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CONTROVERSIES IN CARE: Chandelier-Assisted Scleral Buckle Surgery vs Traditional Scleral Buckle Procedure

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Scleral buckle surgery with a permanent exoplant has been used for repair of primary rhegmatogenous retinal detachment since its introduction by Custodis in 1949. Schepens developed the binocular indirect headband ophthalmoscope (1945) and used it to perform the first scleral buckle surgery in the United States in 1951; Lincoff introduced the silicone sponge in 1965 and, with Kreissig, modern cryotherapy in scleral buckle surgery in 1972. Today, single-operation success rates for treatment of primary uncomplicated rhegmatogenous retinal detachment with this procedure are excellent (approximately 88% — similar to pars plana vitrectomy with or without a scleral buckle, according to a retrospective IRIS registry data analysis from 2013-2016 presented by Richard Kaiser, MD, at the 2017 AAO Retina Subspecialty Day).

Due to advances in small-gauge pars plana vitrectomy techniques with wide-field visualization, pars plana vitrectomy surgery has supplanted scleral buckle surgery to become the dominant procedure used to repair primary rhegmatogenous retinal detachment: only 9% of US retina surgeons queried in the 2017 ASRS preferences and trends survey place scleral buckle exoplants in greater than 60% of their rhegmatogenous retinal detachment cases. In the IRIS registry database referred to above, only 11% of the cohort had scleral buckle surgery alone. Scleral buckle surgery is now most often employed in young, phakic individuals with attached posterior vitreous cortex (so-called “retinogenic” retinal detachments, which often are associated with tears or holes in peripheral lattice degeneration).

Chandelier-assisted scleral buckling takes advantage of the microscope-associated wide-field viewing system using an intraocular “chandelier” light source associated with a pars plana trocar. It was first described in 2012,1 and it has become much more popular recently (and can be used with the “heads-up” viewing system).

Figure 1. Chronic inferior macula-involving “retinogenic” rhegmatogenous retinal detachment, right eye, associated with peripheral retinal lattice degeneration with atrophic holes, inferior-temporal midperipheral retinal macrocyst and multiple (sequential) demarcation lines (“high water marks”). Because there is no posterior vitreous detachment or horseshoe retinal tear under traction in this phakic eye of a young patient, a scleral buckle procedure would be the primary treatment consideration for this inferior retinal detachment.

We have previously addressed the controversies involved regarding selection of procedure (scleral buckle vs pars plana vitrectomy vs pneumatic retinopexy) for repair of primary rhegmatogenous retinal detachment (January 2011; www.retinalphysician.com/issues/2011/jan-feb/controversies-in-care ). Now, we will consider the use of a traditional scleral buckle procedure (a purely extraocular procedure) vs a chandelier-assisted scleral buckle (which adds the risks associated with an intraocular procedure but has potential advantages of improved visualization). Will this alteration in scleral buckle surgical technique make the scleral buckle procedure more popular?

This month, we are fortunate to have expert opinions regarding chandelier-assisted scleral buckle surgery vs traditional scleral buckle surgery from Edwin H. Ryan, MD, from VitreoRetinal Surgery, PA, in Minnesota and associate clinical professor of ophthalmology at the University of Minnesota, and Jason Hsu, MD, from Mid Atlantic Retina and Wills Eye Hospital and associate professor of ophthalmology at the Thomas Jefferson University Hospital in Philadelphia.

REFERENCES

  1. Aras C, Ucar K, Koytak A, et al. Scleral buckling with a non-contact wide-angle viewing system. Ophthalmologica. 2012;227(2):107-110.

An Argument for Traditional Scleral Buckling

EDWIN H. RYAN, MD
Vitreoretinal specialist at VitreoRetinal Surgery, PA, and associate clinical professor of ophthalmology at the University of Minnesota in Minneapolis, Minnesota.

There is renewed interest in scleral buckling due to recent studies noting superior outcomes compared to vitrectomy for phakic primary retinal detachment.1,2 Scleral buckling use has been declining, and decreased exposure to this very important technique is making fellows in training increasingly uncomfortable with the binocular indirect ophthalmoscopy (BIO) skills needed to perform the surgery. Also, faculty don’t perform enough surgeries to feel competent teaching standard scleral buckling. Because of these trends, the use of a chandelier light for illumination and a noncontact microscopic viewing system for performance of scleral buckling surgery is being advocated.

