Article

Tips and Tricks for Scleral Buckles in the 21st Century

Nuanced techniques for an essential skill.

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The rate of scleral buckling for primary rhegmatogenous retinal detachment repair has been on the decline in recent years with rising popularity of modern small-gauge vitrectomy.1 Despite this, scleral buckling remains an essential skill for vitreoretinal surgeons, offering potential advantages to vitrectomy. There remain cases where most surgeons would agree a primary scleral buckle to be the optimal surgical approach; for example, the oft-cited inferior detachment in a young phakic myope with atrophic holes and no posterior vitreous detachment. In such a case, a scleral buckle allows for preservation of the crystalline lens and rapid visual rehabilitation, all without need for postoperative positioning. In addition, vitrectomy in these cases can be challenging with a tightly adherent hyaloid and can lead to proliferative vitreoretinopathy (PVR).

Even as an adjunct to vitrectomy, encircling scleral bands have an important role in cases with PVR, multiple clock hours of breaks, or extensive inferior pathology. Because scleral buckling will always have a role for these patients at a minimum, we like to keep a number of tricks in our buckle tool-belt to optimize outcomes. Here, we will discuss a number of nuances to the practice of scleral buckling, including our commonly used elements, pearls for drainage, chandelier-assisted buckling, and the use of encircling buckles in young patients with primary PVR.

BEYOND THE BAND: ELEMENTS

Buckles come in all different shapes and sizes. We also have various techniques to choose from, including encircling bands, radial buckles, and segmental buckles. Determining the correct type is crucial to ensuring success and is influenced by detachment characteristics, including number, size, and location of the breaks. Radial and segmental buckles offer the advantage of limited surgery (and some of the associated complications) without a refractive shift, while encircling buckles may help support additional or missed breaks and can be used in conjunction with vitrectomy to support the vitreous base. Often, localized and radial buckles achieve adequate height without the need to drain, as in a detachment with less extensive pathology or in a bullous localized detachment. In addition, larger single tears may be amenable to radial elements with less concern of “fish mouthing” seen more commonly with circumferential ones. We tend to encircle if the buckle needs to cover more than 4 to 6 clock hours, when there is pathology in multiple quadrants, and/or if we suspect additional unseen breaks.

For primary encircling scleral buckles, we typically use a type 41 band (3.5 mm) or a 42 band (4 mm). Options for fixation include scleral tunnels (belt loops) or mattress sutures (nonabsorbable, such as nylon or Mersilene [Ethicon/Johnson & Johnson). Both techniques work well and the approach is usually determined by surgeon preference and experience. We tend to suture our bands, which can be done efficiently and potentially poses reduced risk of large perforation or hemorrhage compared to belt loops. During suturing, it is important to avoid areas of scleral thinning and the choroidal vasculature, which can be seen with careful inspection.

Various elements can be used with encircling bands to support larger areas of pathology. We like the 516-grooved silicone element (6.4 mm x 2.3mm) (Figure 1). The element slides nicely under the band to hold it in place, and imbricating 5-0 Mersilene horizontal mattress sutures achieve added support and height.

Figure 1. A 32-year-old female presented with macula-on inferotemporal retinal detachment in the left eye with lattice and holes superiorly and multiple larger holes inferiorly associated with the detachment (A, B). She underwent successful placement of a 41 band with a 516 grooved element and cryotherapy, which provided circumferential support to include superior pathology (C) as well as broader support to the inferior pathology spanning a larger anteroposterior distribution (D). Preoperative and postoperative central acuities were both 20/20 in this eye.

In certain patients (as detailed above), negative consequences of an encircling band can be avoided with the use of a segmental silicone sponge. Segmental scleral buckles are a quick and efficient means of repairing retinal detachments, offering rapid visual rehabilitation without the discomfort and potential complications of encircling bands. Although older reports cite increased infection risks with the use of sponges, modern closed-cell sponges and preoperative antibiotic soaks have helped to minimize the risk of infection and extrusion.2 We prefer using a type 506 segmental sponge (3 mm x 5 mm oval) or 511 (2.75 mm x 7.5 mm half oval) for repair of more localized pathology (Figure 2). The sponge is secured with imbricating horizontal mattress 5-0 Mersilene sutures (passed parallel to the limbus for a circumferential element, or perpendicular for a radial one). Because these elements are not passed underneath all 4 rectus muscles, which helps secure a buckle posteriorly, we perform “double closure” overlying the sponge. This is done by first suturing the Tenon capsule to cover the sponge followed by closing the conjunctiva to prevent late element extrusion.

Figure 2. A 38-year-old female who was 29 weeks pregnant presented with inferior fovea-sparing retinal detachment in the left eye associated with multiple localized holes inferiorly (A). Subretinal fluid encroached just inferior to the fovea, with intraretinal fluid involving the fovea with 20/20 acuity with subjective distortion. She underwent placement of a 506 sponge with cryotherapy. She experienced slow improvement in fluid postoperatively with subjective improvement and 20/20 acuity (B) (no drainage performed).

WHEN AND HOW TO DRAIN

Drainage is not always required with scleral buckle placement. Many shallow detachments have the break opposed to the retinal pigment epithelium just by the indentation effect alone. For example, with the 506 element described above, 3 mm or more of indentation can be achieved with a segmental sponge, which displaces subretinal fluid to either side of the indentation allowing for apposition of the break without drainage.3 Alternative theories suggest that the altered eye wall changes the dynamic traction on the break that was pathologic in the first place (allowing apposition of the retinal break as the detachment shallows).4

To minimize potential complications associated with drainage, we typically drain in highly bullous detachments when we are concerned the detachment will remain bullous after indentation or tightening of the buckle, which is not infrequent with encircling bands. Drainage can also serve as a means to manage intraocular pressure elevation that occurs after tightening, as opposed to performing an anterior-chamber paracentesis. We also typically drain chronic or inferior macula-off detachment cases, where the fluid may take a while to clear, resulting in prolonged foveal injury.

