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ORIGINAL ARTICLE
Year : 2017  |  Volume : 4  |  Issue : 1  |  Page : 6-8

Excellent results of scleral buckling in the era of microincision vitreous surgery


Department of Ophthalmology, Adesh Medical College and Hospital (Affiliated by PT.B.D Sharma University of Health Sciences), Kurukshetra, Haryana, India

Date of Web Publication20-Apr-2017

Correspondence Address:
Vartika Sobat Anand
House No. 169, Sector 19A, Chandigarh - 160 019
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/erj.erj_15_16

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  Abstract 

Purpose: The purpose of this study is to evaluate the anatomical and functional outcomes of sutureless scleral buckling for the repair of rhegmatogenous retinal detachment (RD). Materials and Methods: Retrospective analysis of fifty eyes of fifty patients with rhegmatogenous RD, who underwent sutureless scleral buckling from January 2014 to August 2015. Results: Primary retinal reattachment rate of 41 patients was achieved with single surgery, but final anatomical success was 94% with additional pars plana vitrectomy with silicone oil injection and with vitrectomy with epiretinal membrane removal. The mean follow-up was 6 months. Conclusion: Sutureless scleral buckling achieves excellent anatomical and functional success in majority of the patients with rhegmatogenous RD.

Keywords: Rhegmatogenous retinal detachment, scleral buckle, sutureless


How to cite this article:
Khan B, Anand VS, Wasil A, Kashyap M. Excellent results of scleral buckling in the era of microincision vitreous surgery. Egypt Retina J 2017;4:6-8

How to cite this URL:
Khan B, Anand VS, Wasil A, Kashyap M. Excellent results of scleral buckling in the era of microincision vitreous surgery. Egypt Retina J [serial online] 2017 [cited 2017 Aug 18];4:6-8. Available from: http://www.egyptretinaj.com/text.asp?2017/4/1/6/204837


  Introduction Top


Rhegmatogenous retinal detachment (RD) is characterized by a break in neurosensory retina (rhegma means hole) with seepage of fluid into the subretinal space. Scleral buckling surgery has been considered as the "gold standard" for uncomplicated RD, despite recent trend toward pars plana vitrectomy. The final anatomical success rate of 40% and 32% in phakic and pseudophakic and 28% in myopic RD, respectively, treated with scleral buckling, and 96.7% and 95.5% in patients treated with primary vitrectomy was reported in a major multicenter, randomized clinical trial.[1] More recently, European VitreoRetinal Society RD Study Group has shown significantly higher final failure rate with vitrectomy with or without buckle as compared to scleral buckle alone in uncomplicated RD in phakic eyes, but no significant difference in pseudophakic eyes.[2]

Inadvertent penetration of globe while passing mattress sutures to secure the buckle has been reported to occur in about 5% of cases.[3] The presence of suture material is associated with the risk of buckle infection, which may in turn result in buckle extrusion. Sutureless scleral buckling technique avoids these complications. In this case series, we report the anatomic and functional outcomes of sutureless scleral buckle in the treatment of selected cases of rhegmatogenous RD. There are scarce data on the sutureless scleral buckling technique. A search on the PubMed.gov database using the keywords "sutureless," "scleral buckle" resulted in only one case report by Sternberg et al., in which belt loop made of polymethyl methacrylate was fixed with cyanoacrylate adhesive to a patient with RD with thin sclera.[4] Moreover, Shanmuga et al., in which sutureless sclera buckle is used for the management of rhegmatogenous RD.[5]


  Materials and Methods Top


Medical records of all consecutive patients, who underwent sutureless scleral buckling surgery at fully equipped eye hospital from January 2014 to August 2015 are included in this study.

