By John Kitchens, MD
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If you talk to any retinal surgeon that can remember examining the macula without the assistance of an OCT, they will tell you of the vast advances in the management of vitreoretinal diseases. They will also likely tell you that fellows graduating from their training programs have lost the ability to “buckle”. They lament the fact that the first treatment option for a phakic retinal detachment is often a buckle-vitrectomy or (gasp) a primary vitrectomy.
By no means am I an authority on scleral buckling, nor can I clearly remember life before the OCT. I merely am the beneficiary of some excellent teachers during my residency and fellowship. I also owe a great debt to my current partners who are outstanding bucklers. It is their “pearls” that I hope to pass along to people who are a bit hesitant to dive into the “buckle” head-long.
Who does well with buckles
On the first few patients, it is key to select the ideal candidate for a scleral buckle. There are some patients who are better for a scleral buckle: those who are phakic, those with other pathology (such as lattice) that would benefit from the additional support a buckle provides, those who have a clearly visible break(s) with good media (no vitreous hemorrhage). Less than ideal are those patients with multifocal IOLs and those who have had refractive surgery (although most refractive doctors will not mind “touching up” patients left a bit myopic by a scleral buckle).
There is one set of patients that a scleral buckle is very beneficial: the young myope with a detachment secondary to an atrophic hole in lattice and no PVD. These patients will often have a shallow detachment that is amenable to buckling. More importantly, trying to induce a PVD in these patients can be difficult at best. The induction of the PVD can result in tearing of the retina in areas remote to your original pathology leading to multiple retinal tears secondary to the surgery.
Minimalistic Approach
Dr. Donald Gass was an amazing retinologist. Everyone associated with retina knows the immense amount of knowledge added to this field by Dr. Gass. What many do not know is that he was a tremendous buckler. I had the opportunity to talk to several of the surgical nurses who worked with Dr. Gass at Bascom Palmer and they all commented on what an effective and efficient surgeon he was. They noted that he almost always used a combination of a 270 band and a 240 sleeve. These smaller buckles can be effective, easier to place, and have a lower incidence of diplopia.
Needle Drainage of Subretinal Fluid
Dr. Steve Charles was the first to describe this very effective approach to the drainage of subretinal fluid. The technique was further modified by Dr. Glenn Jaffe and colleagues to allow of safer and more effective fluid drainage. The technique involves positioning and tightening the scleral buckle. Select a drainage site in the most bullous portion of the detachment. I will usually try to go as close to the superior or inferior rectus to decrease the risk of hemorrhage. A critical next step is to place a 2-0 silk suture around the tightened buckle 180 degrees away from the drain site. This step allows for better visualization of your entry site and will provide the ability for your assistant to increase the IOP by pulling on the suture in case of hemorrhage and to encourage fluid to egress through the needle. Prior to draining, have a syringe with gas or filtered air ready in case of hemorrhage or hypotony. The best needle for this drainage is a 26 gauge 3/8 inch needle (B&D Needles) on a 3 cc syringe with the plunger removed. The bevel of the needle is directed away from the retina and the needle is advanced through the sclera starting (externally) at the anterior edge of the buckle. This provides some added security if there is accidental penetration of the retina with the needle as the site will lie on the buckle. It is advanced until it can be visualized in the subretinal space and the retina begins to billow. Be aware that it is tough to visualize the needle in patients that have very bullous detachments. Be careful not to advance the needle too far at first. Your assistant should pull on the 2-0 silk suture as the eye begins to soften. As the retina flattens, the needle will become much more visible. Remove the needle as the retina gets close to it and continue to have your assistant hold tension on the 2-0 silk as the subretinal fluid will continue to drain despite the needle being removed. No sutures are needed to close the entry site and the retina should not become incarcerated. Needle drainage is challenging at first and it will take at least 10 cases before you may be comfortable with performing this technique. The ability to see the retina flatten is not only satisfying, but allows for a more complete drain and the ability to monitor what is happening during the drain.
Segmental Elements
One of my current partners introduced me to the 103, 106, and 112 segmental elements (see figures 1, 2, 3). All of these elements are similar and have an “L” shape and slide very nicely under a 41 or 42 band. The last digit (ie. 3, 6, 12) represents how wide the element is. These are extremely useful when there is a larger break or one that extends more posteriorly. They can be slid beneath the buckle at the end of the case to prevent fish-mouthing and allow for more posterior support. They do not need to be sutured into place as their posterior “lip” will lock into place on the posterior edge of the band.
Figure 1
Figure 2
Figure 3
Multiple uses for cryotherapy
One thing that has increased my efficiency with buckling is to use the cryoprobe to perform my depressed examination. This allows me to perform cryo immediately upon finding the break. I will also use the cryoprobe to mark the break. Visualization of the internal cryotherapy allows you to judge the position of the probe in relation to the break and helps to avoid paralax. When the probe is frozen to the eye wall, it can be used to rotate the eye in to a position to allow for marking the break.
Don’t Forget the Gas
If there is a question of if the break is flat on the buckle, I will add gas to the vitreous cavity. In most cases where drainage of subretinal fluid occurs, the eye will be soft and will readily accept 0.3 cc of SF6 or C3F8. The gas serves to “re-inflate” the eye and provides an excellent tamponade to any tear that may still have subretinal fluid.
Don’t Give Up
If the first few surgeries don’t go well, don't give up. Analyze what may have gone wrong and make efforts to correct these areas. A buckle can be a great “weapon” in the war against detachments. Don’t let this be a dying art.
Please share any advice or pearls you may have when it comes to scleral buckling with us.