There are several ways to fix retinal detachments. The most popular operations include vitrectomy and scleral buckle. These two procedures may be used singly, or in combination.
Nowadays, most retina specialists choose to repair retinal detachments using vitrectomy (and gas) alone. While the scleral buckle has been around for several generations, I rarely use it alone to fix a retinal detachment.
Most often I use just vitrectomy, but when do I use BOTH vitrectomy and scleral buckle for repair of retinal detachments?
First of all, there is no dogma. I’ve developed my own indications for using both procedures. Hence, the elegance of “the practice of medicine.”
No Retinal Tear
All rhegmatoneous retinal detachments, by definition, are caused by a retinal tear or retinal hole. This the more common type of retinal detachment.
One of the keys to successful surgery is find the retinal tear or retinal hole causing the retinal detachment.
Sometimes, despite my best efforts, I can’t locate the tear causing the retinal detachment.
Placing a scleral buckle increases the likelihood of successful reattachment AND the likelihood the retina remains attached.
Multiple Retinal Tears
Only one retinal tear is “required” to cause a complete retinal detachment. In most cases, I find only one or two tears. There are occasions where multiple retinal tears are found and in these cases, I am more than likely to use both vitrectomy and scleral buckle.
Also, in cases where the retina detaches again…I’ll choose to add the scleral buckle.
Old Inferior Retinal Detachments
In my opinion the most difficult situation to repair is a chronic (been there a long time, e.g. several months) retinal detachment located in the inferior portion of the retina (i.e. bottom).
Fluid underneath the retina tends to get thicker with time. Usually the “subretinal” fluid is very watery (because it is basically water). With time, however, this fluid accumulates protein and starts to thicken.
This thicker fluid is more difficult to remove. Patients must keep a strict “face down” head position, but the chance of re-detachment increases due to these two factors.
Again, scleral buckles improve the initial success rate!
Scleral Buckle Has Side Effects
There are several side effects of scleral buckle;
1. Increased myopia (nearsightedness) – by placing a buckle around the eye, the eye elongates, thus causing an increase in myopia. Sometimes this can be dramatic and is difficult to correct with glasses or contacts.
If the refractive error is too different between the two eyes, your brain won’t tolerate this situation and you may see double.
2. Possible Double Vision – the scleral buckle involves manipulation of the extraocular muscles – the muscles attached to the outside of the eye which are responsible for eye movements. In theory, this could cause damage to one of the muscles. It doesn’t happen very often, but it can. I’ve found it to be surgeon related.
3. Healing – the post-operative period is a little more complicated than when just performing a vitrectomy alone. There is more swelling due to the surgery performed on the outside of the eye. There may be additional discomfort (shouldn’t be frank pain).
4. Time – while not really a side effect, the extra time required by your retina specialist to install a scleral buckle varies greatly. This can add as little as 10 minutes to the procedure or increase the operating time to hours.
What Does this Mean?
These are my basic considerations when deciding to repair a retinal detachment with BOTH scleral buckle and vitrectomy.
While the success rate (in my opinion) is higher, we need to consider the risks and benefits overall.
I hope this was somewhat helpful in explaining a very complex and curious situation.
I look forward to hearing from you!