There are problems with this proposed technique. One is that the view afforded using a chandelier is not as high quality as some may claim. In the setting of a cortical cataract, the view is poorer than what is seen with adroitly performed BIO. In addition, with manipulations that occur during scleral buckling surgery, inadvertent lens trauma from the light fiber is a definite risk. Also, this procedure requires a penetrating injury into the vitreous cavity, an occurrence that was previously considered a complication when noted during scleral buckle surgery. There are several published and anecdotal reports of endophthalmitis with this technique as well.3-5

Why is this adaptation needed? The performance of a scleral buckle surgery demands very competent BIO skills, and good surgical planning requires a painstaking preoperative examination. The detailed retinal drawings of old forced the trainee to acquire excellent skills with the indirect ophthalmoscope. These skills are not being trained to the same degree in the vitrectomy era, as the assumption is that the retinal breaks will be found in the operating room, and a detailed drawing is not necessary.

If excellent preoperative exams are not considered necessary, the skills will be lost. The BIO skills required for scleral buckling give the proficient examiner the ability to see a wide range of peripheral pathology in the office that less skilled retinologists will miss.

In addition, training for scleral buckle surgery requires the instructor to trust that the trainee is treating the correct area when applying cryotherapy to a tear. This can require switching the headset between surgeons multiple times, making surgery prolonged. This problem can be solved by having both the surgeon and the trainee wear a BIO.

In addition, it is advocated that the chandelier technique allows for drainage of subretinal fluid to be carried out under visualization.6 This can be accomplished more simply and safely using the BIO performing standard drainage with cut down to the choroid and needle puncture, with the surgeon switching sides and viewing with the indirect once drainage is initiated.

Chandelier scleral buckling adds risk to scleral buckling, and detracts from the training discipline necessary for mastery of a technique that continues to be part of the critical skill set that defines a fully formed retinal surgeon. Chandelier scleral buckling is a bad idea.

REFERENCES

  1. 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 1. Ophthalmology. 2013;120:1804-1808.
  2. Heimann H, Bartz-Schmidt KU, Bornfeld, N et al. Scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment: A prospective randomized multicenter clinical study. Ophthalmology. 2007;114:2142-2154. 
  3. Sakono T, Otsuka H, Shiihara H, et al. Acute bacterial endophthalmitis after scleral buckling surgery with chandelier endoillumination. Am J Ophthalmol Case Rep. 2017;8:7-10.
  4. Hu Y, Si S, Xu K, et al. Outcomes of scleral buckling using chandelier endoillumination. Acta Ophthalmol. 2017; 95(6):591-594.
  5. Imai H, Tagami M, Azumi A. Scleral buckling for primary rhegmatogenous retinal detachment using noncontact wide-angle viewing system with a cannula-based 25 G chandelier endoilluminator. Clin Ophthalmol. 2015;9:2103-2107.
  6. Patterson DF, Ryan EH. Controlled drainage of subretinal fluid using continuous monitoring with indirect ophthalmoscopy. JAMA Ophthalmol. 2013;131(2):228-231.

An Argument for Chandelier Scleral Buckling

JASON HSU, MD
Vitreoretinal specialist at Mid Atlantic Retina and codirector of retina research for the retina service of Wills Eye Hospital in Philadelphia, and associate professor of ophthalmology at the Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia.

Scleral buckling is still an essential procedure that every vitreoretinal specialist should feel comfortable performing. While vitrectomy has increasingly become the go-to technique for repairing retinal detachments, there are cases in which scleral buckles have a clear advantage, such as in young phakic patients with no pre-existing posterior vitreous detachment. The problem is that fewer retina fellows are being trained to perform primary scleral buckles. This may in part be contributing to the declining use of this technique.

Scleral buckling poses some additional challenges to those who are more used to vitrectomy systems. It can be more difficult to teach as the trainee does not directly see what the attending surgeon is doing, and vice versa. We have to switch indirect ophthalmoscopes and trust that each observer is seeing the same thing. Using a 20-diopter lens can be more challenging due to the relatively less magnified view compared to looking under a microscope through a wide-angle viewing system. This can make it easier to miss tiny breaks and was postulated as one of the reasons that there was a higher failure rate when performing scleral buckles in pseudophakic eyes in the European Scleral Buckling vs Primary Vitrectomy in Rhegmatogenous Retinal Detachment (SPR) study.1 Finally, scleral buckling requires a greater “leap of faith” as the retina may not be flat at the end of the case, particularly if no external drainage is performed. However, even with drainage, there is often some residual subretinal fluid that remains. The surgeon must then trust that the technique is going to work.

