With vitrectomy on rise, scleral buckling a viable option in retinal detachment

Evolving surgical techniques have increasingly improved the prognosis of rhegmatogenous retinal detachment, but no uniform agreement has been reached on the best method to reattach the retina.

Comparisons between the two main procedures used today, scleral buckling and vitrectomy, continue to generate lively debate, particularly because small-gauge techniques have made vitrectomy safer. A combination of the two procedures is another option that some surgeons still consider. Pneumatic retinopexy, an office-based procedure, is popular for specific cases in the United States but rarely used in Europe and other parts of the world.

In recent years, there has been an extraordinary shift away from scleral buckling in favor of vitrectomy, Heinrich Heimann, MD, said.

This is particularly true in the United States, where more than 70% of rhegmatogenous retinal detachment (RRD) cases are now treated with primary vitrectomy. Medicare data show that scleral buckling is down by 70% since 1997, while vitrectomy is up by 80%.

The European scenario is more varied. In Germany, the proportion of scleral buckling vs. vitrectomy is currently about 40% vs. 60%, while in the United Kingdom, vitrectomy has gone up to 80% to 90% of cases.

“Personally, I think [the large shift toward vitrectomy is] wrong,” Dr. Heimann said. “There are clear indications for scleral buckling that are often disattended. For instance, doing vitrectomy in young patients with an attached vitreous, like many young myopes, or in patients with ora dialysis is a big mistake.”

Of the RRD cases that Dr. Heimann personally treats, at least 30% are scheduled for scleral buckling.

In cases in which it can be performed, scleral buckling has the advantage of being an extraocular procedure, which is also, in the case of failure, more forgiving than vitrectomy, according to Susanne Binder, MD, OSN Europe Edition Board Member. In addition, it does not induce cataract, which occurs in almost 80% of vitrectomized phakic eyes within 1 year to 2 years.

Dr. Binder prefers to do buckling in young patients when there is a single tear or multiple tears but an attached vitreous.

“Sparing the lens is a priority in these cases,” she said. “I also prefer buckling in trauma cases with dialysis because a high percentage of success is achieved with a single buckle.”

However, over the years, Dr. Binder has increased the number of vitrectomy procedures she performs. Ten years ago, she used to do 60% buckling and 30% vitrectomy, but now the proportion is reversed.

“I envisage that 15% buckling, in the cases that are really suitable with 100% guaranteed success, is going to be the future,” she said.

According to Donald J. D’Amico, MD, vitrectomy is also safe in phakic eyes, if the correct surgical maneuvers are performed.

“I use a specific technique to avoid contact with the lens. Nine out of 10 of my phakic cases are now vitrectomy, and still my cataract rate is very low,” he said.

“I use scleral buckling in just a few selected cases, such as inferior temporal dialysis in phakic patients, typically younger patients with post-traumatic detachment. Also, phakic eyes with many breaks around the periphery may benefit from an external approach. However, with the same condition in aphakic eyes, I perform vitrectomy. To put it simply, 100% of aphakic eyes in my hands are treated with vitrectomy now,” he said.

Disadvantages of techniques

Cesare Forlini, MD, believes that vitrectomy, rather than scleral buckling, should be limited to only a few selected cases such as posterior breaks, multiple or large breaks, and highly myopic eyes with a thin sclera. His philosophy is to stay away from the vitreous whenever possible.

“Though vitrectomy may seem easier, it is an insidious ground you are operating on, and you can incur endless complications,” he said.

When operating on phakic eyes, one of those complications is cataract. Another is proliferative vitreoretinopathy (PVR), which occurs in 3% to 11.5% of patients and increases the possibility of reoperation from 13.2% to 24.5%, according to Sundaram Natarajan, MD.

“The same complication develops in only 1.9% of patients after scleral buckling, and reoperation is required in 7.3% of the cases,” he said.

“If you fail with vitrectomy as a primary procedure, PVR will develop more quickly than in buckle cases. Vitrectomy is less forgiving, and failure will turn your case in a more severe case compared to buckling,” Dr. Binder said.

The major drawback of primary vitrectomy is that it is still associated with significant rates of anatomical and functional failures, Dr. Heimann said.

“Though it achieves almost a 100% [chance] of instant success, followed by a honeymoon period of weeks to months with the intraocular tamponade in place, late failure may occur due to new breaks, missed breaks, insufficient tamponade of existing breaks and PVR,” he explained.

Many surgeons, Dr. Heimann said, underestimate the actual failure rate of vitrectomy because late failures may not be accounted for, while failure of scleral buckling is obvious within the first days after surgery.

On the other hand, scleral buckling may alter the shape of the globe, inducing muscle imbalance, ocular motility disturbance and refractive changes. In addition, it is known to be a difficult technique that requires skill and experience at every step, from localizing the tears to indenting the sclera and draining the subretinal fluids.