The baseline characteristics that were collected includes: age, sex, preoperative best-corrected visual acuity (BCVA), extent of RD, attached or detached status of macula, presence or absence of proliferative vitreoretinopathy (PVR), retinal breaks (types, location, number, and size), presence or absence of high myopia, and lens status. The extent of RD varied [Table 1]. All intraoperative and postoperative complications, including redetachment, were noted. The details of additional surgical techniques used to repair redetachment and their outcome were also recorded. Final postoperative visual acuity (VA) was noted as BCVA at final follow-up visit. VA was analyzed by means of logarithm of minimum angle of resolution (log MAR) given by Ferris et al.[6] The conversion of Snellen visual acuities to log MAR was done by the method given by Holladay.[7]
Table 1: Baseline demographic of the patients who underwent scleral buckling

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Technique of sutureless scleral buckling in all the cases, 2.5 mm silicone band (240 band) was used as encircling material along with a segmental scleral buckle. The encircling band was anchored to the sclera with partial thickness scleral tunnels. The tunnels were made with crescent knife 14 mm away from the limbus one in each quadrant, except in that quadrant where a segmental silicone tire is to be placed. The segmental scleral buckle was secured beneath the encircling band, placed episclerally over the retinal break. Two scleral tunnels placed at the margins of the segmental buckle ensured that the buckle did not slip laterally. The encircling band passing between the two closely placed tunnels "buckles" the segmental silicone tire, and the sclera to create an adequate buckle effect provided that the segmental buckle is 3 clock hours in extent. The antero-posterior extent of the segmental buckle was based on the size of rhegma, the buckle being adequate to cover the retinal break and 2–3 mm of surrounding retina. For breaks located in more than one quadrant, multiple segments of silicone tire, one in each quadrant, were used to support the retinal breaks. Watzke sleeve was used to secure the ends of encircling band. Drainage of subretinal fluid (SRF) by external needle drainage method (Charle's technique) was performed as judged by the surgeon. Cryotherapy around the retinal break was done in all cases. In one case, air was injected due to hypotony. The conjunctiva was apposed with sutures (6-0 vicryl).


  Results Top


A total of fifty eyes of fifty patients (33 male and 17 female) were included in this study. The most common configuration was macula-off superior RD, and the most common retinal break was a tear. Median follow-up of the patients was 6 months.

The primary anatomic success of 82% (41 out of fifty cases) was achieved by single procedure.

The intraoperative and postoperative complications were observed as shown in [Table 2]. subretinal hemorrhage was observed in 5 (10%) of eyes. Ten (20%) patients experienced raised intraocular pressure (IOP >21 mm Hg) during postoperative period; which was controlled with antiglaucoma medications in all patients IOP was controlled except in two patients, who required glaucoma surgery. Two patients had buckle infection which was treated after buckle removal. Two patients converted to suturing on table as perforation with crescent knife occurred while making tunnels. PVR changes were observed in seven patients and epiretinal membrane (ERM) in two patients; these two patients underwent vitrectomy with ERM removal after 3–4 weeks.
Table 2: Intra operative and post operative complications

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  Discussion Top


In our series of fifty eyes with rhegmatogenous RD sutureless scleral buckling, primary retinal reattachment with single surgery could be achieved in 82% of eyes, and final reattachment in 94% after subsequent retinal procedure. Anatomical outcomes of our study correlate well with other major studies showing primary success rate of scleral buckling of 63%–84%.[1],[8] The functional outcomes in terms of improvement in BCVA also corroborate well with the other major studies with 30 (60%) eyes showing BCVA log MAR 0.50 (6/18) at final follow-up.[1] The success rate of buckling surgery in our study were not influenced by the lens status of the patient with phakic and pseudophakic eyes showing no significant difference in terms of outcome, similar to the finding of Thelen et al. in their large retrospective study.[8]

Sutureless scleral buckling avoids the risk of inadvertent penetration of the globe when passing sutures. Intrascleral placement of the sutures is associated with a steep learning curve, while the sutureless technique is easily mastered by the novice surgeon. In our series, intraoperative complications were minimal (10%) and consisted only of subretinal hemorrhage and hypotony-related to drainage of SRF and not attributable to the sutureless technique described here.

Buckle infection, a significant postoperative complication, has been reported to occur between 0.5% and 5.6% of patients and is related to the use of sutures, which act as a nidus for infection.[9],[10] Sutureless scleral buckling grossly decreases this risk of buckle infection.

