Scleral Buckle

A scleral buckle is performed for retinal detachment to reestablish the geometric proximity of separated
layers in the retina. Retinal detachment is an ophthalmologic emergency that can rapidly progress to
irreversible vision loss in the affected eye.
The sensory retina is dependent on its underlying layers (retinal pigment epithelium, choroid) for delivery of
oxygen, trophic factors, and nutritional substrates. Therefore, any damage or disruption in the conduit
between the layers has great potential to lead to ischemic damage and cell death. The vast majority of
detachments are caused by the formation of tears (rhegma) in the retina, which allow the entrance of
liquefied vitreous into the subretinal space, with subsequent fluid separation of the retinal layers.
Scleral buckling is based on the anatomic correction of the space created between the detached sensory
retina and the underlying retinal pigment epithelium. This is done by the inward indentation of the sclera
from the exterior, creating a ridge (or buckle) that reduces the tear to allow for the reapposition of separated
layers, thus reestablishing their physiologic connection. The sclera itself is most commonly indented by
placement of a permanent explant beneath the retinal tear, although there are variations where temporary
buckles are used.
The external pressure from the buckle explant reduces the volume of the globe, and in doing so relieves a
portion of the vitreous traction contributing to the retinal tear and detachment. Although this procedure
involves exposure of the globe and considerable intraorbital manipulation, it is often performed on an
outpatient basis.
In addition to the placement of the explant to displace the eye layers inward, it is important that the retinal
tears are sealed by the formation of chorioretinal adhesions. This is performed by inducing a thermal injury
via the use of cryotherapy, diathermy, or laser energy. In conjunction with the generation of such adhesions,
the physical closure of the break by the explant enables the attachment of the retina. The dynamic forces
that generated the detachment (vitreoretinal traction and inflow of liquefied vitreous) are countered by these
maneuvers.
Once secured, the normal physiologic forces preventing separation may then maintain the retinal layers.
Depending on the extent of detachment and underlying pathology, there may also be indications for
auxiliary procedures during the placement of the scleral buckle, such as the removal of accumulated
subretinal fluid and/or the injection of intravitreal gas.[1]
Although modalities such as vitrectomy and pneumatic retinopexy are increasingly used to deal with
detachments, buckling continues to be a principal approach in many clinical scenarios. Given the poor
visual outcomes that attend the course of an uncorrected detachment, scleral buckling is most often
performed on an emergent basis to preserve acuity.

Indications
Scleral buckling is indicated for the following conditions:

Rhegmatogenous retinal detachment

Detachments due to dialysis
Complex retinal detachments
The most common mechanism causing retinal detachments is the formation of rhegmas or full-thickness
tears in the retina. Rhegmatogenous detachments account for 90% of detachments, resulting from the
traction exerted on the retina by the posterior vitreous. As the rhegma forms, liquefied vitreous is allowed
access to a pathway into the subretinal space. It subsequently acts as a wedge to separate the retina from
the retinal pigment epithelial.
Although the initial presentation of patients with symptomatic detachment can vary widely, there are
common salient features, including the following symptoms:

Photopsia (flashing lights related to mechanical stimulation of the retina through vitreous traction)
Floaters (from abrupt detachment of vitreous)
Visual field defects (often described by the patient as a sudden black curtain that enlarges over
time)

Decreased visual acuity (particularly in detachments involving the macula)

Detachments may be due to dialysis, in which the retina detaches circumferentially from its insertion point
at the ora serrata on the retinal periphery. This is a less common etiology and is most often seen in the
setting of trauma.
Rhegmatogenous retinal detachments complicated by tractional forces from proliferative vitreoretinopathy,
as well as other proliferative processes, require vitrectomy with scleral buckling when the traction is present
in the peripheral retina in order to achieve high success rates of reattachment. These surgeries may
require also advanced surgical techniques, such as membrane peeling, silicone oil, and retinectomies. [2]

