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.

Introduced in 1949 by Ernst Custodis, scleral buckling was the gold standard for rhegmatogenous retinal detachment (RRD) for many years.

“It has had great masters who have handed down their knowledge through generations of surgeons. However, because it is a difficult technique, in which success is highly surgeon dependent, it has largely been abandoned in favor of vitrectomy in recent years,” Donald J. D’Amico, MD, said.

Robert Machemer, MD, introduced vitrectomy in the early 1970s. Initially, it was reserved for only complicated or recurrent detachments. In 1985, the first vitrectomy for a primary uncomplicated retinal detachment took place. Slowly thereafter, throughout the 1990s, the technique was more widely adopted for primary uncomplicated retinal detachment repair, with or without a combination of scleral buckling.

“While scleral buckling has remained practically unchanged, vitrectomy has greatly evolved over the years. Wide-field viewing systems have made it much more accurate and easier, and other advances such as [perfluorocarbon liquid] and small-incision techniques have greatly enhanced safety and patient comfort,” Carl D. Regillo, MD, OSN Retina/Vitreous Board Member, said.

According to Medicare data, approximately 80% more vitrectomies are performed now in the U.S. than in 1997, while scleral buckling is down by 70%. More than 70% of primary retinal detachment cases are currently treated with vitrectomy.

“Nine out of 10 RRD cases are vitrectomy in my hands. A small minority is vitrectomy with [scleral buckling], and 5% to 8% at the most are [scleral buckling] only. My practice has definitely evolved towards more and more vitrectomies. The No. 1 advance that fueled this change for me and many others was wide-field viewing with the curved illuminated laser probe,” Dr. Regillo said.

Dr. D’Amico uses vitrectomy on all of his pseudophakic patients and approximately 90% of phakic eyes. He uses buckling in only a few selected cases.

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. Even though the tendency toward doing more vitrectomy is the same, scleral buckling has more and greater advocates in Europe.

“Personally, I think [the large shift toward vitrectomy is] wrong,” Heinrich Heimann, MD, said. “There are clear indications for scleral buckling that are often disattended.”

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 Dr. D’Amico, vitrectomy is 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.

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.

Pros, cons, indications

Vitrectomy has significant advantages, according to Dr. Regillo. There is less pain immediately after surgery and in the long run. In addition, intraoperative visualization of retinal breaks allows the surgeon to accurately close all the breaks and reattach the retina in an easier and faster way.

Disadvantages are mainly associated with postoperative positioning and the need for a gas bubble.

“The use of gas promotes IOP rise and cataract, which occurs in almost 80% of the cases within 1 to 2 years. This is of course a concern, particularly in younger patients,” Dr. Binder said.

“In pseudophakic eyes, the bubble may cause the IOL to shift and move, and IOL subluxation may occur as a consequence,” Dr. Regillo said.

Retinal folds and proliferative vitreoretinopathy (PVR) are other potential complications.

“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 into 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.

“In the hands of expert surgeons this happens rarely, and scleral buckling can be really safe and minimally traumatic. Since it does not require positioning, 90% of the patients can go home the day after surgery,” Dr. Forlini said.

“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.

Myopic retinal detachment, which typically occurs in young patients, is an indication for buckling, as is ora dialysis and any localized detachment over one or two quadrants in which the tear is clearly visible and the vitreous is attached, according to Dr. Heimann.

Dr. Forlini is more selective with vitrectomy, which he uses only in cases of posterior or large breaks, in high myopes and in eyes with a thin sclera in which a buckle is likely to create problems.

Sustaining scleral buckling

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

“It would be a big mistake to give up scleral buckling,” Dr. Heimann said. “The problem is that scleral buckling is difficult not only to learn but also to teach. Showing how to do a vitrectomy is much easier.”

Training is the key, he said. If the technique fades away, it is not because it is inferior or useless, but because many senior surgeons no longer want to teach it.

“If it is not taught and learned properly, results are dangerously poor. In that case, [it is] better to do vitrectomy than mess up the eye,” he said.

“The great masters of scleral buckling are no longer practicing or are near retirement,” Dr. D’Amico said. “Although scleral buckling has successfully treated millions of eyes, whether we like it or not we must come to terms with the reality that young surgeons are no longer doing it. Things constantly change, and there is no point in being nostalgic.”

Dr. Binder, on the other hand, believes that scleral buckling will not disappear.

“If it disappeared, it would be reinvented in a few years. It’s a good technique, and we’ll always need it, though in a reduced proportion,” she said.

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.

Surgical pearls

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.

