How I Practice Retinal Detachments

Scleral Buckle and Vitrectomy to Fix Retinal Detachments

Vitrectomy for repair of retinal detachmentThere 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.

Scleral Buckle to repair retinal detachment.  Randall Wong, M.D., Retina Specialist, Fairfax, VA 22031

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!

Retinal Detachments Surgery

Scleral Buckle vs. Vitrectomy

Retinal detachment, Randall Wong, M.D., Fairfax, Virginia

This is a recent question I received via email.  It brings up a few good points about choosing scleral buckle vs. vitrectomy to repair a retinal detachment.  I receive many questions via the comments section after an article.  This time, I’m trying something new and making the question a part of the post.


Dear Dr. Randall Wong,

I am not sure whether you do online diagnosis if I send you some
diagnostic data (fundus photo) from my retina doctor. I know online
exam will never be complete, but I wanted the opinion from a highly
regarded retina doctor like yourself.

I was diagnosed with a retinal detachment on the nasal inferior side.
This is a macula on retinal detachment. My doctor used laser to
prevent the detachment from spreading further into the macula. He
couldn’t completely seal off the rest because of the subretinal
fluids. After about 1 week of subretinal fluid not going away, he
recommended scleral buckle surgery but allowed me to look for a second

I did ask about Vitrectomy and he said, there’s high risk for
cataracts and it is more expensive than scleral buckle due to the high
end equipment used.

What is your take on my type of retinal detachment? Should I do
Scleral Buckle or Vitrectomy? I would gladly send my data over to you
if you request them.

Thank you for your time,



Laser Treatment for Retinal Detachment

In this case, it seems that a laser was first attempted to “wall off” the retinal detachment and prevent it from spreading.  The rationale for doing so is similar to containing a forest fire…dig ditches around the fire to prevent the spread.

I personally rarely treat retinal detachments in this fashion.  I don’t feel that there is anything wrong, but I’ve seen too many “walled off” retinal detachments spread, albeit years after the retinal detachment.

In my opinion, simply lasering around the retinal detachment does not fix the problem.

Vitrectomy and Cataracts

Without complicating the matter too much, vitrectomy to repair retinal detachment requires the use of intraocular gas and head positioning after the surgery.  Often, the gas can cause cataract though vitrectomy is an excellent choice for fixing the retinal detachment.

I can’t make a remark about the cost.  You’ll have to check in your own particular area.  I think insurance companies may pay the same or similar rates based upon the fact that the same procedure code is used for scleral buckle and vitrectomy.

Scleral Buckle

There are two ways to use a scleral buckle to repair retinal detachment;  with gas and without.

Scleral Buckle With Gas

After placing the scleral buckle around the eye, gas is injected at the end of the case.  After the gas is injected, proper head positioning is required to keep the gas pressing on the retinal tear.  Remember, the gas can cause cataract.

Scleral Buckle Without Gas

This is the original method used (way back when) to repair a retinal detachment.  The scleral buckle is placed around the eye, no gas is injected and the retina often reattaches.  In this way, gas is avoided and so is early development of a cataract.

What Does This Mean?

I can not make an online diagnosis nor review your case.

For me to make a diagnosis online, without examination, would be impossible.  I get many, many requests for a specific opinion and diagnosis based upon an email or comment on the website.  It’s impossible.  I also want to avoid the liability.

In this case, for instance, I can talk about retinal detachments and my approach to repairing them, but without making specific judgements about this specific patient.

Overall, I can NOT review your specific documentation or studies.  It simply takes too much time, involves potential liability by possibly starting a doctor-patient relationship, and I still can NOT examine you.

On rare occasion, I could be retained to such work.

With regard to fixing the retinal detachment, there are many ways to repair a retinal detachment.

Everyone gets a cataract eventually – with or without retinal detachment surgery.

Retinal detachments can lead to permanent blindness, cataracts do not.

Every effort should be made to repair the retinal detachment without worry to cataract, or even cost.  If all things are equal, then, and only then, would I consider cost.



How I Practice Retinal Detachments

Fixing a Retinal Detachment | Retina Specialist, Fairfax, Va.

Retinal Detachment Threatening the MaculaThere are several methods to repair a retinal detachment.  None is the best or right method and retina specialists all seem to have their own preferences.

In my opinion, the decision on what procedure(s) to employ depends upon the nature of the retinal detachment, skill of the surgeon and time required to perform the procedure.

Methods for fixing a retina detachment;

1.  Scleral Buckle
2.  Pneumatic Retinopexy
3.  Vitrectomy
4.  Scleral Buckle and Vitrectomy Combined

Scleral Buckle

This is the oldest method to repair a retinal detachment.  It repairs a retinal detachment by placing an “element” outside of the eyeball.  The scleral buckle (aka element) may be placed all the way around the eye or partially.

