Scleral Buckling

Definition
Purpose
Demographics
Description
Diagnosis/Preparation
Aftercare
Risks
Normal results
Morbidity and mortality rates
Alternatives

Definition

Scleral buckling is a surgical procedure in which a piece of silicone plastic or sponge is sewn onto the sclera at the site of a retinal tear to push the sclera toward the retinal tear. The buckle holds the retina against the sclera until scarring seals the tear. It also prevents fluid leakage which could cause further retinal detachment.

Purpose

Scleral buckling is used to reattach the retina if the break is very large or if the tear is in one location. It is also used to seal breaks in the retina.

Demographics

Retinal detachment occurs in 25,000 Americans each year. Patients suffering from retinal detachments are commonly nearsighted, have had eye surgery, experienced ocular trauma, or have a family history of retinal detachments. Retinal detachments also are common after cataract removal. White males are at a higher risk, as are people who are middle-aged or older. Patients who already have had a retinal detachment also have a greater chance for another detachment.

Some conditions, such as diabetes or Coats’s disease in children, make people more susceptible to retinal detachments.

Description

Scleral buckling is performed in an operating room under general or local anesthetic. Immediately before the procedure, patients are given eye drops to dilate the pupil to allow better access to the eye. The patient is given a local anesthetic. After the eye is numbed, the surgeon cuts the eye membrane, exposing the sclera. If bleeding or inflammation blocks the surgeon’s view of the retinal detachment or hole, he or she may perform a vitrectomy before scleral buckling.

Vitrectomy is necessary only in cases in which the surgeon’s view of the damage is hindered. The surgeon makes two incisions into the sclera, one for a light probe and the other for instruments to cut and aspirate. The surgeon uses a tiny, guillotine-like device to remove the vitreous, which he or she then replaces with saline. After the removal, the surgeon may inject air or gas to hold the retina in place.

After the surgeon is able to see the retina, he or she will perform one of two companion procedures.

• Laser photocoagulation. The laser is used when the retinal tear is small or the detachment is slight. The surgeon points the laser beam through a contact lens to burn the area around the retinal tear. The laser creates scar tissue that will seal the hole and prevent leakage. It requires no incision.
• Cryopexy. Using a freezing probe, the surgeon freezes the outer surface of the eye over the tear or detachment. The inflammation caused by the freezing leads to scar formation that seals the hole and prevents leakage. Cryopexy is used for larger holes or detachments, and for areas that may be hard to reach with a laser.

After the surgeon has performed laser photocoagulation or cryopexy, he or she indents the affected area of the sclera with silicone. The silicone, either in the form of a sponge or buckle, closes the tear and reduces the eyeball’s circumference. This reduction prevents further pulling and separation of the vitreous. Depending on the severity of the detachment or hole, a buckle may be placed around the entire eyeball.

When the buckle is in place, the surgeon may drain subretinal fluid that might interfere with the retina’s reattachment. After the fluid is drained, the surgeon will suture the buckle into place and then cover it with the conjunctiva. The surgeon then inserts an antibiotic (drops or ointment) into the affected eye and patches it.

For less severe detachments, the surgeon may choose a temporary buckle that will be removed later. Usually, however, the buckle remains in place for the patient’s lifetime. It does not interfere with vision. Scleral buckles in infants, however, will need to be removed as the eyeball grows.

Diagnosis/Preparation

Retinal detachment is considered an emergency situation. In the case of acute onset detachment, the

KEY TERMS

Conjunctiva— The mucous membrane that lines the visible part of the eye and the inner eyelid.

Glaucoma— Disease of the eye characterized by increased pressure of the fluid inside the eye. Untreated, glaucoma can lead to blindness.

Sclera— The outer part of the eyeball that creates the visible white of the eye and surrounds the optic nerve at the back of the eyeball.

Vitreous— Between the lens and the retina, this area contains a clear jelly called the vitreous humor.

longer it takes to repair the detachment, the less chance of successful reattachment. Usually the patient sees floating spots and experiences peripheral visual field loss. Patients commonly describe the vision loss as having someone pull a shade over their eyes. In extreme cases, patients may lose vision completely.

An ophthalmologist or optometrist will take a complete medical history, including family history of retinal detachment and any recent ocular trauma. In addition to performing a general eye exam, which includes a slit lamp examination, examination of the macula and lens evaluation, physicians may perform the following tests to determine the extent of retinal detachment:

• echography
• 3-mirror contact lens/panfunduscopic
• scleral indentation

Small breaks in the retina will not require surgery, but patients with acute onset detachment require reattachment in 24-48 hours. Chronic retinal detachments should be repaired within one week.

Because this is usually an emergency procedure, there is no long-term preparation. Patients are required to fast for at least six hours before surgery.

Aftercare

Immediately following the surgery, patients will need help with meals and walking. Some patients must remain hospitalized for several days. However, many scleral buckling procedures are performed on an out-patient basis.

After release from the hospital, patients should avoid heavy lifting or strenuous exercise that could increase intraocular pressure. Rapid eye movements should also be avoided; reading may be prohibited until the surgeon gives permission. Sunglasses should be worn during the day and an eye patch at night. Pain, redness, and a scratchy sensation in the eyes also may occur after surgery. Ice packs may be applied if the conjunctiva swells. Patients may take pain medication, but should check with their physician before taking any over-the-counter medication.

Excessive pain, swelling, bleeding, discharge from the eye or decreased vision is not normal, and should immediately be reported to the physician.