“Success is highly surgeon dependent, and this is the main reason why it is drifting out of our surgical armamentarium,” Dr. D’Amico said.

However, he noted that extending vitrectomy to 100% of retinal detachment cases is a dangerous thing and a great limitation of a surgeon’s ability.

“There are cases in which buckling has enormous benefits. Knowing how to buckle well is essential and an elegant way to fix the eye,” he said.

Beyond the generalized opinion that buckling has merits in phakic eyes and vitrectomy is useful in pseudophakic and aphakic eyes, the choice of surgical technique depends on patient compliance, availability of appropriate instrumentation, experience and capability of the surgeon, and cost of surgery, Dr. Natarajan said.

“For instance, I believe that buckling is still a better option also in an aphakic eye in case of localized RRD with identified breaks or a single break,” he said.

Sustaining scleral buckling

Surgeons who are strong advocates of scleral buckling are adamant about not letting it fade away.

After the Frankfurt Retina Meeting in March, where it became apparent that the use and knowledge of scleral buckling is in great decline, especially among younger surgeons, a group of specialists met to discuss strategies to keep the technique alive.

“We decided that we will not let it disappear as a technique. I am convinced that many of us still do it, but we need to talk more about it at big meetings. We also need multicenter studies, but it’s difficult to find the industries that sponsor studies on buckling,” Dr. Natarajan said. “Even without studies, we can write editorials on scleral buckling in retina-oriented journals as well as in general peer-reviewed ophthalmic journals.”

The greater involvement of industry in vitrectomy explains a lot of the success of the technique compared with buckling, according to Dr. Heimann.

“Scleral buckling is a low-budget procedure, while vitrectomy uses expensive equipment. It is obvious that industries push toward using, studying, spreading and publicizing vitrectomy,” he said.

On the other hand, the lower cost of buckling should be an incentive to keep it alive and use it more, according to Dr. Forlini.

“The average cost of a buckling procedure in Europe is €92, while the average cost of a 23-gauge vitrectomy is €615,” he said.

One-on-one training is crucial in handing down the expertise of scleral buckling to the next generation of surgeons. One of the problems, according to Dr. Natarajan, is that in many practices, senior surgeons are drifting away from buckling and do not train their younger fellows.

“Personally, I spend a lot of time teaching how to do buckle and when. I make my trainees practice on eye bank eyeballs that are not suitable for transplantation, video record their performance and discuss it at the end. When they have enough experience, I let them operate on patients,” he explained.

“The problem is that scleral buckling is difficult not only to learn but also to teach,” Dr. Heimann said.

Training is the key, he said, and if it is not taught and leaned properly, results are dangerously poor.

“In that case, [it is] better to do vitrectomy than mess up the eye,” he said.

What a surgeon should acquire is the ability to deal with every single case in a minimally invasive way and to use various buckling methods.

“Buckling is an elegant form of surgery with many variations, and the more of them one surgeon knows, the more options he or she will have to reattach the retina,” Dr. D’Amico said.

Surgical pearls

When asked for pearls to successful scleral buckling surgery, Dr. Heimann said that surgeons must work well with indirect ophthalmoscopy.

“Basically, scleral buckling is indirect ophthalmoscopy,” Dr. Heimann said. “Nowadays, people don’t learn it and look at the retina with the slit lamp. However, only classic indirect ophthalmoscopy allows you to go far out in the periphery of the retina. It’s a lot more hassle, and you have to learn it over a long period of time, but if you don’t learn it in the first place, there is no way you can perform scleral buckling.”

Localizing all retinal breaks before surgery is a crucial first step, Dr. Natarajan said.

“Surgeons who are not confident with indirect ophthalmoscopy feel that vitrectomy should be done for internal search of the breaks, which is not such a great idea,” he said.

Dr. Forlini said that there are two high-risk steps in scleral buckling. The first is drainage, which can lead to retinal incarceration and hemorrhage and dramatically change the outcomes of the procedure. The second is sealing the breaks, because cryopexy, which is commonly used, may stimulate postoperative PVR.

“In both cases I use the endolaser. In the first case, to perform the choroidotomy and, prior to it, to thin the choroid by quickly passing the laser beam over it. It is a safe technique because no pointed instrument is inserted in the eye, the hole is tiny, and there is no risk of a too rapid drainage and consequent exudative choroidal detachment. By using the laser also to seal the breaks, cryopexy can be avoided. This step is performed using a transpupillary approach, only after drainage has been performed and the retina reattached,” Dr. Forlini explained.

Dr. Binder uses a microsurgery approach and performs the entire operation under the operating microscope. She never drains and aims at being minimally traumatic in all her maneuvers.