Contraindications
Detachments that emanate from breaks anterior to the equator (the anterior-posterior circumferential
midpoint of the globe) are more amenable to placement of buckles. Breaks significantly posterior to the
equator are anatomically more difficult to approach due to hindrances from the bony orbit. Thus, these may
be difficult technically.
Opaque media may preclude visualization of retinal tears and thus proper accounting of the breaks. This is
most often seen in scenarios of vitreal hemorrhage, most commonly in the setting of severe retinal
neovascularization.
In patients with significant vitreoretinal traction, such as with proliferative vitreoretinopathy and diabetic
neovascularization, using a scleral buckle exclusively is usually insufficient to reattach the retina. However,
buckling can be part of the surgical approach, in addition to vitrectomy.
Many surgeons prefer to avoid possible anterior ischemia caused by buckling in patients with vasoocclusive disease, such as sickle cell anemia.

Technical Considerations
Best Practices
If there is a significant tractional component to the retinal detachment, such as in proliferative
vitreoretinopathy and proliferative diabetic retinopathy, a vitrectomy approach may be favored over scleral
buckling.[3, 4, 5]
If subretinal drainage occurs, it is important to rule out retinal incarceration in the tract.
Procedure Planning
The most crucial aspect of any approach to treating rhegmatogenous detachments is the ability to localize
all of the retinal tears. Not locating a tear would predispose any technique to failure because it allows for
the new influx of subretinal fluid. This is performed with the use of indirect ophthalmoscopy via the aid of a
condensing lens, most often a 20- or 28-D variant. The use of scleral indentation to bring the peripheral
retina into view is indispensible.
Initially, full visual acuity testing should be performed to assess the patients baseline level of vision. This is
crucial in the primary care or emergency department setting. A drastically reduced visual acuity may be an
indication of macular involvement and thus lessens the need for a more urgent intervention.
Extraocular muscle testing is important to establish a baseline because strabismus may develop
postoperatively.
Tonometry is indicated because retinal detachment frequently lowers intraocular pressure. Postoperatively,
buckling may increase intraocular pressure as a function of volume reduction.
Laboratory tests, as guided by the medical history, may be requested as part of the preoperative
evaluation. Coexisting systemic diseases may increase anesthetic and surgical risks, as well as the
potential for local complications (eg, thrombocytopenia).

Outcomes
Postsurgical visual outcomes are related to the extent of initial macular involvement. Anatomic
reattachment is achieved in 90% of cases, with success rates nearing 100% in certain case series.
However, there is a significant discrepancy between favorable anatomic correction and functional visual
outcomes.

The most important issue dictating success in restoring visual acuity is the presence of macular
involvement. In macula-off detachments (in which the detachment involves the macula), only 40-60% of
patients have restored visual acuity of 20/50 or better.[6] Visual restoration is much more successful in
detachments sparing the macula,[7] with one large series reporting that 90% of such patients had vision of
20/40 or better following surgery.[8]
Factors predicting poor visual function include the following:

Age (>70 y)
Macular detachment occurring more than 7 days prior to surgery
Severe proliferative vitreoretinopathy
Intraoperative hemorrhage
However, the most reliable predictor for poor postoperative outcome is poor preoperative visual acuity.[9]

Relevant Anatomy
The sensory retina, composed of photoreceptors and adjacent ganglion cells, overlies the retinal pigment
epithelium. The blood supply for the sensory retina is derived from two circulations, both originating from
the ophthalmic artery. The anterior circulation comes from the retinal artery as it branches into arterioles
that course along the surface of the sensory retina and supply the inner (more proximate to the vitreous)
layers. Changes in this circulation are seen with vitreous retinopathy, most commonly in patients with
diabetes, who are predisposed to tractional detachments. The posterior (uveal) circulation supplies the
outer segments of the retina (the photoreceptors and the retinal pigment epithelial). It is the loss of contact
with this supply that proves disastrous in the course of detachment.
The peripheral edge of the retina is defined by the orra serrata, the junction with the ciliary body located
anteriorly. In this region, the inner and outer retinal layers are tightly adherent.
The sclera is the protective outer covering of the eye composed of fibrous connective tissue. It has the
structural integrity to support the placement of an explant. The sclera itself is contained within Tenons
capsule, which merges anteriorly with the conjunctiva. These two structures must be penetrated to place
the buckle.
For more information about the relevant anatomy, see Retina Anatomy.

