Controversies in Vitreoretinal Surgery

8/16/2019 Controversies in Vitreoretinal Surgery

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Controversies in Vitreoretinal Surgery: IsScleral Buckling an Important Mainstay inthe Treatment of Retinal Detachment in

2!"#By Gaurav K. Shah, MD ; Baseer Ahmad, MD ; and Szilárd Kiss,MD

These articles are based on the debate-style presentations at the American Academy of

Ophthalmology Retina Subspecialty Day in New Orleans November 1-1!" #$1%& The

arguments presented by the authors" a'rmative or negative" were assigned to them

and do not necessarily re(ect their own opinions and practices&

SC$%R&$ B'C($% )*R R%TI+&$ D%T&C,M%+T: -R*

By .aurav (/ Shah0 MD1 an Baseer &hma0 MD

Is scleral buckling surgery for retinal detachment (RD) repair here to stay? We believe

the answer is “yes! but only if ophthalmologists continue to perform and teach these

procedures" If we do not scleral buckling procedures will pass into history"

#here is no doubt that pars plana vitrectomy ($$%) is an e&ective procedure valued day

in and day out" 'o are scleral buckling procedures however for appropriate cases" venso scleral buckling procedures have become eclipsed by $$%" $ub*ed search revealed

the following+ since ,-./ 012. articles have been published on scleral buckling3 since

,-14 ,0 52, articles have been published on $$%3 since ,-10 ,415 articles have been

published on scleral buckling plus $$%" In the past . years the di&erence is even more

pronounced with 5-. articles on scleral buckling 5,0/ on $$% and 052 on both

procedures"

*edicare claims data (6igure ,) also re7ect this trend" 6rom 0444 to 04,, use of the

$$% code has more than doubled from about ,. 444 annual procedures to about 50

444" *eanwhile the use of scleral buckling has declined from /444 to 0444 procedures

per year"

'everal factors may be responsible for these changes"

http://retinatoday.com/search.asp?q=Gaurav+K.+Shah%2C+MD&l=ahttp://retinatoday.com/search.asp?q=Baseer+Ahmad%2C+MD&l=ahttp://retinatoday.com/search.asp?q=Szil%C3%A1rd+Kiss%2C+MD&l=ahttp://retinatoday.com/search.asp?q=Szil%C3%A1rd+Kiss%2C+MD&l=ahttp://retinatoday.com/search.asp?q=Baseer+Ahmad%2C+MD&l=ahttp://retinatoday.com/search.asp?q=Szil%C3%A1rd+Kiss%2C+MD&l=ahttp://retinatoday.com/search.asp?q=Szil%C3%A1rd+Kiss%2C+MD&l=ahttp://retinatoday.com/search.asp?q=Gaurav+K.+Shah%2C+MD&l=a


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#he availability of small8gauge instrumentation wide8angle viewing systems high8

speed cutters and better illumination have made $$% much easier" 'urgeons may also

lack con9dence in their skills with indirect ophthalmoscopy and there is less time spent

on scleral buckling by mentors and training programs" conomic and time factors play a

role" In addition there is no industry support of scleral buckling at this point"

t the same time there is a growing list of misconceptions about scleral buckling" #hese

include the following+

• #he success rate with scleral buckling is lower than that with $$%3

• #he choice of initial treatment does not make a di&erence in failure outcomes3

• 'cleral buckling has a high incidence of complications3

• #here is a signi9cantly higher amount of myopia after scleral buckling compared

with $$%3

• Rates of proliferative vitreoretinopathy ($%R) are higher after scleral buckling

than after $$%"

MISC*+C%-TI*+S %3&MI+%D

look at the relevant literature shows that all of the above are incorrect assumptions"

Success rates. Reviewing the published results of retrospective and prospective

comparative case series from 0444 to the present,8,.

the single8operation success rateis better with $$% in some papers and with scleral buckling in others with no

preponderance of greater success with $$% or scleral buckling" :owever when results

are broken down into phakic and pseudophakic groups it becomes clear that in

pseudophakic eyes $$% is the more common procedure with the higher success rate"

;onversely in phakic eyes single8operation success with scleral buckling seems to be

e rhegmatogenous RDs by ,1/ surgeons on . continents" 6inal success

rate in phakic eyes was higher with scleral buckling than with $$% (--". vs ->"13 ) @