In either case, the goal is to get the sclera, or the wall of the eye, to indent or “buckle” (as in the way a road may buckle).  This buckling causes a decrease in the internal diameter of the eye thereby reducing traction, or pulling, on the retina by the vitreous.

Advantages of Scleral Buckle

Fewer Redetachments – after the initial operation, because stress is reduced in the vitreous, it becomes much more difficult for the vitreous to pull on the retina and cause additional tears.

The key to fixing any rhegmatogenous retinal detachment is to locate and treat the causative retinal tears and retinal holes.  This is not always easy.  Thus, in these complex situations, a scleral buckle may be more effective in preventing recurrent retinal detachment by foreshortening the amount of retina which may re-detach.

Disadvantages of Scleral Buckle

Required Skill – this may be the most difficult operation performed by a retinal specialist.   It can be difficult to position the buckle element precisely on the outside of the eye.  There is not a lot of space in the small eye socket which holds your eye.  This can take some surgeons…hours.

More Side Effects such as near-sightedness, anisometropia, double vision are all related to manipulating the eye and its muscles.

Swelling and Discomfort – quite simply the longer the operation, the more manipulation of the tissues, the more swelling and post-operative discomfort.

My Preferences for Using a Scleral Buckle

I prefer using a scleral buckle;

1.  Total retinal or large retinal detachment – with most or all of the retina detached, it is difficult to examine the retina thoroughly when looking for holes or teras.  This reduces the chances of my missing a retinal tear, and thus, reduces the chances of re-detachment.

2.  I have used the same type of scleral buckle, without exception, for over 15 years.  While there are various shapes and sizes, I don’t think it matters very much.

3.  I always pass the scleral buckle around the entire eye.  This reduces abnormal amounts of astigmatism which may develop with buckles placed in certain segments of the eye.  The amount of induced myopia is also easier to estimate as the same procedure is repeated time after time.

4.  By using the same buckle and encompassing the entire eye, I am able to complete the operation by minimizing variation and minimizing operating time.  My surgical team always knows what I am doing.

This increase in speed and efficiency translates to less surgical trauma to the eye, fewer chances of side effects and quicker recovery.


“Other” Eye Conditions Retinal Detachments Surgery

What is Anisometropia?

Image size diffence results from anisometropia, a common cause of double vision following scleral buckle surgery. Randall Wong, M.D.Anisometropia is an imbalance in the prescription needed between your two eyes.  There are several causes of anisometropia, but the most common for a retinal surgeon is a result of a scleral buckle used to repair a retinal detachment.

“Double Vision”

When looking at an object, in most people, we see one single object.  In actuality the left eye and right eye each see something slightly different.  Our brain assimilates each image.  If the images between the two eyes are similar, then we “see” one object.  If the images seen between the two eyes are too dissimilar, then we see double.

If one eye requires a much stronger prescription than the other, you might have double vision due to the large difference in prescription.

Induced Myopia

Every scleral buckle causes in increase in nearsightedness (the ability to see closely without glasses).  After scleral buckle surgery for retinal detachment, the eye elongates, causing the eye to become longer, and therefore, more near sighted.  Over every millimeter longer, there is an increase in 3 diopters of nearsightedness.

Although each eye may have the ability to see 20/20 with separate prescriptions, with both eyes open, the difference may be intolerable.

Inherent with a change in prescription is a change in actual size of the object we are viewing.  Our brain can only tolerate about a 3% difference in the size seen by one eye versus the other.

Cataracts Increase Nearsightedness

A second factor causing anisometropia is cataract.  Most cataracts cause an increase in myopia.  Often intraocular gas is used to help repair the retinal detachment in addition to the scleral buckle.  This intraocular gas can increase the rate of cataract formation and, hence, myopia.

What Does this Mean?

I often get questions on this blog about double vision following retinal detachment surgery.  My own experience tells me that anisometropia is a common cause of double vision following successful retinal detachment repair.

The symptoms are usually ghosting, distortion and double vision.

Contact lens sometimes improve double vision from anisometropia as there is less image size difference with contact lens wear.

True misalignment from the scleral buckle can occur and this needs to be ruled out as a possible cause, too.

My recommendation is to usually see a pediatric ophthalmologist.  These specialists handle all kinds of eye misalignment in both kids and adults.  They are masters at refraction (they refract babies!) and most are well versed in assessing adult cataracts.

Anisometropia due to scleral buckle is a temporary problem.  If, and when, cataract surgery is needed, the intraocular implant (IOL) can be calculated to better match the fellow eye!



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