Most of the arguments against vitrectomy in RRD are related to phakic eyes and the danger of causing damage to the lens with the tamponade and intraocular surgical maneuvers. According to Dr. D’Amico, most of these concerns can be reduced if the operation is performed in a minimally invasive way, allowing for treatment of the retina without placing the lens at risk.

Using external cryotherapy to treat retinal breaks avoids using the endolaser probe in the far periphery of the retina, where there could be danger of contact with the posterior area of the lens. Using the minimum amount of tamponade necessary, with just air whenever possible, saves the lens from the detrimental effects of longer-acting gases. Positioning the patient in a way that avoids prolonged contact of the gas with the lens is also important, he said.

“The reward for doing this type of surgery is excellent visual results, no significant change to the patient refraction and a very low incidence of cataract,” Dr. D’Amico said.

He emphasized that doing vitrectomy does not mean sacrificing the lens.

“The lens can and should be preserved. There are surgeons who, in many of the cases, reach quickly for cataract extraction, producing a more invasive surgery than necessary. Patients should be allowed to remain phakic,” he said.

Studies

Although vitrectomy may be rapidly gaining ground, the literature shows that scleral buckling is still well represented as a topic of many studies. Several single-center studies and a few multicenter studies have also compared the two techniques, and “none of them has so far demonstrated that vitrectomy is better in all cases,” Dr. Binder said.

Overall, the majority of these trials demonstrate that primary vitrectomy achieves functional and anatomical results comparable to scleral buckling surgery.

This conclusion was reached, among other studies, by a retrospective, bi-center study of 230 patients conducted at the University of Vienna and the Weill Cornell Medical College of New York, U.S.A. Dr. Binder and Dr. D’Amico were both involved in the study.

A larger, prospective, randomized trial, the Scleral Buckling versus Primary Vitrectomy in Rhegmatogenous Retinal Detachment (SPR) study, in which Dr. Heimann was first author, involved 25 centers in five countries. The two techniques were compared in two groups of 265 pseudophakic patients and 416 phakic patients.

“The study showed that in complicated phakic patients, scleral buckling is better than vitrectomy, while in pseudophakic patients, vitrectomy is better. We also found that combined vitrectomy and scleral buckling leads to better results than vitrectomy alone in pseudophakic eyes,” Dr. Heimann said.

“Results were not what we expected,” he said. “We were positively surprised because we thought that vitrectomy would do better in all cases.”

A limitation of the SPR study was that the use of additional buckling when performing a vitrectomy was nonrandomized and left to the individual surgeon. Another study, the Vitrectomy plus Encircling Band vs. Vitrectomy alone for the Treatment of Pseudophakic Retinal Detachment (VIPER) study, is currently under way. It is a multicenter randomized trial being conducted in Germany and England to compare vitrectomy alone vs. vitrectomy plus an encircling band in pseudophakic eyes only.

“Since the previous SPR study showed that pseudophakic eyes do better if you combine vitrectomy with buckling, this study wants to look at whether it really increases the success rate in a randomized way,” Dr. Heimann said.

A study promoted by the European VitreoRetinal Society, the 2011 EVRS-RD study, was the largest study ever performed on retinal detachment. It included 7,678 patients treated over a 1-year period by 180 surgeons from 48 different countries. The goal of the study was to highlight the variables that affect the final outcome of retinal detachment surgery and build a decision tree to guide surgeons in their practice.

The main conclusion that emerged from the study was that no single procedure can be used for all RRD cases. The tendency to do systematic vitrectomy by some centers was found to have a negative impact on the results and to lead to unnecessary complications in simple cases. Multiple strategies are necessary, and there are cases in which an external procedure is needed.

Role of pneumatic retinopexy

To have a complete picture of the options available for RRD, pneumatic retinopexy must also be considered. Introduced 25 years ago, pneumatic retinopexy has limited indications and requires specific conditions and a close collaboration with the patient.

“Two recent case series have shown a primary success rate between 66% and 75% and a final success rate of 99%. Visual acuity results are superior to those of scleral buckling and vitrectomy because the procedure is minimally invasive,” Dr. D’Amico said.

As an office procedure, it is reimbursed in the United States but not in Europe, and European surgeons rarely use it.

“Primary success rate is what we should look at because final results with retinal detachment are 98% anyway with all procedures,” Dr. Binder said. “Recently published Medicare data showed that of the three methods of retinal detachment surgery, pneumatic retinopexy had the highest rates of additional surgeries.”

According to Dr. Natarajan, pneumatic retinopexy is a viable procedure for repairing selected detachments.

“Its efficacy depends on induction of retinopexy around all retinal breaks with cryo or laser, intraocular gas injection and consistent postoperative head positioning for appropriate gas tamponade to achieve closure of retinal breaks. I use it for uncomplicated RRD with retinal breaks in the superior 8 clock hours,” he said.

