal fluid via scleral cut down or needle drainage in cases of bullous retinal detachments. Be cautious for subretinal hemorrhage, retinal incarceration, choroidal detachment, or hypotony if this is done. In many cases, if the retinal break(s) are appropriately supported, bullous subretinal fluid will resorb in the days or weeks to follow due to the RPE pump.
7. Confirmation that all retinal breaks are treated and supported via scleral indentation and direct visualization (typically with indirect ophthalmoscopy), and that the central retinal artery is perfused
8. Closure of conjunctiva with primary suture closure (e.g., 6-0 plain gut or 7-0 Vicryl suture)
9. Optional expansile gas tamponade injection may be used at the end of the case to better juxtapose a bullous retinal detachment to the newly indented and cryo- or laser-treated retina.

Pitfalls: When to avoid a primary scleral buckle

There are specific scenarios in which a primary SB is relatively contraindicated and include:

1. Difficult visualization (e.g. vitreous hemorrhage, small pupils, multifocal IOLs) which limits ability to treat retinal breaks
2. Posterior breaks which make placement of SB difficult
3. Scleral thinning due to increased risk of globe rupture
4. Vitreoretinal traction (e.g., tractional membranes in diseases like proliferative vitreoretinopathy and proliferative diabetic retinopathy)
5. Patient with significant vascular risk factors or sickle cell disease due to increased risk of anterior segment ischemia or intraocular bleeding
6. Patient with previous strabismus or glaucoma tube shunt surgery
7. Complex cases where a 180-degree or 360-degree retinectomy may be needed.

Conclusion

In summary, SB implantation is an “oldie, but a goodie”. While it may be far less commonly performed compared to PPV for RD repair, it still offers potentially more optimal outcomes in selective cases. It is also a tool for the retinal surgeons to be familiar with; while “hindsight is 20/20”, one rarely (if ever) will regret having placed a SB in cases of RD repair.