Scleral Buckling: A Look at the Past, Present and Future in View of Recent Findings on the Importance of Photoreceptor Re-Alignment Following Retinal Re-Attachment

Cross-Sectional Survey of Vitreoretinal Surgery Fellowship Training in Secondary Intraocular Lens Placement

Purpose: To assess current trends in vitreoretinal surgical fellowship training for placement of secondary intraocular lenses (IOLs). Methods: A cross-sectional survey was administered to vitreoretinal surgical fellowship graduates who completed their program between 2019 and 2023. Results: Completed responses were obtained from 70 (22.5%) of 311 eligible recipients. Training settings included academic (80%), hybrid academic/private practice (15%), and private practice (5%). During their fellowship, the majority of respondents reported 10 or fewer cases using anterior chamber (AC) IOLs (69%), 5 to 50 cases using scleral-sutured IOLs (64%), and 5 to 25 cases using sutureless scleral-fixated IOLs (52%). Most fellows (79%) did not have exposure to iris-fixated IOL placement during fellowship training. The Akreos AO60 (78%) and Envista MX60 (10%) IOLs were the most common choice for scleral-sutured placement. Most fellows (67%) placed fewer than 10 secondary IOLs through scleral tunnels. Overall, scleral-sutured IOL placement (Akreos Gore-Tex [polytetrafluoroethylene] sutured, 49%) and scleral-fixated IOLs (modified Yamane, 45%) were the preferred and most comfortable surgical techniques for recent graduates after completing training. There was a significant association between surgical case volume during fellowship training and self-reported competency for each type of secondary IOL (P ≤ .005). Conclusions: The majority of vitreoretinal surgical fellows receive limited training in the placement of AC IOLs or construction of scleral tunnels during their fellowship. Aligned with their experience during fellowship, recent graduates generally prefer implanting scleral-fixated or scleral-sutured IOLs. Analysis of trainees' exposure to various techniques and postgraduate surgical preferences may identify areas for improvement in surgical education.

The necessity and role of scleral buckling for rhegmatogenous retinal detachment

PURPOSE OF REVIEW

With a decline in the use of scleral buckling for rhegmatogenous retinal detachment (RRD) repair in recent years, this review seeks to provide a summary of the most recent research findings regarding the role of scleral buckling in the repair of RRD.

RECENT FINDINGS

Many recent studies have compared visual and anatomic outcomes between scleral buckling and pars plana vitrectomy (PPV) for RRD repair. Some suggest superior outcomes with primary scleral buckling, particularly in younger, phakic patients, and in association with other risk factors that we review. Children do best with primary scleral buckling surgery. Functionally, scleral buckling may also result in lower rates of retinal displacement compared to PPV. When PPV is necessary, a supplemental buckle may benefit certain patients, while the advantage remains unclear in other clinical scenarios and necessitates further investigation.

SUMMARY

Scleral buckling is an important technique for the repair of RRD and it is crucial to continue training retina surgeons in this technique to maximize patient outcomes.

Review and analysis of history and utilization of pneumatic retinopexy after pneumatic retinopexy versus vitrectomy for the management of primary rhegmatogenous retinal detachment outcomes randomized trial (PIVOT)

PURPOSE OF REVIEW

We describe the history and series results of pneumatic retinopexy (PnR)and provide an analysis of PnR utilization after publication of results of pneumatic retinopexy versus vitrectomy for the management of primary rhegmatogenous retinal detachment outcomes randomized trial (PIVOT).

RECENT FINDINGS

No significant trends were found for average number of services ( P  = 0.153) of PnR after the publication of PIVOT results.

SUMMARY

PnR is a rhegmatogenous retinal detachment (RRD) repair technique that was first described in the early 1900 s and has evolved over time to become a modern-day, minimally invasive, underutilized treatment option. Other repair techniques for RRD include scleral buckling and pars plana vitrectomy (PPV), which has been compared to the use of PnR in PIVOT. Results of PIVOT concluded that PnR offered superior visual acuity and noninferiority. PnR is underutilized in the United States even after publication of results of PIVOT deemed it a noninferior treatment. Lack of a significant increase in national utilization of PnR could be associated with multifactorial clinician, systems, and financial reasons in the real-world setting.