In a year, on average, Dr. Natarajan performs 300 to 350 scleral buckling procedures, 500 to 600 vitrectomies and 35 to 40 pneumatic retinopexies.

Although popular, pneumatic retinopexy has probably reached its maximum use in the United States, according to Dr. D’Amico.

“Understanding the difference between vitrectomy and buckling and defining their role is now the critical argument,” he said.

“The most important point in this controversy is to understand that retinal detachment requires a customized approach,” Dr. Natarajan said. “Equally critical is to make sure that the coming generations of surgeons have good fundamentals in each technique and the ability to understand what’s best in individual cases. I like to remember Dr. Charles Schepens, who was my mentor’s mentor. He used to say, ‘Do the minimum to reattach the retina.’ So wherever scleral buckling is indicated, irrespective of cost difference, it should be done, and wherever vitrectomy is indicated, it should be done irrespective of cost difference.” – by Michela Cimberle

 

Would you recommend drainage of subretinal fluid during scleral buckling?

 

Drainage can be performed with no complications

Drainage provides great advantages. Once the retina is flattened, the retinal pigment epithelial cells activate immediately. The surgeon does not have to wait for the reabsorption of subretinal fluid, and the eye is settled on the same day. Eliminating all subretinal fluid removes all retinal folds. The retina is stretched and folds are ironed out, also preventing the occurrence of fishmouth phenomenon and macular fold.

There is another advantage of drainage, related to volume and space. When buckling and gas injection are performed, an available vacuum is needed for the bubble of gas. Buckling takes away some space in the eye, but if the subretinal fluid is eliminated, space is gained and gas can be injected without the risk of hypertonia.

The only problems with drainage are complications, mainly hemorrhage and retinal incarceration.

To avoid both complications, I developed my own technique, known as the Didier Ducournau Drainage (DDD) technique. Most surgeons perform a pre-incision in the sclera with a knife to expose the choroid, but in this way, they open a large door in which the retina can enter. I make a puncture without pre-incision using an 8-0 needle, so that the hole I produce is smaller than the thickness of the retina. Anatomically the retina cannot enter, even if there is a pressure of 60 mm Hg in the eye. To avoid hemorrhage, I do the puncture in one of the four areas in which there are no choroidal vessels: at 12 o’clock or 6 o’clock in the middle of the vortex vein or at 3 o’clock or 9 o’clock along the long ciliary artery. It takes 10 seconds to drain with this technique, avoiding the consequences of hypotony and the risk of bleeding.

Didier Ducournau, MD, is a physician at Clinique Sourdille, Nantes, France. Disclosure: Dr. Ducournau has no relevant financial disclosures.

 

Non-drainage avoids possible serious complications

Retinal detachment surgery was developed to get rid of the fluid beneath the retina. But soon one had to recognize that this alone does not work and that in addition the causative break had to be found and closed.

So it seemed justified to remove this fluid during surgery, thus to reattach the retina and to close the break. As a result, the retina is already reattached at the table. But whether it is only momentarily reattached due to the performed drainage is a question that will be answered after follow-up.

In contrast to this is the concept of the Custodis procedure of reattaching the retina without drainage of subretinal fluid during the operation. This technique was subsequently modified by substituting the polyviol plombe with the sponge (Lincoff) and diathermy with cryosurgery (Lincoff, Kreissig), resulting in minimal extraocular surgery for retinal detachment without drainage. The disadvantage of this non-drainage procedure is that it is more difficult to localize a detached break and that intraoperatively the retina is still detached. But this is a problem for the surgeon, who has to be concerned about the success of surgery until the next day.

However, the great advantage of non-drainage is that it avoids the hazards of draining subretinal fluid because this implies perforation of the vascular network of the choroid, which might result in intraoperative complications: intraocular hemorrhage, retinal and vitreous incarceration, infection and retinal perforation.

Not draining subretinal fluid, which is feasible by using the elastic sponge buckle, might be challenging, but it avoids possible serious vision-threatening complications and the need for an intraocular gas injection, which has complications such as postoperative proliferative vitreoretinopathy and new breaks. But if the retina reattaches spontaneously after surgery, this implies for the surgeon that all breaks had been found and tamponaded sufficiently. Thus, the postoperative spontaneous disappearance of subretinal fluid becomes the proof of successful surgery.

Ingrid Kreissig, MD, is university professor of ophthalmology at University of Mannheim-Heidelberg, Germany, professor at Ufa Eye Research Institute, and adjunct professor of clinical ophthalmology at Cornell University, New York-Presbyterian Hospital, U.S.A. Disclosure: Prof. Kreissig has no relevant financial disclosures.