When draining, we aim for an area where the retina is most elevated, but not directly underneath the tear to avoid possible incarceration. We carefully inspect to avoid the choroidal vasculature and the potential for hemorrhage. Safer sites are typically closer to one of the rectus muscles.

To drain, a cutdown approach or external needle drainage are techniques commonly employed. Multiple variations of these techniques have been described to minimize potential complications of drainage, including hemorrhage and incarceration. One such variation involves a guarded needle for external drainage as described previously by Kitchens.5 In brief, a 270 Watzke sleeve element is threaded over a 26-gauge 3/8-inch needle on a 1-cc syringe with the plunger removed so that approximately 4 mm of needle tip is exposed beyond the sleeve. This guarded sleeve helps to minimize deep penetration during drainage. A steep angle of approach is maintained with the bevel of the needle oriented away from the retina to facilitate globe penetration and minimize the risk of retinal incarceration. Visualization can be achieved with the indirect ophthalmoscope or with a chandelier (see below).

During drainage, iatrogenic elevation of the intraocular pressure is important to help passive efflux of subretinal fluid and minimize risk of hemorrhage. Pressure can be maintained through continued traction on the bridle sutures looping the rectus muscles, tightening of the encircling band, or with external pressure from cotton tipped-applicators or your finger, among other techniques. Filtered air should be on standby to immediately restore pressure to a soft eye.

WHEN VISUALIZATION IS KEY: HANG A CHANDELIER

One of the most critical components of successful buckle surgery is break localization and marking. This is done with meticulous scleral depression both preoperatively and then confirmed intraoperatively in a more controlled environment under anesthesia. Missed breaks and poorly positioned buckles result in the most common complication following scleral buckle surgery: recurrent detachment.6 Even if an obvious break exists, it is crucial to search for any additional breaks, paying close attention to Lincoff’s rules. Intraoperatively, we use an O’Connor scleral depressor-marker with careful indirect ophthalmoscopy to mark the location ensuring no anteroposterior error due to parallax.

One option to enhance visualization while marking and treating breaks involves the placement of a chandelier endoilluminator (Figure 3). It utilizes the advanced wide-angle visualization systems available to us in the operating room. As described by Kim and Nagpal, this setup allows for excellent visualization of peripheral pathology at high magnification while liberating the surgeon’s hands from holding a condensing lens (eg, 20D).7,8 The high magnification helps to localize small peripheral breaks that might be missed at lower magnification. The directional lighting and shadowing provided by a dynamically manipulated chandelier can highlight subtle pathology. Furthermore, at training institutions it allows for concurrent visualization of the areas being actively evaluated and treated by trainee and attending, which allows for better instruction and better outcomes. As described elsewhere, we place the chandelier 180 degrees away from the detachment in pseudophakic patients for adequate illumination, or 90 degrees away in phakic patients to avoid cataract formation.9

Figure 3. A 23-year-old phakic female with a macula-sparing inferonasal retinal detachment underwent repair with a chandelier scleral buckle. With visualization using a noncontact wide angle viewing system and a chandelier in the inferotemporal quadrant, scleral depression in the inferonasal quadrant highlighted one of the clusters of causative breaks (A). An external view demonstrates marking of the posterior-most break and the location of the chandelier approximately 90 degrees away (B). Cryotherapy was applied with chandelier visualization to all causative breaks. This patient had 360 degrees of lattice degeneration, and an encircling band was placed with resolution of the detachment.

The use of a 25-gauge instrument is not without some potential risks. There have been case reports of endophthalmitis associated with chandelier buckling, as well as the potential for vitreous prolapse, retina breaks, and cataract. It also involves an additional expense. For the majority of cases, we use careful indirect ophthalmoscopy alone during our buckles and achieve good outcomes. We consider chandelier assisted surgery in cases when we suspect additional holes preoperatively or have difficult visualization, such as in a high myope with blond fundus.

TACKLING PRIMARY PROLIFERATIVE VITREORETINOPATHY

Finally, we also use simple encircling bands as an effective means for primary PVR cases, particularly in young patients. In our clinics, we have encountered a number of chronic retinal detachments in patients under the age of 40 with extensive PVR but manifesting only as subretinal bands, typically indicating that the hyaloid is still firmly attached. A vitrectomy with elevation of the attached hyaloid can place these patients at risk for further retinal breaks and progression of already active PVR, particularly on the retinal surface and vitreous base. These patients are good candidates for an encircling band, with additional posterior elements as needed, to support the vitreous base and relax tension from the subretinal bands, which are fairly pliable in these patients (Figure 4).

Figure 4. A 15-year-old female presented with 4 months of central vision loss following 4 years of progressive vision loss in the left eye after blunt trauma with a tennis ball. Her preoperative visual acuity was 20/500 with a near total macula-off detachment associated with extensive subretinal bands and multiple holes inferotemporally (without dialysis) (A, C). She underwent placement of an encircling 41-band covering the inferotemporal breaks with cryotherapy and drainage and was successfully reattached with resolution of the detachment 6 months postoperatively. Postoperative OCT revealed persistent subfoveal outer retinal loss due to the chronicity of the retinal detachment (B, D).

In summary, we find scleral buckles to be an essential part of our vitreoretinal surgical armamentarium. Aided by some of the tricks above, a scleral buckle can be a service to our patients and provide an easy and efficient means of rhegmatogenous detachment repair. There will always be the profile of patients who would benefit from buckles, and these pearls may help maintain a place for the scleral buckle on retina specialists’ tool belt. RP

REFERENCES

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