Outcomes of Chandelier-Assisted Scleral Buckling in Rhegmatogenous Retinal Detachments: Systematic Review and Meta-analysis

Purpose: To examine the outcomes of chandelier endoillumination-assisted scleral buckling (chandelier scleral buckling) for rhegmatogenous retinal detachments (RRDs) and compare them with those of standard scleral buckling using indirect ophthalmoscopy. Methods: A literature search was performed on April 15, 2023. Outcomes analyzed included the primary anatomic success rates, surgical duration, and complication rates. A meta-analysis of proportions estimated the pooled success rate of chandelier scleral buckling. In addition, meta-analyses compared the success rates between pseudophakic eyes and phakic eyes having chandelier scleral buckling and compared success rates and surgical duration between standard scleral buckling and chandelier scleral buckling. Results: Thirty studies with 1133 eyes were included. The pooled primary anatomic success rate of chandelier scleral buckling was 91.7% (95% CI, 89.6%-93.6%). In studies comparing success rates between the 2 techniques, there was no significant difference (risk ratio, 1.01; 95% CI, 0.94-1.08; P = .80). The surgical times were significantly shorter with chandelier scleral buckling than with standard scleral buckling (mean difference, -18.83; 95% CI, -30.88 to -6.79; P = .002). There was no significant difference in the success rate between pseudophakic eyes and phakic eyes (risk ratio, 0.99; 95% CI, 0.91-1.08; P = .89). No cases of endophthalmitis were reported. Conclusions: Chandelier endoillumination-assisted scleral buckling may be a promising technique given its high rate of primary anatomic success for RRDs and success rates similar to those of standard scleral buckling. There was no significant difference in the efficacy of chandelier scleral buckling between pseudophakic eyes and phakic eyes.

Surgical Outcomes of Rhegmatogenous Retinal Detachment and Fellow Eye Involvement in Adolescent and Young Adult Patients

PURPOSE

To investigate the associations, fellow eye retinal tear or detachment, and surgical outcomes of rhegmatogenous retinal detachments (RRDs) in young adults.

DESIGN

Retrospective consecutive case series.

SUBJECTS

Patients aged ≤ 30 years who underwent surgical repair for RRD between 2014 and 2021 at a single practice. The mean age was 23.85 years (range, 12-30 years).

METHODS

Data collected included demographics, preoperative clinical features of the RRD, visual acuity (VA), type of surgery performed, anatomic outcomes, OCT findings, fellow eye retinal tear or detachment, and postoperative complications.

MAIN OUTCOME MEASURES

Postoperative VA and single-surgery anatomic success rate.

RESULTS

One hundred one patients (109 eyes) were included. Sixty-seven patients (74 eyes) and 17 patients (19 eyes) were followed for ≥ 1 year and 5 years, respectively. The most common associations were myopia (66 eyes, 60.6%), trauma (8 eyes, 7.3%), and prior ocular surgery (7 eyes, 6.4%). Median preoperative Snellen VA was 20/70. The macula was attached in 31 eyes. Scleral buckle (SB) alone was performed in 75 eyes, pars plana vitrectomy (PPV) + SB was performed in 27 eyes, PPV alone was performed in 6 eyes, and cryotherapy with pneumatic retinopexy was performed in 1 patient. Single-surgery anatomical success was 88.7% for SB, 89.7% for PPV + SB, and 75% for PPV. The median final postoperative Snellen VA was 20/50. Twelve patients presented with bilateral RRDs, and sequential surgery was performed in 8 patients, followed by 4 patients who underwent surgery with fellow eye laser barricade. Fourteen patients (13.9%) developed a retinal tear or detachment in the fellow eye, with a mean interval of 8 months from presentation. Of the 17 patients who were followed for ≥ 5 years, 3 patients (17.6%) developed a fellow eye retinal tear or detachment. After initial anatomical success, 6 eyes (5.5%) developed proliferative vitreoretinopathy.