"40>)" #he study authors concluded that in the treatment of uncomplicated phakic RD

repair using scleral buckling is at least e


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'cleral buckling o&er some advantages over $$%" In young patients the crystalline lens

and therefore accommodationis preserved" In older patients the vitreous is

preserved" 6or patients with eAtensive lattice degeneration or an abnormal vitreoretinal

interface scleral buckling provides 5/4E support of the vitreous base and peripheral

retina" 'cleral buckling is an eAtraocular surgery unless drainage of subretinal 7uid is

re


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#he myths about scleral buckling are simply not true" #reatment decisions are driven by

perceptions and by economic time and convenience factors" We must tailor our

treatments to patientsG needs whether the choice be scleral buckling scleral buckling

plus $$% or $$% alone rather than adhering to a single approach"

;urrently many ophthalmology training programs are moving away from teaching

scleral buckling" If the decline in scleral buckling teaching and use is not corrected this

skill will soon be lost to our profession" We believe that scleral buckling procedures

continue to be important tools in the vitreoretinal surgeonGs armamentarium" #he less

fre


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D%C$I+I+. 'S%

#he $references and #rends ($#) surveys by the merican 'ociety of Retina

'pecialists,o&er insights into current practices among our colleagues" When asked in

04,, “In what percentage of RD cases do you implant a scleral buckle?! about 2. ofrespondents (n@55.) said they used scleral buckling 04 of the time or less often" Hnly

about 0. said they would use scleral buckling more than /4 of the time"

Hther


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candidates for vitrectomy including phakic patients and those with inferior retinal

breaks may also be treated with $$%"

ntil the middle of the past decade there was no prospective randomi=ed multicenter

trial comparing scleral buckling with $$%" Reviewing the literature in 044/ 'chwart= and6lynn said the consensus “appears to be that scleral buckling and primary $$% may

yield comparable single8operation success rates and visual acuity outcomes for a wide

variety of rhegmatogenous retinal detachments"!2

In 0441 a prospective randomi=ed trial comparing scleral buckling and $$% in

rhegmatogenous RD found a visual bene9t for scleral buckling in phakic patients" In

pseudophakic patients there was no signi9cant di&erence in visual bene9t with scleral

buckling compared with $$%" Cased on better anatomic outcomes with $$% the study

authors recommended the use of $$% in these patients".

&DV&+T&.%S *) -&RS -$&+& VITR%CT*M6

#here are numerous advantages of $$% over scleral buckling surgery" With $$% the

surgeon is better able to visuali=e all retinal breaks and tears and to ensure removal of

all media opacities and synechiae" $$% a&ords the opportunity to relieve the vitreous

traction that caused the RD" 'mall8gauge $$% techni


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In a recent ,48year retrospective analysis of 0.> eyes1 successful initial attachment

was achieved in // of eyes" Hf failed cases 11 were attached with , more

operation and 9nal anatomic success was achieved in --"0 cases"

C*+C$'SI*+S

t current levels of scleral buckling usage as future generations of retinal surgeons are

trained their ability to perform buckling procedures will not be e


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,2" 'hah JP lmony Clinder P hmad C" Recurrent retinal detachment" $aper presented at+

Retina 'ubspecialty Day nnual *eeting of the merican cademy of Hphthalmology3 November

,4 04,03 ;hicago"

,." *ansouri lmony 'hah JP Clinder PQ 'harma '" Recurrent retinal detachment+ Does

initial treatment matter? ;r 6 Ophthalmol& 04,43 -2(,4)+,5228,521"

,/" delman R $arnes Q Ducournau D3 uropean %itreo8Retinal 'ociety (%R') Retinal

Detachment 'tudy Jroup" 'trategy for the management of uncomplicated retinal detachments+ the

uropean vitreo8retinal society retinal detachment study report

," Ophthalmology& 04,53,04(-)+,>428,>4>"

,1" 'hah JP lmony Clinder PQ" $ostoperative complications of retinal detachment repair with

scleral buckles" $aper presented at+ Retina 'ubspecialty Day nnual *eeting of the merican

cademy of Hphthalmology3 Hctober ,/ 04,43 ;hicago"

,>" Regillo ;D Censon W" Retinal Detachment+ Diagnosis and *anagement" $hiladelphia+

Mippincott8Raven+ ,-->"

,-" 'harma OR Parunanithi ' =ad R% %ohra R $al N 'ingh D% ;handra $" 6unctional and

anatomic outcome of scleral buckling versus primary vitrectomy in pseudophakic retinal

detachment" Acta Ophthalmol Scand&044.3>5(5)+0-580-1"

04" 'eider *I Naseri 'tewart Q*" ;ost comparison of scleral buckle versus vitrectomy for

rhegmatogenous retinal detachment repair" Am 6 Ophthalmol& 04,53,./(2)+//,8////"

Controversies in Vitreoretinal Surgery

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