Scleral BucklingEdit
Scleral buckling is a foundational procedure in the management of rhegmatogenous retinal detachment, a condition in which fluid accumulates beneath the retina through a tear or break and causes the retina to separate from underlying tissues. The operation uses an external band or "buckle" placed around the sclera (the white part of the eye) to indent the wall of the eye and support the tear, enabling the retina to reattach. In practice, scleral buckling is one of several vitreoretinal techniques, the others including pars plana vitrectomy and pneumatic retinopexy, each chosen based on the specifics of the detachment and patient factors. The method has a long track record of safety and effectiveness when performed by skilled surgeons and remains particularly relevant in certain clinical scenarios and practice settings.
In its modern form, scleral buckling often combines external indentation with internal laser or cryocoagulation to seal the breaks, and may involve drainage of subretinal fluid when needed. The approach preserves the natural contents of the eye and avoids intraocular implants, aligning with a conservative, precision-based philosophy of ocular repair. The technique is taught and practiced worldwide and is accessible in many health systems, contributing to a diverse set of treatment options for retinal detachments.
History
Scleral buckling emerged in the mid-20th century as surgeons sought reliable, external methods to counteract the forces pulling the retina away from the underlying tissues. Early iterations relied on indentation methods that used external materials to mechanically support the retina. Over time, the repertoire expanded to include segmental and encircling buckles, as well as a range of buckle materials such as silicone sponges and silicone rubber bands. The integration of directed cryotherapy or laser retinopexy with scleral buckling helped create robust adhesion at tear sites, improving reattachment rates. As surgical techniques evolved, clinicians increasingly tailored the buckling approach to tear location, lens status, and the presence of proliferative vitreoretinopathy (PVR), a scarring process that can complicate detachment repair.
Indications and technique
Indications
- Rhegmatogenous retinal detachment with identifiable retinal breaks, particularly in eyes with localized or superior breaks in phakic patients.
- Detachments in which the vitreous has not undergone extensive traction or scarring, where an external buckle can effectively relieve retina-pulling forces.
- Situations where preservation of the natural lens is desirable, or where internal surgical manipulation is preferred to minimize intraocular instrumentation.
Technique
- The procedure is performed under anesthesia, with exposure of the sclera through a conjunctival peritomy.
- A buckle—segmental or encircling—is positioned to encircle or indent the area of the breaks. The buckle material ranges from silicone sponge to solid bands, chosen based on the surgeon’s assessment of tear configuration and ocular anatomy.
- Cryopexy or laser photocoagulation is applied to the tear margins to promote adhesion between the retina and the underlying pigment epithelium.
- In selected cases, drainage of subretinal fluid is performed to facilitate reattachment and reduce tension on the retina.
- Postoperative positioning and routine ophthalmic care follow the procedure to monitor reattachment and detect complications early.
Subspecialty considerations
- Tear location matters: superior breaks respond well to buckling, while inferior breaks or complex PVR patterns may prompt consideration of alternative approaches such as pars plana vitrectomy.
- Lens status influences choice: phakic eyes historically favored buckling in certain detachments to preserve the natural lens, whereas pseudophakic eyes may be managed with either buckling or vitrectomy depending on tear pattern and prior surgical history.
Outcomes and comparisons
Effectiveness
- When appropriately selected, scleral buckling achieves reattachment rates that are competitive with alternative approaches, particularly in uncomplicated detachments with discrete breaks.
- Re-detachment rates vary with tear pattern, presence of PVR, and the surgeon’s experience, but many series report single-surgery success in a majority of suitable cases.
Visual outcomes
- Visual recovery depends heavily on macular status at presentation, duration of detachment, and the extent of proliferative changes. Buckling can preserve useful vision by maintaining the eye’s natural contents and minimizing intraocular manipulation.
Comparisons with other approaches
- Pars plana vitrectomy (PPV) is often favored for complex detachments, inferior breaks, or significant PVR, where internal vitreous traction is prominent.
- Pneumatic retinopexy offers a less invasive option in select cases with favorable tear patterns and good media clarity, but may require staged procedures and careful patient selection.
- In many patients, the choice among buckling, PPV, and pneumatic retinopexy reflects a balance between anatomical success, functional outcome, and resource considerations, rather than a single universal standard.
Complications and controversies
Common complications
- Diplopia or motility disturbances due to changes in extraocular muscle balance or buckle-induced distortion.
- Buckle-related issues such as infection, extrusion, or erosion, and, in some cases, suture-related irritation.
- Refractive changes, including a myopic shift from scleral indentation and chronic refractive instability.
- Rare but serious risks include choroidal detachment, hypotony, glaucoma, or endophthalmitis (in the event of infection).
Controversies and debates
- The primary debate centers on when scleral buckling is the optimal initial approach versus pars plana vitrectomy or pneumatic retinopexy. Proponents of buckling emphasize its external nature, avoidance of intraocular instrumentation, and potential for rapid, outpatient management, especially in resource-conscious settings or in eyes with specific tear configurations. Critics argue that vitrectomy has matured to handle a wider range of detachments, including those with inferior breaks or complex PVR, and that PPV can offer direct access to vitreous traction and better management of peripheral pathology.
- From a policy and systems perspective, some observers stress cost-effectiveness and patient throughput, noting that buckling can be performed in ambulatory settings with shorter hospital utilization. Others caution that surgeon experience and patient selection are critical; without these, outcomes can be inferior to modern PPV in certain cases.
- Woke criticisms sometimes target the notion that older techniques are inherently inferior and that reimbursement and training biases drive method selection. In a practical sense, evidence shows that the best outcomes arise when the surgical plan is tailored to the individual patient’s pathology, lens status, and eye anatomy, rather than adherence to a single preferred approach. Advocates of value-driven care argue that choosing the method with the strongest case-specific probability of success—while considering cost, recovery, and complication risk—represents prudent stewardship of healthcare resources. Critics of blanket dismissals of older methods argue that such blanket timelines ignore durable, evidence-based options that remain valuable in real-world practice.