Periprocedural Care
Equipment
Equipment for sclera buckling includes the following:

Operating room spot lights

Indirect ophthalmoscope and condensing lenses (28 and 20 D)
Surgical loupes or operating microscope (sometimes used)
Lid speculum
Muscle hooks
Westcott scissors
Stevens scissors (curved)
Various forceps, including 0.12 forceps, needle holders, Nugent forceps, Bishop forceps
Sleeve expander forceps
Schepens retractor
Sutures
Needles and blades for subretinal fluid drainage, depending on preferred technique
Hemostasis cautery is used by some surgeons
Marking pen
Localizer (variable instrumentation, such as a marking depressor or diathermy probe) Retinopexy
applicator of choice, such as cryotherapy (most common), diathermy, or laser
Silicone buckling elements include the following (see image below):
Silicone sponge
Silicone hard rubber
Silicone encircling band
Silicone sleeve

See the image below.

Sleeve, encircling, and buckling elements.

Air, SF6, and C3 F8 gas (in select cases requiring pneumatic retinopexy) are also needed. [10]

Patient Preparation
Anesthesia
Scleral buckling may be performed under either local or general anesthesia. Retrobulbar local anesthesia
with sedation may be used. However, some surgeons routinely use general anesthesia for buckling. There
is frequently a few minutes of discomfort associated with manipulation of the recti muscles that occurs from
the insufficient reach of the block at the posterior insertion of these muscles. General anesthesia may be
preferred in pediatric patients.
There are two principal approaches to administration of local anesthetic: retrobulbar block or peribulbar
block.
With retrobulbar block, anesthetic is injected posterior to the globe into the retrobulbar space. The most
concerning risks of retrobulbar injection of anesthetic are the potential for retrobulbar hemorrhage, optic
nerve damage, injection of anesthetic into the subarachnoid space, and perforation of the globe.
With peribulbar block, anesthetic is introduced more anteriorly, into the muscle cone surrounding the globe.
This reduces some of the risks associated with the more posterior injection necessary in the retrobulbar
approach, such as optic nerve damage and retrobulbar hemorrhage.
Both of these techniques provide both sensory anesthesia and akinesia of the rectus muscles. A mixture of
bupivacaine (0.75%) and lidocaine (2%) is the most commonly administered local anesthetic for both
approaches. This provides both a long-acting anesthetic (bupivacaine) and a short-acting agent (lidocaine).
Epinephrine should be avoided given the risk of central artery occlusion that exists with resulting
vasoconstriction.
Positioning
Patients are positioned in supine manner on an eye bed and placed under the operating room spotlights.

Monitoring & Follow-up

Patients should be seen the next day to assess for emerging postoperative complications, such
as choroidal detachment, high intraocular pressure, or persistent retinal detachment. Further follow-up is
variable, performed approximately at postoperative weeks 1, 4, 8, 12, and 30 with annual examinations
afterwards, or as dictated by a complicated postoperative recovery.
Poor visual acuity may be a function of chronicity of the macular detachment,cystoid macular edema,
macular pucker, or the presence of subretinal fluid. These may be further assessed with imaging such as
fluorescein angiography and/or optical coherence tomography.[11]

Postoperative Complications
General complications may include the following:

Refractive error (due to the increased axial length from pressure of buckle)

Strabismus (if explant is placed so that it entraps a rectus muscle)

Extrusion of the explant
Ischemia of the anterior segment of eye (from the use of encircling bands; often revealed by
corneal edema or clouding)

Elevated intraocular pressure (due to reduction of total globe volume)

Macular edema or macular pucker

Other complications may result from the drainage of subretinal fluid, including the following:

Choroidal or subretinal hemorrhage

Retinal incarceration within the sclera perforation
Neovascularization or proliferative retinopathy
Endophthalmitis [12]
Patients may have increased myopic refractive error due to axial lengthening of the globe.
Macular edema and macular pucker may cause worsening vision several days after surgery.

