Scleral buckling
Definition
Scleral buckling is a surgical procedure in which a piece of silicone plastic or sponge is sewn onto the sclera at the site of a retinal tear to push the sclera toward the retinal tear. The buckle holds the retina against the sclera until scarring seals the tear. It also prevents fluid leakage which could cause further retinal detachment.
Purpose
Scleral buckling is used to reattach the retina if the break is very large or if the tear is in one location. It is also used to seal breaks in the retina.
Demographics
Retinal detachment occurs in 25,000 Americans each year. Patients suffering from retinal detachments are commonly nearsighted, have had eye surgery, experienced ocular trauma, or have a family history of retinal detachments. Retinal detachments also are common after cataract removal. White males are at a greater risk, as are people who are middle-aged or older. Patients who already have had a retinal detachment also have a greater chance for another detachment.
Some conditions, such as diabetes or Coats' disease in children, make people more susceptible to retinal detachments.
Description
Scleral buckling is performed in an operating room under general or local anesthetic. Immediately before the procedure, patients are given eye drops to dilate the pupil to allow better access to the eye. The patient is given a local anesthetic. After the eye is numbed, the surgeon cuts the eye membrane, exposing the sclera. If bleeding or inflammation blocks the surgeon's view of the retinal detachment or hole, he or she may perform a vitrectomy before scleral buckling.
Vitrectomy is necessary only in cases in which the surgeon's view of the damage is hindered. The surgeon makes two incisions into the sclera, one for a light probe and the other for instruments to cut and aspirate. The surgeon uses a tiny, guillotine-like device to remove the vitreous, which he then replaces with saline. After the removal, the surgeon may inject air or gas to hold the retina in place.
After, the surgeon is able to see the retina, he or she will perform one of two companion procedures.
-
Laser photocoagulation. The laser is used when the retinal tear is small
or the detachment is slight. The surgeon points the laser beam through a
contact lens to
burn the area around the retinal tear. The laser creates scar tissue that will seal the hole and prevent leakage. It requires no incision.
In a scleral buckling procedure, one of the eye's rectus muscles are severed to gain access to the sclera (A). The sclera is cut open (B), and an electrode is applied to the area of retinal detachment (C). A silicone buckle is threaded into place beneath the rectus muscles (D), and the severed muscle is repaired. (Illustration by GGS Inc.) - Cryopexy. Using a freezing probe, the surgeon freezes the outer surface of the eye over the tear or detachment. The inflammation caused by the freezing leads to scar formation that seals the hole and prevents leakage. Cryopexy is used for larger holes or detachments, and for areas that may be hard to reach with a laser.
After the surgeon has performed laser photocoagulation or cryopexy, he or she indents the affected area of the sclera with silicone. The silicone, either in the form of a sponge or buckle, closes the tear and reduces the eyeball's circumference. This reduction prevents further pulling and separation of the vitreous. Depending on the severity of the detachment or hole, a buckle may be placed around the entire eyeball.
When the buckle is in place, the surgeon may drain subretinal fluid that might interfere with the retina's reattachment. After the fluid is drained, the surgeon will suture the buckle into place and then cover it with the conjunctiva. The surgeon then inserts an antibiotic (drops or ointment) into the affected eye and patches it.
For less severe detachments, the surgeon may choose a temporary buckle that will be removed later. Usually, however, the buckle remains in place for the patient's lifetime. It does not interfere with vision. Scleral buckles in infants, however, will need to be removed as the eyeball grows.
Diagnosis/Preparation
Retinal detachment is considered an emergency situation. In the case of an acute onset detachment, the longer it takes to repair the detachment, the less chance of successful reattachment. Usually the patient sees floating spots and experiences peripheral visual field loss. Patients commonly describe the vision loss as having someone pull a shade over their eyes. In extreme cases, patients may lose vision completely.
An ophthalmologist or optometrist will take a complete medical history, including family history of retinal detachment and any recent ocular trauma. In addition to performing a general eye exam, which includes a slit lamp examination, examination of the macula and lens evaluation, physicians may perform the following tests to determine the extent of retinal detachment:
- echography
- 3-mirror contact lens/panfunduscopic
- scleral indentation
Small breaks in the retina will not require surgery, but patients with acute onset detachment require reattachment in 24–48 hours. Chronic retinal detachments should be repaired within one week.
Because scleral buckling is usually an emergency procedure, there is no long-term preparation. Patients are required to fast for at least six hours before surgery.
Aftercare
Immediately following the surgery, patients will need help with meals and walking. Some patients must remain hospitalized for several days. Many scleral buckling procedures however are performed on an outpatient basis.