A good viewing system is mandatory for successful vitrectomy, according to Dr. Regillo. A transscleral small-incision approach should be used.

“If a surgeon has been using 20 gauge, [it is] better to transition to small incision with 23 gauge rather than 25 gauge, because the instruments are stiffer and easier to handle. But a fine job can be done with 25 gauge, too,” he said.

A rinse with balanced salt solution should be done to ensure complete washout of perfluorocarbon liquid from the vitreous cavity if this liquid is used intraoperatively to facilitate retinal reattachment. Dr. Regillo also recommended that the retinotomy should be generous in advanced PVR cases.

“The biggest mistake people do in advanced PVR cases is not to make it large enough,” he said.

In addition, it is important when doing vitrectomy for retinal detachments to only laser the tears and the area immediately surrounding them and to not laser 360° routinely.

Both Dr. Regillo and Dr. D’Amico agreed 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,” Dr. D’Amico said.

“With wide-field viewing you can see through even a fair amount of cataract and move comfortably around and behind the lens,” Dr. Regillo said.

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.”

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.

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. Dr. Binder and Dr. D’Amico were both involved in the study.

A monocentric retrospective study conducted at the Walter Reed Army Medical Center found that primary pars plana vitrectomy and pars plana vitrectomy combined with scleral buckling had similar efficacy in two groups of patients with primary noncomplex pseudophakic retinal detachment. There was no statistically significant difference in the complication rates between the groups.

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. Medicare data show that it is up by 23% compared with 1997.

“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.

“If you adhere to the original indication criteria, you have a good success rate, especially in phakic eyes,” Dr. Regillo said.

“Success largely depends upon how confident you are that you have seen all the breaks. If you don’t see well enough, you should not even try it. But if you are confident that you are dealing with a single break or a small area of breaks, it’s a good procedure,” he said.

The best candidates are patients with a small detachment, in one or two quadrants at the most.

“In case of superior RD with superior retinal break and good visualization, I would choose this as a primary procedure. About 10% of patients are probably good candidates. But make sure the case meets all the criteria,” Dr. Regillo said.

Pneumatic retinopexy is an office procedure, and as such, it is reimbursed in the U.S. but not in Europe.

“That’s the main reason why we rarely do it,” Dr. Forlini said.

“In Europe, we have access to operating theaters within 24 hours at the most; therefore, there is little point in doing a procedure in the office,” Dr. Heimann said.

At the annual meeting of the British and Eire Association of Vitreoretinal Surgeons, it turned out that nobody is currently doing pneumatic retinopexy, he said.

Dr. Binder said she no longer uses this procedure.

“If it fails, the eyes develop new tears and PVR within a short time,” she said. “Primary success rate is what we should look at because final results with retinal detachment are 98% anyway with all procedures. Recently published Medicare data showed that of the three methods of retinal detachment surgery, pneumatic retinopexy had the highest rates of additional surgeries.”

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

“Understanding the difference between vitrectomy and buckling and defining their role is now the critical argument,” he said. – 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 fish mouth 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 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 serious vision-threatening complications

Drainage of subretinal fluid has been an accepted part of retinal reattachment surgery for more than 90 years. However, the complications that most frequently cause permanent surgically induced loss of vision, such as choroidal hemorrhage, endophthalmitis, retinal incarceration and proliferative vitreoretinopathy, are most often associated with drainage of subretinal fluid.

In my experience, there are only a few specific indications for drainage. One of these is chronic open-angle glaucoma because the transient rise in IOP during non-drainage surgery may cause further damage to an already compromised nerve. The second is in eyes with thin sclera because the sutures required to obtain an adequate buckle cannot be placed in staphylomatous thin sclera. I also consider drainage in cases of defective choroidal pump or excessive vitreous traction. Finally, it is indicated when the configuration of the break after the scleral buckle has been placed shows excessive folding or fish mouthing, which would cause the procedure to fail.

Drainage is not recommended if an adequate buckle is possible and can be expected to achieve retinal reattachment. Difficult cases that required ab externo drainage of subretinal fluid when treated with buckling alone, such as giant tears, penetrating injuries and advanced stages of proliferative vitreoretinopathy, are now treated with pars plana vitrectomy and ab interno drainage of subretinal fluid.

In order to avoid the previously mentioned most severe complications of retinal reattachment surgery with scleral buckling, I would recommend drainage of subretinal fluid only in those situations in which non-drainage surgery cannot be successfully performed. 

Frank P. La Franco, MD, is an associate professor at Northwestern University, Chicago. Disclosure: Dr. La Franco has no relevant financial disclosures.