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Scleral Buckling Versus Vitrectomy for Primary Rhegmatogenous Retinal Detachment Aditya Maitray1, V Jaya Prakash2 and Dhanashree Ratra3

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Scleral Buckling Versus Vitrectomy for Primary Rhegmatogenous Retinal Detachment Aditya Maitray1, V Jaya Prakash2 and Dhanashree Ratra3 Major Review Scleral buckling versus vitrectomy for primary rhegmatogenous retinal detachment Aditya Maitray1, V Jaya Prakash2 and Dhanashree Ratra3 1Fellow, Introduction include increased postoperative morbidity like Sri Bhagwan Mahavir Retinal detachment (RD) surgery is the most pain and periorbital oedema, drainage-related Vitreoretinal Services, common retinal surgery performed. RD can be complications like vitreoretinal incarceration, sub- Sankara Nethralaya, Chennai, India repaired either by scleral buckling (SB) or pars retinal haemorrhage and choroidal detachment, plana vitrectomy (PPV). Pneumoretinopexy, laser diplopia due to muscle restriction, chorioretinal delimitation or observation can be done in circulatory disturbances, refractive changes (typic- 2Associate consultant, selected cases. The decision to perform SB or ally axial myopia), epiretinal membrane forma- Consultant, vitrectomy depends on various factors, including tion, buckle intrusion, extrusion and infection. Sri Bhagwan Mahavir age of the patient, duration and extent of RD, Subretinal fluid may take time to absorb in case Vitreoretinal Services, presence of proliferative vitreoretinopathy (PVR) of non-drainage procedure delaying anatomical Sankara Nethralaya, fi Chennai, India changes, the number, location and size of retinal recovery and resulting in poorer nal visual breaks and the lens status. Other factors which outcomes. influence the decision are availability of operating 3Senior Consultant, room equipment or staff, various patient factors Sri Bhagwan Mahavir Pars plana vitrectomy (especially expected compliance with positioning The major advantage of PPV over SB is the Vitreoretinal Services, after surgery) and surgeon preference.1 Until Sankara Nethralaya, improved internal search for breaks with micro- about a decade ago, SB was the preferred proced- Chennai, India scopic visualization of peripheral fundus by scleral ure, but there is a general trend towards vitrec- indentation and internal illumination. Other major tomy with the development of newer technology. advantage usually cited is the direct elimination Correspondence: There are several retrospective and prospective of vitreous traction and removal of the vitreous Dhanashree Ratra, studies which compare SB and vitrectomy for Senior Consultant, leading to elimination of PVR-stimulating primary RD. The anatomical and visual outcomes 3 Shri Bhagwan Mahavir environment. following retinal reattachment surgeries reported Vitreoretinal Services, It can help to clear media opacity, can address Medical Research Foundation, in the recent peer-reviewed literature will be dis- very posterior breaks and giant retinal tears and Sankara Nethralaya, cussed in this article. allow use of PFCL, internal drainage of subretinal Chennai, India. fluid and intraoperative retinal attachment. Email: [email protected] Scleral buckling With the development of improved visualization SB provides target-oriented retinal attachment. It systems and smaller gauge surgical techniques, is ideally suited for detachments with anterior the success rate of vitrectomy has improved con- retinal breaks and dialysis. It is also a very siderably. The potential problems with vitrectomy rewarding surgery for suitable paediatric RDs are the increased rate of cataract formation, iatro- wherein PVD induction during PPV is a challenge. genic breaks, requirement for postoperative posi- It is efficacious for both superior and inferior tioning and higher cost. breaks, does not cause cataract, does not require Table 1 summarizes the basic differences postoperative positioning, unless gas or air is between the two techniques. Based on the above injected, and has a high single-surgery success differences between SB and vitrectomy, it is rate (SSSR). Success rate can be further improved obvious that a few cases like localized detachment by meticulous preoperative and intraoperative with single or neighbouring breaks are ideal for search for breaks. Chandelier-assisted SB has also SB and complicated cases like PVR grade C or D, been described that can allow direct intraoperative giant retinal tears, very posterior breaks and visualization of peripheral retina under magnifica- macular holes are better treated with vitrectomy. tion.2 On the other hand, patients with giant However, for a vast majority of cases that lie in retinal breaks (GRTs), posterior breaks, PVR worse between these two extreme scenarios, there exists than grade B, thin sclera, glaucoma drainage some confusion regarding which surgical modality device, previous strabismus surgeries and media would give the best