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Treatment
Scleral Buckle Surgery
A scleral buckle is a type of surgical procedure performed to reattach a detached retina. Although this procedure is used less frequently that it was in the past, it is still used at times either as a single procedure, or in combination with vitrectomy surgery.
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During scleral buckle surgery a piece of silicone rubber, either a solid piece or a sponge, is attached to the external wall of the eye (the sclera) which is a tough, leathery tissue. This can be accomplished either by sewing the silicone piece to the sclera, dissecting a layer of the sclera and implanting the piece within the sclera, or creating tunnels in the sclera and encircling the globe with a silicone band which runs through the tunnels and is secured together at the ends like a belt.
The purpose of these maneuvers is to indent or “buckle” the wall of the eye inward. The cause of many retinal detachments is contraction and shrinkage of the vitreous gel that fills the inside cavity of the eye. This is a normal aging process which frequently results in floater ( see “Floaters”) as the gel peals away from the retina. However, on rare occasions the gel can be abnormally adherent to the retina or there can be thin spots in the retina. When the gel shrinks it pulls on the retina which can cause a retinal tear to develop. As the gel continues to pull on the retina, fluid from inside the eye can get through the hole and dissect between the retina and the wall of the eye causing a the retina to detach.
The scleral buckle is intended to indent the wall of the eye where the retinal holes have formed, thereby bringing the inside wall of the eye closer to the retinal holes, closing the holes and relieving the pulling force of the gel on the retina. A small hole is sometimes created to drain the fluid from under the retina and close the holes. Either laser treatment or cryopexy (creating small frozen spots around the retinal holes) is used to stimulate the production of fibrin, which is a natural tissue glue, to seal the holes. Over a period of weeks the areas treated form a scar which tightly and permanently binds the retina to the wall of the eye and prevents fluid from entering the holes.
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Scleral buckle surgery is sometimes combined with vitrectomy surgery, where the surgeon uses small instruments to enter the eye and remove some of the gel. A small hole can then be made in a noncritical area of the retina and the fluid can be extracted from under the retina with suction. Laser or cryopexy can then be used to seal the retina holes.
Scleral buckle surgery is usually done in adults under local anesthesia, using a retrobulbar block, in which local anesthetic is injection behind the eye through the eyelids. Intravenous sedation is used to reduced anxiety and relieve any discomfort from the administration of the anesthesia. Once the eye is blocked there is usually no vision or pain from the eye during the procedure. The surgery usually takes between one to two hours and the patient then returns to the recovery room with a patch over the eye and is discharged as soon as is medically stable.
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Scleral buckle surgery was the first procedure developed to reattach the retina and it was the mainstay of retinal detachment surgery for many years. However, over the last 20 years it has been discovered that vitrectomy surgery alone, without using a scleral buckle, can be very effective at reattaching the retina.
The surgery is very successful in most cases and it can be a very appropriate choice in some cases. It does have some disadvantages over vitrectomy surgery. The silicone material is left in the eye permanently and in most cases this does not cause any problems. A larger incision must be made in the eye than for vitrectomy surgery, so the postoperative recovery period tends to have more pain and discomfort that vitrectomy surgery. Dissolvable sutures are used to close the wound at the end of the procedure and a sensation in the eye like a foreign body from the stitches is common for several weeks after surgery. Some patients complain that they can feel the silicone material in the eye long after the surgery, but this is uncommon. Another rare complication is reopening of the wound with extrusion of the silicone material after the surgery, requiring surgical removal of the silicone. Double vision can occasionally occur following surgery which may require prism glasses or additional surgery.
Because these complications are not usually seen after vitrectomy surgery ( see “Vitrectomy surgery” for a more complete discussion), scleral buckle surgery has largely been supplanted. However, there are conditions under which scleral buckle surgery may be necessary and advisable.