Sutureless scleral buckling technique can be employed to treat most rhegmatogenous RDs, but not those with multiple breaks close to each other at various distances from the ora serrata and with extensive PVR changes. The buckle effect achieved is adequate. For the sutureless technique to work, the extent of the buckle should not be more then 3 clock hours; scleral tunnels for more extensive buckles would have to be placed further apart, and the resulting laxity of the encircling band causing an inadequate buckle effect. However, in our series, most commonly used was 279 buckle with 10 mm width. Considering that the presence of multiple breaks in different quadrants is most often managed with vitrectomy, most cases that are candidates for simple scleral buckling can be managed with the sutureless technique. The sutureless technique also has the advantage of avoiding unnecessarily high and/or irregular buckle, which often can occur when employing sutures, we can also move the buckle after SRF drainage as the tunnels are wide apart.

Subanalysis of the nine cases of failed primary surgery showed that preoperative factors such as preexisting PVR and multiple horseshoe tears (HSTs) and a large two-disc diameter-sized HST as the possible causes of failure. Postoperatively, failure occurred due to fish mouthing of the break and PVR.

The drawback of our study is being a retrospective in nature would require prospective validation or head-to-head comparison between sutureless scleral buckling with already established techniques of repairing RD.

There has been a continuous debate over the last decade about the best surgical procedure for RD, and some centers have greatly increased their percentage of pars plana vitrectomy as a primary procedure for RD.[11] Scleral buckling is practiced/taught with decreasing frequency with a preference toward sutureless vitrectomy (23G, 25G, 27G) in recent times. The major recent clinical trials both randomized and nonrandomized have, however, shown the benefits of scleral buckling over vitrectomy in terms of both anatomical and functional outcomes in the management of uncomplicated rhegmatogenous RDs.[1],[2] Scleral buckling results in earlier visual recovery in the absence of tamponades used with vitrectomy decreases the risk of cataract that occurs after vitrectomy, and a second surgery to remove the tamponade is also not required. Sutureless scleral buckling is relatively easy to master and is likely to revive scleral buckling for treating simple rhegmatogenous RD.


  Conclusion Top


Sutureless scleral buckling is easy to adapt to and achieves excellent anatomical and functional success in the majority of the patients with rhegmatogenous RD without PVR changes. The head-to-head randomized controlled trial is required with a large number of patients to compare both techniques.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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;114:2142-54.  Back to cited text no. 1
    
2.
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;120:1804-8.  Back to cited text no. 2
    
3.
Brown P, Chignell AH. Accidental drainage of subretinal fluid. Br J Ophthalmol 1982;66:625-6.  Back to cited text no. 3
    
4.
SternbergP Jr., Tiedeman J, Prensky JG. Sutureless scleral buckle for retinal detachment with thin sclera. Retina 1988;8:247-9.  Back to cited text no. 4
    
5.
Shanmugam PM, Singh TP, Ramanjulu R, Rodrigues G, Reddy S. Sutureless scleral buckle in the management of rhegmatogenous retinal detachment. Indian J Ophthalmol 2015;63:645-8.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Ferris FL 3rd, Kassoff A, Bresnick GH, Bailey I. New visual acuity charts for clinical research. Am J Ophthalmol 1982;94:91-6.  Back to cited text no. 6
    
7.
Holladay JT. Proper method for calculating average visual acuity. J Refract Surg 1997;13:388-91.  Back to cited text no. 7
    
8.
Thelen U, Amler S, Osada N, Gerding H. Success rates of retinal buckling surgery: Relationship to refractive error and lens status: Results from a large German case series. Ophthalmology 2010;117:785-90.  Back to cited text no. 8
    
9.
Tsui I. Scleral buckle removal: Indications and outcomes. Surv Ophthalmol 2012;57:253-63.  Back to cited text no. 9
    
10.
Yoshizumi MO, Friberg T. Erosion of implants in retinal detachment surgery. Ann Ophthalmol 1983;15:430-4.  Back to cited text no. 10
    
11.
Johansson K, Malmsjö M, Ghosh F. Tailored vitrectomy and laser photocoagulation without scleral buckling for all primary rhegmatogenous retinal detachments. Br J Ophthalmol 2006;90:1286-91.  Back to cited text no. 11
    



 
 
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  [Table 1], [Table 2]



 

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