For buckling to remain in our armamentarium, the essentials of the technique must be passed along to future generations. Adopting some of the advances seen in vitrectomy would seem to be an intuitive next step in the evolution of scleral buckling. In 2013, Kim2 and Nagpal3 described the use of 25-gauge cannula-based chandelier illumination in combination with the standard microscope and wide-angle viewing system during primary scleral buckling. Using a single pars plana cannula and attaching a chandelier light allows the surgeon to take full advantage of visualization system with which we are so familiar when performing vitrectomies. As a result, the surgery can easily be viewed by trainees and observers, which may enhance teaching.4 The improvements in light sources in combination with the modern viewing systems allows higher magnification and greater resolution, thereby permitting easier identification of even tiny breaks. Because holding an indirect lens is no longer necessary, the surgeon has both hands available to perform a controlled external needle drainage under direct visualization with the wide-angle viewing system (see video: https://www.aao.org/clinical-video/chandelier-scleral-buckling-with-subretinal-fluid- ).5

Outcomes with this technique appear to be on par with traditional scleral buckling. In one study of 79 eyes that underwent chandelier scleral buckling, 92.4% had successful single-surgery reattachment.6 While some may worry about the more “invasive” nature of placing a cannula, reported complications have been uncommon. In the series mentioned before, the authors experienced only 2 cases with complications thought to be related to the cannula or chandelier placement. One case had a new retinal break near the cannula that was treated. The other case had lens touch during cryopexy, though this did not progress to cataract formation postoperatively. While one case of endophthalmitis has been reported with this technique,7 cases of endophthalmitis with traditional scleral buckling are known to occur rarely as well.8

While traditional scleral buckling is certainly a well-proven and successful technique, it is clearly on the decline. The less it is used, particularly in training programs, the less likely future generations will feel comfortable with the technique. If it does not evolve to take advantage of some of the innovations we have seen with vitrectomy, the scleral buckle may not survive. RP

REFERENCES

  1. Heimann H, Bartz-Schmidt KU, Bornfeld N, Weiss C, Hilgers RD, Foerster MH. Scleral Buckling versus Primary Vitrectomy in Rhegmatogenous Retinal Detachment Study Group. Scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment: a prospective randomized multicenter clinical study. Ophthalmology. 2007;114(12):2142-2154.
  2. Nam KY, Kim WJ, Jo YJ, Kim JY. Scleral buckling technique using a 25-gauge chandelier endoilluminator. Retina. 2013;33(4):880-882.
  3. Nagpal M, Bhardwaj S, Mehrotra N. Scleral buckling for rhegmatogenous retinal detachment using vitrectomy-based visualization systems and chandelier illumination. Asia Pac J Ophthalmol. 2013;2(3):165-168.
  4. Narayanan R, Tyagi M, Hussein A, Chhablani J, Apte RS. Scleral buckling with wide-angled endoillumination as a surgical educational tool. Retina. 2016;36(4):830-833.
  5. Haug SJ, Jumper JM, Johnson RN, McDonald HR, Fu AD. Chandelier-assisted external subretinal fluid drainage in primary scleral buckling for treatment of rhegmatogenous retinal detachment. Retina. 2016;36(1):203-205.
  6. Imai H, Tagami M, Azumi A. Scleral buckling for primary rhegmatogenous retinal detachment using noncontact wide-angle viewing system with a cannula-based 25 G chandelier endoilluminator. Clin Ophthalmol. 2015;9:2103-2107.
  7. Sakono T, Otsuka H, Shiihara H, Yoshihara N, Sakamoto T. Acute bacterial endophthalmitis after scleral buckling surgery with chandelier endoillumination. Am J Ophthalmol Case Rep. 2017;8:7-10.
  8. Ho PC, McMeel JW. Bacterial endophthalmitis after retinal surgery. Retina. 1983;3(2):99-102.