Scleral buckling should not be abandoned, surgeon says

Issue: January 25, 2012

Ali Abri

VIENNA, Austria — Scleral buckling has been gradually abandoned in favor of pars plana vitrectomy for rhegmatogenous retinal detachment, but the procedure should be resumed because it offers better patient comfort, lower costs and superior results in some cases, according to a presenter here.

“The decade between 1997 and 2007 witnessed a rapid shift toward vitrectomy, mostly due to the introduction of the new, minimally invasive, sutureless procedures with wide-angle viewing systems and improved illumination,” Ali Abri, MD, said at the Advanced Retinal Therapy meeting.

A study evaluating the use of retinal procedures in the U.S. between 1997 and 2007 found that vitrectomies for primary retinal detachment increased by 72%, whereas scleral buckling decreased by 69%.

“The same trend was seen in our department at the Convent Hospital in Wels, Austria. In 1990, scleral buckling was performed in 90% [of cases] but decreased to 50% in 2000 and is now only 24%,” Dr. Abri said.

SPR study

The Scleral Buckling vs. Primary Vitrectomy in Rhegmatogenous Retinal Detachment Study, a prospective, randomized, multicenter, controlled clinical trial conducted at 25 centers in five European countries, showed that scleral buckling holds advantages in a number of cases. Patients in two subgroups, one including 416 phakic eyes and the other including 256 pseudophakic eyes, were randomly assigned to scleral buckling or vitrectomy; results for the two groups were analyzed separately. Reports No. 4 through No. 6 of the study were published in 2011.

Report No. 3, published in 2007, was central to the study, providing anatomical and functional results for the two procedures. In the phakic subgroup, best corrected visual acuity outcomes were shown to be significantly better with scleral buckling, with a mean gain of seven lines compared to five lines for the vitrectomy subgroup. Primary success (60%), final anatomical success (93%) and proliferative vitreoretinopathy rate were comparable, but significantly fewer cataract cases were found after scleral buckling (46%) than after pars plana vitrectomy (77%).

In the pseudophakic subgroup, there was no difference in BCVA, with a gain of four lines in both groups. The success rate was higher in the pars plana vitrectomy (PPV) group (72%) than in the scleral buckling group (53%) after a single operation, but comparable in both groups (94%) at the end of follow-up. The proliferative vitreoretinopathy rate was slightly higher in the scleral buckling group (23%) than in the PPV group (15%).

“These results show that scleral buckling might be a better option in phakic patients, who have a better chance of gaining vision and a significantly lower chance of developing cataract,” Dr. Abri said.

Reconsidering scleral buckling

Scleral buckling has gradually decreased in prevalence because success is dependent on surgical skill and requires more experience.

“Vitrectomy is easy to teach and fascinating for the younger generation,” Dr. Abri said. “We should reconsider this surgery in selected cases. Complications like refractive shift can be avoided with the appropriate surgical maneuvers, and being an extraocular procedure, it has advantages like no risk of cataract formation or endophthalmitis. There is also no need for patient positioning.”

Scleral buckling is cost-effective and cheaper than PPV because the equipment required is less specific. Vitrectomy costs $1,000 more than buckling, something to consider in times of budget cutbacks, Dr. Abri said. – by Michela Cimberle

References:

Heimann H, Bartz-Schmidt KU, Bornfeld N, et al. Scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment: a prospective randomized multicenter clinical study. Ophthalmology. 2007;114(12):2142-2154.

Heussen N, Feltgen N, Walter P, et al. Scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment study (SPR Study): predictive factors for functional outcome. Study report no. 6. Graefes Arch Clin Exp Ophthalmol. 2011;249(8):1129-1136.

Heussen N, Hilgers RD, Heimann H, et al. Scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment study (SPR study): multiple-event analysis of risk factors for reoperations. SPR Study report no. 4. Acta Ophthalmol. 2011;89(7):622-628.

Ramulu PY, Do DV, Corcoran KY, et al. Use of retinal procedures in Medicare beneficiaries from 1997 to 2007. Arch Ophthalmol. 2010;128(10):1335-1340.

Ali Abri, MD, can be reached at Convent Hospital Wels-Grieskirchen, Grieskirchner Str. 49, 4600 Wels, Austria. 43-664-1644223; email: ali.abri@augenlaserteam.at.

Disclosure: Dr. Abri has no relevant financial disclosures.