Scleral Buckling: A Look at the Past, Present and Future in View of Recent Findings on the Importance of Photoreceptor Re-Alignment Following Retinal Re-Attachment

Abstract

Scleral buckling (SB) remains an important technique to master for those interested in treating rhegmatogenous retinal detachment (RRD). Several ways to repair RRD include pneumatic retinopexy (PR), pars plana vitrectomy (PPV), SB or a combination of these. There is a growing worldwide trend that favors PPV as the preferred method for retinal reattachment of primary uncomplicated RRD. Reimbursement issues, operating room access, and technological advances in PPV that improve retinal visualization and less exposure to SB during fellowship training may explain this trend. As the number of SB cases decreases over time, there is a risk that SB becomes a dying art and surgeons in training may not be trained in SB. SB is preferred in eyes with no posterior vitreous detachment and retinal dialysis. SB with minimal gas vitrectomy may be indicated for eyes with inferior pathology. Non-contact wide-angled visualization with chandelier assisted SB may be well suited for teaching new generations of aspiring vitreoretinal surgeons. Its functional and anatomic results compare favorably with conventional SB for primary uncomplicated primary RRD. The main advantage of this technique is the improved visualization even through small pupils. Better visualization ensures treatment of all breaks while avoiding complications during drainage of subretinal fluid and a safer placement of intrascleral sutures for scleral fixation of the buckling element. Recordings of the procedure are easily performed, allowing the surgeons involved to review the case and learn from it. The main disadvantage is the cost involved with the chandelier and the need to have a microscope or a 3D system with a wide angle viewing system. Photoreceptor re-alignment following retinal re-attachment is an important determinant of the post-operative functional outcomes. Different methods of retinal re-attachment apparently result in different degrees of photoreceptor re-alignment. SB may hold an advantage over PPV in this regard.

Outcomes of Chandelier-Assisted Scleral Buckling in Rhegmatogenous Retinal Detachments: Systematic Review and Meta-analysis

“…Chandelier scleral buckling has been reported to have intraoperative risks similar to those of standard scleral buckling with regard to choroidal and subretinal hemorrhages and scleral perforations. 43,46 The most common postoperative complications of chandelier scleral buckling were also similar to those of standard scleral buckling, including redetachment, PVR, and elevated IOP. 46 These complications are more related to the scleral buckle technique itself rather than the implementation of the chandelier viewing device.…”

“…43,46 The most common postoperative complications of chandelier scleral buckling were also similar to those of standard scleral buckling, including redetachment, PVR, and elevated IOP. 46 These complications are more related to the scleral buckle technique itself rather than the implementation of the chandelier viewing device. Unfortunately, our analysis was unable to directly compare complication rates between chandelier scleral buckling and standard scleral buckling because the majority of studies only reported complications for chandelier scleral buckling.…”

Chandelier-Assisted Scleral Buckling: A Literature Review

“…A recent study showed that when performing SB, 3D surgery proved safe and offered non-inferior results to conventional microscope viewing [ 43 ]. Surgical time reduction seems another valuable feature in chandelier-assisted scleral buckling (CSB) compared to conventional SB [ 44 ]. Although chandelier insertion changed SB from an extraocular to an intraocular procedure, there is rarely evidence of complications related to this procedure, such as IOL displacement, iatrogenic break [ 24 ], retinal incarceration, vitreous prolapse, or endophthalmitis [ 45 ].…”

Rhegmatogenous retinal detachment surgery: A review

“…As this has become more readily accessible to surgeons there has been increasing literature to support its non‐inferiority to standard indirect viewing. To date, chandelier assisted scleral buckle repair has shown primary reattachment rates ranging from 78% to 95% which is at least equally favourable to our conventional repair methods 44–46 . Unfortunately, more data are needed to see if the possible complications from disturbing the vitreous (i.e., prolapse and iatrogenic breaks) may make this technique less advantageous than it would appear.…”