After release from the hospital, patients should avoid heavy lifting or strenuous exercise that could increase intraocular pressure. Rapid eye movements should also be avoided; reading may be prohibited until the surgeon gives permission. Sunglasses should be worn during the day and an eye patch at night. Pain and a scratchy sensation as well as redness in the eye also may occur after surgery. Ice packs may be applied if the conjunctiva swells. Patients may take pain medication, but should check with their physician before taking any over-the-counter medication.
Excessive pain, swelling, bleeding, discharge from the eye or decreased vision is not normal, and should immediately be reported to the physician.
If a vitrectomy was performed in conjunction with the scleral buckling, patients must sleep with their heads elevated. They also must avoid air travel until the air bubble is absorbed.
After scleral buckling, patients will use dilating, antibiotic or corticosteroid eye drops for up to six weeks to decrease inflammation and the chance of infection. Best visual acuity cannot be determined for at least six to eight weeks after surgery. Driving may be prohibited or restricted while vision stabilizes. At the six-to-eight week postoperative visit, physicians determine if the patient needs corrective lenses or stronger prescription lenses. Full vision restoration depends on the location and severity of the detachment.
Risks
Complications are rare but may be severe. In some instances, patients lose sight in the affected eye or lose the entire eye.
Scar tissue, even pre-existing scar tissue, may interfere with the retina's reattachment and the scleral buckling procedure may have to be repeated. Scarring, along with infection, is the most common complication.
Other possible but infrequent complications include:
- bleeding under the retina
- cataract formation
- double vision
- glaucoma
- vitreous hemorrhage
Patients may also become more nearsighted after the procedure. In some instances, although the retina reattaches, vision is not restored.
Normal results
The National Institutes of Health reports that scleral buckling has a success rate of 85–90%. Restored vision depends largely on the location and extent of the detachment, and the length of time before the detachment was repaired. Patients with a peripheral detachment have a quicker recovery then those patients whose detachment was located in the macula. The longer the patient waits to have the detachment repaired, the worse the prognosis.
Morbidity and mortality rates
The danger of mortality and loss of vision depends on the cause of the retinal detachment. Patients with Marfan syndrome, pre-eclampsia and diabetes, for example, are more at risk during the scleral buckling procedure than a patient in relatively good health. The risk of surgery also rises with the use of general anesthesia. Scleral buckling, however, is considered a safe, successful procedure.
Severe infections that are left untreated can cause vision loss, but following the prescribed regimen of eye drops and follow-up treatment by the physician greatly minimizes this risk.
Alternatives
Vitrectomy is sometimes performed alone to treat retinal detachments. Laser photocoagulation and cryopexy also may be used to treat less serious tears. The more common alternative, however, is pneumatic retinopexy, which is used when the tear is located in the upper portion of the eye. The surgeon uses cryopexy to freeze the area around the tear, then removes a small amount of fluid. When the fluid is drained and the eye softened, the surgeon injects a gas bubble into the vitreous cavity. As the gas bubble expands, it seals the retinal tear by pushing the retina against the choroid. Eventually, the bubble will be absorbed.
The patient is required to remain in a certain position for at least a few days after surgery while the bubble helps seal the hole. Pneumatic retinopexy also is not as successful as scleral buckling. Complications include recurrent retinal detachments and the chance of gas getting under the retina.
Resources
BOOKS
Buettner, Helmut, M.D., editor. Mayo Clinic on Vision and Eye Health. Rochester, MN: Mayo Clinic Health Information, 2002.
Cassel, Gary H., M.D., Michael D., Billig, O.D., and Harry G. Randall, M.D. The Eye Book: A Complete Guide to Eye Disorders and Health. Baltimore, MD: Johns Hopkins University Press, 1998.
Everything You Need to Know About Medical Treatments , edited by Stephen Daly. Springhouse, PA: Springhouse Corp., 1996.
Sardgena, Jill, et al. The Encyclopedia of Blindness and Vision Impairment, 2nd Edition. New York, NY: Facts on File, Inc. 2002.
ORGANIZATIONS
American Academy of Ophthalmology. PO Box 7424, San Francisco, CA 94120-7424. (415) 561-8500. http://www.aao.org .
American Board of Ophthalmology. 111 Presidential Boulevard, Suite 241, Bala Cynwyd, PA 19004-1075. (610) 664-1175. info@abop.org. http://www.abop.org .
National Eye Institute. 2020 Vision Place, Bethesda, MD 20892-3655. (301) 496-5248. http://www.nei.nih.gov .