CONCLUSIONS

The most common association of RRD in this study was myopia. Scleral buckle alone was the most common surgical intervention. However, outcomes were generally favorable with SB-only and PPV + SB. Surgeons and patients should be aware of the risk of bilateral retinal detachment and the risk of fellow eye retinal tear and detachment. These patients require long-term surveillance in both eyes.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

Evaluation of the Effect of Scleral Buckling on Anterior Segment and Refractive Changes Using Anterior Segment Optical Coherence Tomography

PURPOSE

To evaluate the changes of anterior segment and refractive parameters after scleral buckling (SB) surgery for uncomplicated rhegmatogenous retinal detachment (RRD) using anterior segment optical coherence tomography (AS-OCT).

METHODS

Thirty-six RRD eyes were consecutively enrolled. Analysis concerned the central corneal thickness (CCT), anterior chamber depth (ACD), anterior chamber volume (ACV), iris-trabecular contact (ITC), angel opening distance (AOD), angle recess area (ARA), trabecular-iris space area (TISA)，trabecular iris angle (TIA) and refractive parameters, including average keratometry (AvgK), cylindrical power (CYL), regular astigmatism, asymmetry and high order irregularity (HOI) at baseline and 1 day, 1 month, 2 months, 6 months and 12 months postoperatively. AS-OCT was performed at RRD diagnosis and day 1, week 1, month 1 and month 6 after SB to evaluate the scleral buckling.

RESULTS

A statistically significant postoperative CCT increase, ACD and ACV decrease were observed at 1 day and 1 month postoperatively. ITC analysis showed that the angle of the entire circumference narrowed at 1 month postoperatively. There was a significant decrease in all the angle parameters (AOD500/750, ARA500/750, TISA500/750, and ARA500/750) at 1 day and 1 month after SB surgery. However, all of the above parameters returned to the preoperative level at 12 months. Refractive parameters including AvgK, regular astigmatism, CYL, asymmetry, and HOI of anterior corneal surface and total corneal increased on the 1 day and 1 month after SB surgery and persisted even after 12 months follow-up. However, there was no significant difference in refractive parameters of posterior corneal surface during follow-up.

CONCLUSION

The changes in the structure of anterior segments after SB surgery were almost returned to the preoperative levels at 12 months postoperatively. However, SB surgery has a long-term effect on refractive parameters throughout a 12-month follow-up.

Chandelier-Assisted Scleral Buckling: A Literature Review

The treatment of retinal detachment (RD) has seen numerous advancements in the last decades. Scleral buckling (SB) is a surgical procedure introduced in the 1950s that has seen a drastic reduction with the advent of vitrectomy. However, due to the new surgical visualization systems, SB has evolved and continues to be an extremely useful procedure in certain conditions. The presence of different case reports or interventional studies with comparable outcomes, as well as the lack of recent studies with direct comparison, may result in an underestimation of its potential nowadays. The aim of this review is to provide a comprehensive update on chandelier-assisted scleral bucking (CSB), with an overview of the surgical evolution, outcomes, advantages, and complications.

Rhegmatogenous retinal detachment surgery: A review

Rhegmatogenous retinal detachment (RRD) is a serious surgical condition with significant ocular morbidity if not managed properly. Once untreatable, approaches to the repair of RRD have greatly evolved over the years, leading to outstanding primary surgical success rates. The management of RRD is often a topic of great debate. Scleral buckling, vitrectomy and pneumatic retinopexy have been used successfully for the treatment of RRD. Several factors may affect surgical success and dictate a surgeon's preference for the technique employed. In this review, we provide an overview and supporting literature on the options for RRD repair and their respective preoperative and postoperative considerations in order to guide surgical management.