Retinal detachment surgery still revolves around buckling vs. vitrectomy question

Issue: June 2012

ByJean-François Korobelnik, MD

Jean-François Korobelnik

Scleral buckling used to be the most commonly used surgical treatment for rhegmatogenous retinal detachment. It was established by Jules Gonin in the 1930s. It involves closing all the retinal breaks to stop fluid from going into the subretinal space.

But in recent years, vitrectomy has become the standard of care in pseudophakic eyes, and is more commonly used in phakic eyes.

Where we are

Scleral buckling remains the treatment of choice in phakic eyes with a retinal dialysis or in eyes with small holes and no PVR. Cryopexy of the breaks and a localized buckle have a high anatomical success rate. Before surgery, careful examination should focus on finding all the breaks. Lincoff rules are helpful to find as well. Various types of bands or sponges exist and can be used. Often, subretinal fluid has to be drained with a transcleral puncture, to help the retina come to the sclera, and to make some space for the buckle before suturing it.

But when possible, subretinal drainage must be avoided, because of the unpredictable risk of subretinal hemorrhage that can be subfoveal if the macula is detached. Solid adhesion will be produced with transcleral cryopexy, focused on the break(s) seen with direct or indirect ophthalmoscopy. If the break is not closed at the end of the procedure, or in the case of bullous detachment, sterile air or gas can be injected into the vitreous cavity, allowing for postoperative internal tamponade of the retina with proper positioning.

Tear response

But if there is a tear, vitrectomy may be considered as a first-choice procedure for rhegmatogenous retinal detachment (RD) without PVR in phakic eyes. Very high speed vitrectomy probes (5,000 cpm) allow for a quick and safe vitrectomy. Wide angle systems, such as the BIOM, will help to provide a global view of the retinal detachment, find the breaks, do an air-fluid exchange and a retinopexy with endolaser or cryo. Most often, transconjunctival 25 g or 23 g cannulas and probes are used. Postoperative recovery is quick, with minimal pain and discomfort.

Scleral buckling and vitrectomy have to be well-known by the surgeon to be used in selected cases of RD.

References:

Gonin J. The evolution of ideas concerning retinal detachment within the last 5 years. Br J Ophthalmol. 1933;17(12):726-740.
Gonin J. Le Decollement de la retine. Pathogenie-traitment. 1934. (Libraire Payot, Lausanne).
Ryan EH. How we currently choose to repair retinal detachment in the United States Medicare population. Am J Ophthalmol. 2012;153(6):1013-1015.

For more information:

Jean-François Korobelnik, MD, can be reached at Unité Médicale Rétine, Uvéites, Neuro-Ophtalmologie, Service d’Ophtalmologie, Hôpital Pellegrin, Place Amélie Raba Léon, 33000 Bordeaux, France; +33 (0)5 56 79 57 41; +33 (0)5 56 79 47 58; email: jean-francois.korobelnik@chu-bordeaux.fr.
Disclosure: Dr. Korobelnik is a consultant for Alcon.