OTHER
Handbook of Ocular Disease Management: Retinal Detachment Review of Ophthalmology [cited April 21, 2003]. http://www.revoptom.com/handbook/SECT5R.HTM .
"Retinal Detachment." VisionChannel.net [cited April 12, 2003]. <http://www.visionchannel.net/retinaldetachment/treatment.shtml #x003E; .
"Retinal Detachment Repair." EyeMdLink.com [cited May 1, 2003]. <http://www.eyemdlink.com/EyeProcedure.asp?EyeProcedureID=52&#x 03E; .
Wu, Lihteh, M.D. "Retinal Detachment, Exudative." emedicine.com . June 28, 2001 [cited May 1, 2003]. http://www.emedicine.com/oph/topic407htm .
Mary Bekker
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
Scleral buckling can be performed by a general ophthalmologist, an M.D. who specializes in treatment of the eye. Even more specialized ophthalmologists, vitreo-retinal surgeons who specialize in diseases of the retina, may be called upon for serious cases.
The surgery is usually performed in hospital settings. Because of the delicacy of the procedure, sometimes an overnight hospital stay is required. Less severe retinal detachments can be treated on an outpatient basis at surgery centers.
QUESTIONS TO ASK THE DOCTOR
- How many scleral buckling procedures have you performed?
- Could other treatments be an option?
- Will I have to stay in the hospital?
- Will my sight be completely restored?
- What is the probability of having another retinal detachment in the same eye?
- Am I likely to have a retinal detachment in my unaffected eye?
Thanks Jay
Long term I have 100% of my vision, though it is not corrected to 20/20 (corrected - I've got a minus 8.0 correction). Its gotten better over time (since May) and I'm hoping that it wil ultimately come back so that I can see 20/20 with glasses. One problem I do have is that there is a "wrinkle" in the center of my vision. If I look at vertical line (for instance) it will appear to "pinch" in at various places along the line. This did not become apparent for a few weeks after surgery as I could not see well enough after surgery to notice it. I am hopeful that this will go away, but the doctor says that it very well may not.
I assume by now that you've had your surgery. Hopefully all went well.
Darrell
I am 64 years old, reasoably fit and very active. I am hypertensive but have no diabetes.
I had Cataract surgery in my right eye in 2005.
In 2006 I underwent the scleral buckle procedure for retinal detachment repair in the same eye.
Last week I had catarct surgery for my left eye. Now I find that my left eye is a great deal clearer than the right eyr which continues to have a blur, but has reasonable vision.
I do know that I am a potential candidate for retinal detachment in the left ete also.
The question I have is that, with necessaary precaution and timely action in the event of any signs or symptoms would it be possible to avoid the scleral buckle procedure, which essentially is a painful procedure with prolonged post operative discomfort.
Thanks and Regards,
George Vargis.
Bangalore,
South India.
All of us had the procedures above, with good results. My retinal surgeon is a miracle-worker. I lost vision completely in left eye, and now use it for reading and close work -- amazing!
The right eye is now 20/20 -- the retina here was only partially detached and required less work. I no longer need glasses. My daughter is doing fine.
My advise is to go for the procedure. I tried the CO2 welding method prior to the buckle and I wish I did that latter first.
i went under traetment
after i week
i was ok
and gave my exams
,
thought i dnt have any problem in vision wt gods grace bt at times i do see some floating things , doctor says avoid it, is it ok?
i want to wear contact lens but i am a nbit scared ?
Thanks
Since that time I have had no problems and all is good!!!
Oh, the worry about flying? No big deal. I am, however, forbidden to indulge in boxing, bungie jumping and barroom brawls...
I continue martial arts despite some doctors opinions (Some says OK others forbidden or it's your choice).
I try to have informations about removing the buckle because i can feel it when i look on the right and sometimes cause headache (I think it's something with the pressure). If you have such informations please Email me or post.
For conclusion i would say that most of the time you still have a normal life and that's the most important. Don't worry
PS : Sorry for my English I'm French
I had a vitrectomy and buckle surgery 17 days ago. I was a good girl and did what the doctor said: no lifting, no reading, no computers, etc. etc. All I did was sit up, watch TV, walk a LOT, and eat lots of antioxidants. I missed only 6 days of work (Friday--surgery, plus the whole next week), then returned and am doing well. I read a lot at work and am on the computer much of the day. I never got any bruising either, just a little swelling and a lot of redness and some crusties every morning.
I do have a pink bump on my eyeball (incision site?) that blocks about 20 degrees of my peripheral vision. And my vision with that eye is still not good. My pupil is still dilated somewhat. From above comments, it looks like that will take more time to get back to "normal."