Technique
Approach Considerations
After anesthetic is administered, the eye is prepped and draped in sterile fashion and a lid speculum is
placed. A conjunctival peritomy is made and the conjunctiva is reflected back. A 360-degree peritomy is
usually made, but a smaller incision may be made if the culprit tear is localized to a single retinal quadrant.
The Tenons capsule is then dissected bluntly and similarly reflected back from the insertion point of the
rectus muscles. Cotton applicators or other means to bluntly push back are frequently used. The rectus
muscles themselves are isolated with muscle hooks and secured with sling sutures (2-0 silk sutures), as
shown in the image below.

Isolation of rectus muscles with sutures.

The most crucial aspect of any approach to treating rhegmatogenous detachments is the ability to localize,
characterize, and seal all of the retinal tears. Not locating a tear would predispose any technique to failure
because it allows for the continued influx of subretinal fluid and the promotion of the detachment. The initial
survey is performed through indirect ophthalmoscopy via the aid of a condensing lens (20 or 28 D). To view
the peripheral retina, it is necessary to indent the sclera to bring possible breaks into the viewing field. This
task becomes significantly more difficult in the setting of opaque media, such as vitreal hemorrhage or
exudates. As a result, if the retina cannot be reliably visualized, the operator cannot be confident that all
tears and areas of degeneration are identified. In this case, vitrectomy should be considered.
The location of the breaks may be marked on the sclera with the use of a localizer (eg, marking depressor,
diathermy probe). Tears are preferentially marked at their anterior edge, which is the area with the most
vitreoretinal traction that must be opposed. Care must be taken to only depress the sclera, not the shaft,

with the tip of the localizer. Otherwise, false localization may result in erroneous buckling. A marking pen
may be applied over the initial mark to make it visible for longer time, as shown in the image below.

Localization

of

rhegmatogenous

retinal

break with probe and condensing lens.

When all of the breaks have been identified and marked appropriately, they may be treated with retinopexy.
Retinopexy is achieved by one of three principal mechanisms:

Cryopexy, which is an external application of cold burn and the most commonly used mechanism
Laser coagulation via indirect ophthalmoscope, which is used less frequently because it only works
once the retina is attached

Diathermy, which is an electrical-induced inflammatory lesion that is of limited use in current

practice because of the significant risk of scleral necrosis
Cryopexy of a particular region is ceased once the ice ball is seen to involve the retina to avoid progression
to necrosis.
The retinopexy applications should be contiguous surrounding the tear but not overlap considerably, as this
may cause excessive damage to the tissue. There should be 1-2 mm of treatment extending past the edge
of the break.

Choice of Buckle Element (Segmental or Encircling)

The explant material is made from either hard silicon rubber or silicon sponge material. These come in a
variety of shapes and sizes that allow the surgeon to tailor the buckling amount and distribution of pressure
to each case.
When choosing a buckling element, the primary factor is the number and location of the breaks. The
patients phakic status, presence of glaucoma, and any comorbid diseases should also be considered.
Encircling bands are most likely to be placed in the following scenarios:

For many breaks or breaks that are scattered over more than two quadrants
When there are possible undetectable breaks
For elevated breaks with copious subretinal fluid (bullous detachments)
Where segmental buckling has previously failed
The rationale of employing an encircling approach is that it allows for numerous seen and unseen breaks to
be bottled, thus preventing the intrusion of vitreous that maintains the detachment. Many surgeons prefer to
use encircling buckles because of their higher success rate over segmental buckles. Encircling also
favorably changes the geometry of the globe by alleviating vitreoretinal traction.
Segmental buckles should be placed in the following scenarios:

With significant pre-existing glaucoma damage to the optic nerve, for which encircling bands have
more potential to elevate intraocular pressure

For patients with sickle cell disease because of an increased risk of anterior segment ischemia
(although consider a vitrectomy instead of buckling)

For a small number of breaks within 1 or 2 clock hours of each other, which may be approached
with radial or segmental buckles