outcome. This group com- haze (e.g. vitreous haemorrhage) precluding visu- prised about 30% of all primary rhegmatogenous alization of peripheral retina are not ideally suited RDs in the SPR recruitment study.4 Certain for scleral bucking procedures and respond more ambiguous cases which include patients with mul- favourably to PPV. The main reasons for failed tiple breaks in different quadrants, bullous rheg- buckle surgery are missed breaks, fishmouthing, matogenous RDs, breaks extending central to the inadequate buckling effect, development of new equator, breaks with marked vitreous traction and retinal breaks and PVR. The drawbacks with SB rhegmatogenous RDs with unclear hole situations 10 Sci J Med & Vis Res Foun July 2017 | volume XXXV | number 2 | Major Review Table 1: SB versus PPV: comparison Scleral buckle PPV Mechanism of vitreous traction Indirect/passive Direct relief Internal tamponade Nil Silicone oil/gas Efficacy for superior/inferior Equal Better for superior breaks breaks Efficacy in the presence of Less Better PVR > grade B Postoperative morbidity* More Less Postoperative positioning Not required Required SSSR 90–95% 85–90% Other advantages Can support missed breaks Clears media opacities Allows air travel Effective for giant retinal tears, posterior Effective for retinal dialysis breaks No cataract formation Potential complications Refractive changes Cataract progression Ocular motility disturbance Raised intraocular pressure Vitreoretinal incarceration Iatrogenic breaks Subretinal/suprachoroidal haemorrhage Migration/exposure of buckle elements Macular pucker Miscellaneous disadvantages Moisture condensation on silicone IOLs during fluid–air exchange Restricted air travel in immediate postoperative period if gas tamponade used Expensive *Pain and periorbital oedema in immediate postoperative period. (no break or not all breaks could be identified on of macular detachment, height and duration of examination before surgery) require a lot of macular detachment (DMD) and amount of pre- debate. existing cataract. The other reported outcomes We searched PUBMED for the following terms: were the number of retinal procedures/reopera- ‘retinal detachment’, ‘scleral buckle’ & ‘vitrectomy’ tions, the redetachment rate and complications and finally analyzed recent relevant studies (pub- like postoperative PVR rate, raised intraocular lished after year 2000) comparing SB and vitrec- pressure, epiretinal membrane and cataract devel- tomy with minimum of 6 months mean follow-up opment (in phakic patients). and a minimum sample size of 30 eyes. Retrospective studies Outcomes Table 2 summarizes the recent retrospective com- The most commonly reported anatomical out- parative studies between SB and PPV for rhegma- comes in these comparative trials between SB and togenous RD. PPV for primary rhegmatogenous RDs include Most of the retrospective studies showed no single-surgery success rate (SSSR: defined by most difference in anatomical and functional outcomes studies as an attached retina at final follow-up between SB and PPV groups (table 2).5–13 after a single surgery) and final anatomical However, Park et al. have reported that PPV might success rate (defined as an attached retina at final show better visual outcomes compared with SB in follow-up after ≥1 surgical interventions). The older phakic patients, the final anatomical out- functional outcomes studied include change in comes still remaining comparable. This may be best-corrected visual acuity (BCVA, in terms of due to the presence of PVD and performing com- logarithm of the minimum angle of resolution bined cataract surgery along with PPV whenever [LogMAR] or Snellen’s acuity expressed as the required.12 proportion of study eyes achieving final vision In pseudophakic eyes with uncomplicated RDs, better than 6/60 −6/18, depending on the study initial and final anatomical outcomes have been criteria). Apart from the surgical technique used, reported to be better with PPV alone/PPV com- the visual acuity results may also be affected by bined with SB compared with SB as per a several other factors like the presence or absence meta-analysis of comparative retrospective studies Sci J Med & Vis Res Foun July 2017 | volume XXXV | number 2 | 11 12 Major Review Sci J Med & Vis Res Foun July 2017 Table 2: SB versus PPV: retrospective studies Study Type of No. of eyes SSSR (p*) Visual outcome (p*) Complications (p*) Comments | volume XXXV surgery (follow-up) Oshima et al. (2000)8, SB 55 91% 0.42 LogMAR Iatrogenic breaks 4% Preoperative VA, IOP and DMD best predictors of Primary uncomplicated (24 months) (final Subretinal/vitreous bleeding 5% postoperative visual recovery in both groups macula off RD reattachment rate Cataract progression 12% 100%) ERM formation 7% PPV group had better visual recovery in patients | number 2 PVR 3.8% with preoperative visual acuity <0.1, DMD >7 days Ocular hypertension 0 and preoperative IOP <7
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