I started driving again after 12 days. This may be too soon, but I turn my head a lot and use great caution. I feel ok going short distances.
Thanks to you earlier posters who said to be patient with all of this. I'm not good at that, but will try to wait it out and keep hoping for continued improvement.
I had a vitrectomy and buckle surgery 3 months ago. My condition was complicated by being diagnosed with leukemia as the cause for the hemorrhage in my eye three years ago . The real problem was a torn retina that eventually healed itself causing a scar. Lucky for me that I got connected with Wills Eye in PA, the most knowledgeable and professional team of folks in the northeast US. Wills has a team of the best professionals in this field. Wills is working very hard to restore my vision. It’s going to take another 3 months before the oil bubble will be removed . So my vision is blurred for now. My best advice to all is have patience. As long as you are confident that you are being cared for by professionals knowledgeable in this field just have faith. If you are in doubt related to your care contact the Will Eye Institute . I know people that really didn’t see an appreciable difference in their sight for almost a year.
It was the biggest mistake I ever made.
The pain after the surgery was excruciating and it lasted for two days before lessening.
My eye looked horrendous after the surgery.
It looked bloody and butchered and it took many weeks to start to resemble my normal eye again.
After about 18 months, my eye looked pretty much normal from the front, but whenever I looked to the side at all, the scarring and buckle were visible, and still are visible to this day (14 years later) ... and people often ask me what it is.
But, that's not the worst part.
The worst part is the nearsightedness.
The eye is virtually useless without glasses and I can't wear glasses because the unusual prescription required to accommodate the drastic difference in vision between my two eyes causes severe headaches.
So ... for the past 14 years I've been seeing most of the world through my one good eye which has been horrible.
I still get headaches unless I keep my bad eye closed all the time, but not nearly as bad as the headaches I get while wearing the glasses.
Also, the vision in my good eye has been getting worse and worse every year as the good eye tries to adjust to match the bad eye.
I'm not saying you shouldn't have the surgery.
If every doctor you visit tells you that you'll go blind without it, then you should probably get it.
But that wasn't the case for me.
The tear in my eye was tiny and I was told there was a chance that it could get worse so I should definitely have the surgery done.
When I asked about the surgery I was told that they would simply freeze the eye that would repair it.
I wasn't told that they would be cutting up my eye and installing a permanent silicone band that would destroy my vision.
It was actually a clear-cut case of malpractice.
The doctor saw that my family was poor ... that my parents were morons and I was a naive 17-year-old, and that our insurance company would pay for the whole thing .. so he went for the gold.
I looked into filing a lawsuit a few years ago but it turns out that my parents basically signed my life away just before I went into surgery.
They never read the paperwork that the doctor handed them to sign and that paperwork made him immune to virtually every kind of lawsuit.
If I could go back to 14 years ago, I would have taken my chances with the tiny tear.
I'm now looking into getting the scleral buckle removed.
Three weeks after surgery, I started wearing contact lenses (dr. said ok)and am seeing better. My vision is still changing, but I see improvement. I still find myself closing my eye pretty often, but not as much.
My one drawback: I have lost some peripheral vision to the right side (of my buckled eye) and down below. I bet I have lost 30% of it. The doctor thinks it's likely due to the re-shaping of the retina via the buckle. And, he says if, after many months, I get the buckle removed, the retina shoul go back to normal shape and I should have this vision again. No guarantee. Anyone else notice limits on peripheral vision after a buckle was installed? I play a lot of sports and am anxious about not having a full field of vision.
I had detachments in both eyes 10 years ago. Both eyes were successfully repaired with a combination of buckles, vitrectomy, cryo. and laser. It did take a long time for the redness of the eye to go away (probably two months), but time does heal. I do have a reduction in peripheral vision. However, my impression was that this was a result of the retinal tears and an optic nerve problem, not from the buckle itself. My surgeon referred me to a neuro-ophthalmologist to have the nerve issue checked out (to rule out strokes and other stuff). 10 years later, the reduced peripheral vision hardly bothers me at all. You learn to compensate very quickly (I turn my head a lot more when driving). I don't play sports so I can't comment on that, though I can see how it would be concerning. Otherwise, I lead a very normal life, as long as I have a pair of sunglasses handy! Good luck to you!
Unfortunately, I have had intense pain for the past 3 years, antibiotics helped though. My retina specialist thinks I have an underlying infection and that is what's causing the pain. On July 27th I am getting the buckle removed and I am pretty nervous about it. Hopefully all goes well.