Scleral buckling (SB) is a procedure that was introduced more than six decades ago for management of rhegmatogenous retinal detachments (RD). Of late, with emphasis on decreased morbidity and quicker recovery times, this procedure is loosing its place to micro incision vitreoretinal surgeries (MIVS).
The perceived disadvantages of SB are significant. When compared to MIVS, patients undergoing SB experience intraoperative discomfort when the eye ball is manipulated access the posterior scleral sections. Placement of an SB with an encircling band traditionally requires a 360-degree peritomy to be performed. This in turn leads to longer recovery times. Buckling can be employed only if the causative break/s are close to each other. The presence of conjunctival sutures is a source of significant ocular discomfort. Strabismus, SB infection, SB extrusion, anterior segment ischemia and changes in refractive error are often cited as reasons to avoid scleral buckling.
Besides these factors, advances in instrumentation for performing vitrectomy have contributed in no small way to the declining popularity of scleral buckling. Surgeons can now confidently work close to the retina as variables such as flow rate and vacuum are in better control. Availability of most surgical instruments in smaller gauges allow for sutureless vitreous surgeries. An RD whose causative break is not made out pre-operatively can still be tackled with vitrectomy is performed.
Despite these advantages offered by internal procedures, SB holds its ground in certain unique clinical situations. The cornerstone of a successful internal procedure for rhegmatogenous RD is the induction of a posterior vitreous detachment (PVD) and clearance of vitreous around the retinal breaks. Therefore, when induction of a PVD and clearance of vitreous around peripheral retinal breaks is difficult, it would be prudent to avoid entering the vitreous cavity. An external procedure or SB thus finds use in children and young adults where induction of a PVD is difficult and where reaching the vitreous base with a vitrectome may lead to clear lens damage. For the above-mentioned reasons, SB is employed for treatment of RD associated with retinal dialysis as well.
It is nothing short of fascinating to observe the retina, which had a bullous detachment at conclusion of buckling, flatten out the next morning. Successful buckling thus requires, besides good surgical skill, excellent clinical expertise to isolate the causative break preoperatively. Young retinal surgeons in their training period must be exposed to scleral buckling and taught the nuances of this delicate art so that a useful tool to manage rhegmatogenous RDs is not lost to future generations of patients.
By,
Dr. Madhana Gopal,
Vitreo-Retinal Surgeon,
JB Eye and Retinal Centre,
Salem, India.