If a vitrectomy was performed in conjunction with the scleral buckling, patients must sleep with their heads elevated. They also must avoid air travel until the air bubble is absorbed.

After scleral buckling, patients will use dilating, antibiotic, or corticosteroid eye drops for up to six weeks to decrease inflammation and the chance of infection. Best visual acuity cannot be determined for at least six to eight weeks after surgery. Driving may be prohibited or restricted while vision stabilizes. At the six-to-eight week postoperative visit, physicians determine if the patient needs corrective lenses or stronger prescription lenses. Full vision restoration depends on the location and severity of the detachment.

Risks

Complications are rare but may be severe. In some instances, patients lose sight in the affected eye or lose the entire eye.

Scar tissue, even pre-existing scar tissue, may interfere with the retina’s reattachment and the scleral buckling procedure may have to be repeated. Scarring, along with infection, is the most common complication.

Other possible but infrequent complications include:

• bleeding under the retina
• cataract formation
• double vision
• glaucoma
• vitreous hemorrhage

Patients may also become more nearsighted after the procedure. In some instances, although the retina reattaches, vision is not restored.

Normal results

The National Institutes of Health reports that scleral buckling has a success rate of 85-90%. Restored vision depends largely on the location and extent of the detachment, and the length of time before the detachment was repaired. Patients with a

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Scleral buckling can be performed by a general ophthalmologist, an M.D. who specializes in treatment of the eye. Even more specialized ophthalmologists, vitreoretinal surgeons who specialize in diseases of the retina, may be called upon for serious cases.

The surgery is usually performed in hospital settings. Because of the delicacy of the procedure, sometimes an overnight hospital stay is required. Less severe retinal detachments can be treated on an outpatient basis at surgery centers.

peripheral detachment have a quicker recovery then those patients whose detachment was located in the macula. The longer the patient waits to have the detachment repaired, the worse the prognosis.

Morbidity and mortality rates

The danger of mortality and loss of vision depends on the cause of the retinal detachment. Patients with Marfan syndrome, preeclampsia, and diabetes, for example, are more at risk during the scleral buckling procedure than a patient in relatively good health. The risk of surgery also rises with the use of general anesthesia. Scleral buckling, however, is considered a safe, successful procedure.

Severe infections that are left untreated can cause vision loss, but following the prescribed regimen of eye drops and follow-up treatment by the physician greatly minimizes this risk.

Alternatives

Vitrectomy is sometimes performed alone to treat retinal detachments. Laser photocoagulation and cryopexy also may be used to treat less serious tears. The more common alternative, however, is pneumatic retinopexy, which is used when the tear is located in the upper portion of the eye. The surgeon uses cryopexy to freeze the area around the tear, then removes a small amount of fluid. When the fluid is drained and the eye softened, the surgeon injects a gas bubble into the vitreous cavity. As the gas bubble expands, it seals the retinal tear by pushing the retina against the choroid. Eventually, the bubble will be absorbed.

QUESTIONS TO ASK THE DOCTOR

How many scleral buckling procedures have you performed?

Could other treatments be an option?

Will I have to stay in the hospital?

Will my sight be completely restored?

What is the probability of having another retinal detachment in the same eye?

Am I likely to have a retinal detachment in my unaffected eye?

The patient is required to remain in a certain position for at least a few days after surgery while the bubble helps seal the hole. Pneumatic retinopexy also is not as successful as scleral buckling. Complications include recurrent retinal detachments and the chance of gas getting under the retina.

Resources

BOOKS

Buettner, Helmut, M.D., ed. Mayo Clinic on Vision and Eye Health. Rochester, MN: Mayo Clinic Health Information, 2002.

Cassel, Gary H., M.D., Michael D. Billig, O.D., and Harry G. Randall, M.D. The Eye Book: A Complete Guide to Eye Disorders and Health. Baltimore, MD: Johns Hopkins University Press, 1998.

Everything You Need to Know About Medical Treatments, edited by Stephen Daly. Springhouse, PA: Springhouse Corp., 1996.

Sardgena, Jill, et al. The Encyclopedia of Blindness and Vision Impairment, 2nd ed. New York, NY: Facts on File, Inc. 2002.

ORGANIZATIONS

American Academy of Ophthalmology. PO Box 7424, San Francisco, CA 94120-7424. (415) 561-8500. http://www.aao.org.

American Board of Ophthalmology. 111 Presidential Boulevard, Suite 241, Bala Cynwyd, PA 19004-1075. (610) 664-1175. info@abop.org. http://www.abop.org.

National Eye Institute. 2020 Vision Place Bethesda, MD 20892-3655. (301) 496-5248. http://www.nei.nih.gov.

OTHER

Handbook of Ocular Disease Management: Retinal Detachment. Review of Ophthalmology. [cited April 21, 2003]. http://www.revoptom.com/handbook/SECT5R.HTM.

“Retinal Detachment.” VisionChannel.net. [cited April 12,2003]. http://www.visionchannel.net/retinaldetachment/treatment.shtml.

“Retinal Detachment Repair.” EyeMdLink.com. [cited May 1, 2003]. http://www.eyemdlink.com/EyeProcedure.asp?EyeProcedureID=52.

Wu, Lihteh, M.D. “Retinal Detachment, Exudative.” eMedicine.com. June 28, 2001 [cited May 1, 2003]. http://www.emedicine.com/oph/topic407htm.

Mary Bekker