In addition to an encircling buckle in an area where higher indentation is desired

The buckle elements are soaked in an antibiotic solution and then placed underneath the rectus muscle.
Securing scleral sutures (5-0 polyester with spatulated needle) are placed parallel to the buckle with partial
thickness depth. Care is taken not to perforate the globe with the suture needle, which should be
spatulated. The previously placed marks localizing the tears on the sclera are used to decide where to
secure the buckle.
With the buckle temporarily in place, indirect ophthalmoscopy is used to confirm the following:

Adequate placement of the buckle underneath the retinal break

The break has not fish-mouthed
The patency of the central retinal artery
It is important that the buckling element extends past the posterior edge of the break. The sutures may be
released and buckle repositioned accordingly. At this juncture, the operator may decide to extend the
procedure and include drainage of subretinal fluid if indicated (see images below). Depending on the size
of the tears, depth of the detachment, and associated vitreoretinal pathology, the operator may choose a
degree of height for the buckle or amount of indentation.

Placement of encircling buckling element

around eye.

Placement of buckling material beneath

retinal break.

Drainage
The choice of draining the subretinal fluid is an often-debated subject among retinal surgeons. It is often a
matter of surgeon preference and its implementation varies widely. However, several compelling indications
exist for initiating drainage:

For a highly elevated detachment due to significant fluid

When the retina is anchored to the vitreous, usually by proliferative vascular disease
For inferior detachments, in which the vitreous will pool in dependent areas and may reform the
tear

When there is concern for intraocular pressure elevation in glaucomatous eyes and eyes with thin
sclera

For chronic detachments, in which the subretinal fluid tends to assume more viscosity with age of
detachment and its reabsorption is prolonged
If drainage is thought to be preferable, the temporarily secured buckle is loosened to allow access and
drainage is performed via a sclerotomy beneath the fluid collection. This site should ideally be covered by
the buckling element afterwards so as to prevent egress of further fluid. The actual entry and drainage can
be performed with a 27- or 30-gauge needle. Some surgeons perform the drainage while inspecting the
retina through indirect ophthalmoscopy. Other surgeons prefer to do a cut-down on the sclera to reach the
choroid, which is cauterized prior to draining.
Should a drainage approach be chosen, it is important to re-examine the site afterwards and confirm that
the retina has not become incarcerated into the drainage tract. Once adequate fluid removal occurs, some
surgeons close the sclerotomy tract with suture (5-0 nylon). If the eye becomes too soft from the amount of
fluid drained, restoring vitreous volume can be achieved with air, gas, or fluid. [13]
During the course of surgery, corneal epithelial edema frequently develops from the combination of
increased intraocular pressure during surgical maneuvering, or sometimes from preservatives in the
wetting agents used to keep corneal clarity. By avoiding the use of wetting agents with toxic preservatives,
corneal epithelial edema can be delayed and the need for epithelial debridement with a surgical blade to
improve visibility can be reduced.[14]
Once the buckle is satisfactorily created, the Tenons capsule and conjunctiva are closed with absorbable
suture (polyglactin or gut). An antibiotic (typically cefazolin or vancomycin in patients with a penicillin
allergy) and steroid (dexamethasone or triamcinolone) are then placed via subconjunctival injection. The
eyelid speculum is removed and antibiotic ointment is placed on the exterior of eye. A temporary eye patch
is placed and kept on until the patient can be examined the following day.[10]

If a nondrainage approach is chosen, it may be necessary to counter intraocular pressure elevation via
medical or surgical means (eg, anterior chamber paracentesis). This situation is more likely in cases for
which encircling bands were employed, given their higher potential for volume reduction.
Significant intraocular pressure elevation may be emergently reduced by either systemic osmotic therapy
with 20% mannitol or surgical paracentesis (drainage of the aqueous humor from the anterior chamber).

Dapus :

Oct 21, 2013 Senad Osmanovic, Enrique Garcia-Valenzuela, Cathleen A Davidson

(http://emedicine.medscape.com/article/1844313-overview#showall)