Scleral buckling in the management of rhegmatogenous retinal detachment: patient selection and perspectives

Abstract

Although the technique of pars plana vitrectomy (PPV) develops rapidly, scleral buckling (SB) has several advantages over PPV for rhegmatogenous retinal detachment (RRD), including early visual rehabilitation and prevention of cataract progression. It is recommended to select the primary procedure for RRD by considering the advantages and disadvantages of each procedure based on the patient status. The vitreous body status affects the features of RRD. Vitreous liquefaction is an age-dependent process, resulting in the development of posterior vitreous detachment (PVD). RRD is usually associated with PVD, typically presenting with a retinal tear, strong vitreoretinal traction, and bullous detachment. In contrast, RRD may develop without PVD, and typically presents with a small atrophic hole, shallow detachment, and slow progression. RRD with less liquefied vitreous and no PVD can be managed successfully with SB alone even in the presence of subretinal strand as less liquefied vitreous acts as bio-tamponade blocking fluid passage. The strong traction induced by PVD and bullous detachment in an eye with extensively liquefied vitreous reduces the success rate of SB. PPV is gaining popularity as the primary procedure for RRD, especially in eyes with retinal tears, PVD, or pseudophakia. Nevertheless, SB remains the preferred procedure in young phakic patients without PVD.

Keywords: age; myopia; posterior vitreous detachment; rhegmatogenous retinal detachment; scleral buckling; vitreous.

Figure 1

Two patterns of RRD based on the presence of PVD. Notes: (A) RRD in an eye with PVD has strong traction, retinal tears, and more liquefied vitreous humor. (B) RRD in an eye without PVD has the characteristics of a small atrophic hole, less liquefied vitreous, and shallow detachment. Abbreviations: PVD, posterior vitreous detachment; RRD, rhegmatogenous retinal detachment; SRF, subretinal fluid.

Figure 2

Different patterns of a retinal break in rhegmatogenous retinal detachment associated with PVD. Notes: (A) A horse-shoe tear has vitreoretinal adhesion on the anterior margin of the break. This retinal break can be seen in eyes with PVD. (B) An operculum tear has the margin separated from the vitreous; this tear can also be found in eyes with PVD. (C) An atrophic hole is not related to PVD. Vitreous humor may be less liquefied, and vitreous traction is not always strong. Abbreviation: PVD, posterior vitreous detachment.

Figure 3

Chronic rhegmatogenous retinal detachment with subretinal strand. Notes: (A and B) Preoperative wide photographs depicting the common characteristics of the small atrophic hole and shallow retinal detachment, which are indicators of a less liquefied vitreous. (C and D) Posterior vitreous detachment was not observed in preoperative or postoperative optical coherence tomography imaging. (E and F) The retina was attached after scleral encircling alone without pars plana vitrectomy despite extensive subretinal strand.

Figure 4

Different effects of SB according to the vitreous status. Notes: (A) The figure depicts the effects of SB in RRD with less liquefied vitreous and no PVD. Because the tractional force is not strong and the size of the retinal break is small, a small narrow buckle effect can adequately close the break. Less liquefied vitreous may play a role as tamponade (bio-tamponade) to close the retinal break. (B) The figure shows that RRD in eyes with PVD and fluidic vitreous humor. Because RRD with PVD has strong vitreous traction and large retinal tear, high and wide buckle effect is usually required. Because the bio-tamponade effect of the formed vitreous is lacking, external drainage of subretinal fluid or gas tamponade may be needed to close the retinal tear. Abbreviations: PVD, posterior vitreous detachment; RRD, rhegmatogenous retinal detachment; SB, scleral buckling.

Figure 5

Intraocular gas tamponade can be an effective adjuvant for scleral buckling when external drainage of SRF fails to close the break because of the extensively liquefied vitreous. Notes: (A) When the liquefied vitreous enters the subretinal space and is drained externally, the retinal break cannot be closed using external drainage of SRF. (B) Injection of intraocular gas is required to close the retinal tear by preventing the flow of the liquefied vitreous into the subretinal space. Abbreviation: SRF, subretinal fluid.

Figure 6

A case of RRD with fluidic vitreous humor without PVD. A 12-year-old girl presented with visual loss for 3 days. Notes: (A) RRD with small atrophic hole was noticed on the inferotemporal quadrant. (B) Preoperative optical coherent tomography showed vitreous–fovea adhesion (no PVD). (C) Although scleral encircling was performed with a high buckle effect, the retinal hole was not closed. External drainage also failed because the liquefied vitreous entered the subretinal space during the drainage. (D) After intravitreal injection of C₃F₈ (0.3 cc), the retina was reattached. Abbreviations: PVD, posterior vitreous detachment; RRD, rhegmatogenous retinal detachment.

Figure 7

Cases of rhegmatogenous retinal detachment less suitable for SB alone. PVD, bullous retinal detachment, and a relatively large retinal tear are noted. Notes: (A–H) Pars plana vitrectomy was performed as the primary operation, and the retina was reattached. (I) The retina was not attached after the SB procedure. Reattachment was achieved after the pars plana vitrectomy. (A–I) PVD was confirmed using preoperative optical coherent tomography and intraoperative vitreous staining using triamcinolone. Abbreviations: PVD, posterior vitreous detachment; SB, scleral buckling.

Figure 8

Cases that are good candidates for scleral buckling. Notes: (A–D) Four cases share the characteristics of having no posterior vitreous detachment, shallow retinal detachment, less liquefied vitreous, and a small atrophic hole. Adhesion between the vitreous and optic disc head was confirmed using preoperative and postoperative optical coherent tomography in all cases.