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Principlesof sclera buckling with complications

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scleral buckling retinal detachment surgery

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Scleral Buckling: Principles and Complications

Kanski's Clinical Ophthalmology: A Systematic Approach, 10th ed.

Definition & Core Concept

Scleral buckling (SB) is an external (conventional) approach to retinal detachment (RD) surgery, in contrast to the internal approach of pars plana vitrectomy (PPV). An explant — a piece of soft or hard silicone — is sutured onto the outer sclera, creating an inward indentation called the buckle.

Dual Purpose

  1. Close retinal breaks by apposing the RPE (retinal pigment epithelium) to the detached sensory retina
  2. Reduce dynamic vitreoretinal traction at sites of local vitreoretinal adhesion
Scleral buckling is always indicated for retinal detachment secondary to post-traumatic dialysis.

Explant Specifications

FeatureDetail
MaterialSoft or hard silicone
Ideal coverage~2 mm of buckle surrounding the entire break
Anterior extentMust cover the vitreous base anterior to the tear (prevents re-opening and anterior SRF leakage)
Size estimationBreak dimensions assessed by comparison with the optic disc diameter

Buckle Configurations

  • Radial — perpendicular to the limbus; good for U-tears
  • Segmental — covers a localised area of breaks
  • Circumferential — parallel to the limbus; spans multiple break locations
  • Encircling — a 360° band around the globe
Configuration chosen depends on the size, shape, and number of retinal breaks.

Surgical Technique

  1. Peritomy — conjunctival incision for access
  2. Break localisation — breaks are identified and marked externally (Fig. 16.30A)
  3. Cryotherapy — applied around the break to create chorioretinal adhesion
  4. Explant placement — sutured to the sclera using mattress sutures; position of buckle checked relative to break (Fig. 16.30B–D)
  5. Verification — buckle height and position confirmed intraoperatively
Scleral buckling — wide-field view showing buckle induced by radial explant (A) and circumferential explant (B)
Fig. 16.29 — Wide-field fundus view showing the buckle effect (A) radial explant; (B) circumferential explant

Drainage of Subretinal Fluid (SRF)

SRF can be drained externally through the sclera (the D-ACE sequence: Drainage → Air → Cryotherapy → Explant).
Indications for SRF drainage:
  • Bullous (high) detachment where the explant cannot adequately close the break without drainage
  • Long-standing RD where SRF is viscous and slow to reabsorb
  • Inferior breaks
  • Elderly patients (slow reabsorption)
  • Situations where postoperative position cannot be controlled (e.g., very young children)
Avoiding SRF drainage (non-drain technique) is preferred when possible as drainage carries its own risks (see below).

Complications

Intraoperative Complications

ComplicationMechanism / Notes
Retinal incarcerationRetina gets sucked into the drainage sclerostomy site — a visually devastating complication
Subretinal haemorrhageChoroidal vessel laceration during drainage; can be massive
Vitreous haemorrhageFrom choroidal or retinal vessel trauma
Iatrogenic retinal breakFrom scleral suture perforation

Postoperative Complications

Buckle/Explant-related:
  • Buckle extrusion — implant erodes through conjunctiva and becomes exposed (Fig. 16.32A — shows visible buckle material under conjunctiva)
Buckle extrusion — implant visible beneath conjunctiva
Fig. 16.32A — Buckle extrusion beneath conjunctiva
Plomb extrusion — silicone implant extruding through conjunctiva
Fig. 16.32B — Plomb (solid silicone) extrusion
  • Buckle infection — requires explant removal
  • Buckle migration — changes position over time
Ocular Motility:
  • Diplopia / ocular motility disturbance — from extraocular muscle trauma, adhesion, or mechanical effect of an encircling band
  • Induced myopia — axial length increase from the encircling band compressing the globe
Anterior Segment:
  • Anterior segment ischaemia — from tightening of encircling band compromising anterior ciliary arteries; features: corneal oedema, anterior uveitis, iris ischaemia
  • Raised intraocular pressure — angle closure or choroidal effusion
  • Choroidal effusion — from vortex vein compression by the buckle
Posterior Segment:
  • Macular pucker (epiretinal membrane) — postoperative fibrocellular proliferation
  • Cystoid macular oedema — post-surgical inflammation
  • "Fish-mouthing" — large superior equatorial U-tear widens following buckling in a bullous RD; the flaps gape open rather than close, requiring further intervention

Surgical Failure

CauseNotes
Inadequate buckle sizeBreak not fully supported
Incorrect positioningExplant not aligned under the break
Inadequate buckle heightCan treat with SRF drainage or intravitreal gas injection; PPV may be preferred
Proliferative vitreoretinopathy (PVR)Most common cause of late failure — tractional forces re-open old breaks and create new ones; typically presents weeks postop with re-detachment
Re-opening of break (no PVR)Inadequate cryotherapy or buckling, or reduction of buckle height over time / after elective removal
Key teaching point — The three commonest causes of failed retinal detachment surgery are:
  1. Proliferative vitreoretinopathy (PVR)
  2. Failure to close all breaks
  3. Development of new breaks

Contraindications to Scleral Buckling

PPV is preferred over scleral buckling when breaks are unlikely to be closed by buckling alone:
  • Giant tears (≥ 90° circumference)
  • Large posterior breaks
  • Established PVR
— Kanski's Clinical Ophthalmology: A Systematic Approach, 10th Edition, Chapter 16

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