|Year : 2014 | Volume
| Issue : 3 | Page : 130-134
Outcome of rhegmatogenous retinal detachment repair by scleral buckling: The experience of a tertiary referral center in Scotland
Vikas Shankar1, Lik Thai Lim1, Elliott Yann Ah-Kee2, Harold Hammer1
1 Tennent Institute of Ophthalmology, Gartnavel General Hospital, 1053 Great Western Road, Glasgow, G12 0YN, United Kingdom
2 University of Glasgow School of Medicine, University Avenue, G12 8QQ, United Kingdom
|Date of Web Publication||11-Oct-2014|
Elliott Yann Ah-Kee
University of Glasgow School of Medicine, University Avenue, Glasgow, G12 8QQ
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Purpose: The primary aim of this study is to report the outcome of patients with rhegmatogenous retinal detachment (RRD) who underwent scleral buckling (SB) surgery.
Methods: This is a retrospective noncomparative case series study of all patients who underwent RRD repair by primary SB between March 2008 and February 2009. Patient demographics, visual outcome, complications, and failure rates were identified and recorded.
Results: A total of 65 patients underwent RRD repair by SB, with a mean age of 44.44 years. Results showed that the primary outcome (primary anatomical success following index surgery) was 90.77%, while the secondary outcome (anatomical success following repeat surgery) was 98.46%.
Conclusion: The study showed a high-success rate of SB in phakic eyes both in terms of postoperative best-corrected visual acuity and complication rates. We recommend the continued use of this technique in selected cases of RRD.
Keywords: Outcomes, retinal detachment, scleral buckling
|How to cite this article:|
Shankar V, Lim LT, Ah-Kee EY, Hammer H. Outcome of rhegmatogenous retinal detachment repair by scleral buckling: The experience of a tertiary referral center in Scotland
. Oman J Ophthalmol 2014;7:130-4
|How to cite this URL:|
Shankar V, Lim LT, Ah-Kee EY, Hammer H. Outcome of rhegmatogenous retinal detachment repair by scleral buckling: The experience of a tertiary referral center in Scotland
. Oman J Ophthalmol [serial online] 2014 [cited 2020 Sep 19];7:130-4. Available from: http://www.ojoonline.org/text.asp?2014/7/3/130/142595
| Introduction|| |
Rhegmatogenous retinal detachment (RRD) is primarily treated either by external approach with scleral buckling (SB), pars plana vitrectomy (PPV) or both. SB has been falling out of favor over the last two decades and is quickly becoming a lost art of vitreoretinal surgery. At present, the trend is toward PPV with advances such as small-incision techniques and wide-field viewing systems. In this study, we looked at the results of SB procedures performed at a tertiary center for treatment of RRDs. The main objective of the study was to study the outcome of RRD repair using the SB technique. We also sought to compare the surgical outcome with national standards and to identify the causes of failure and complications.
| Methods|| |
This is a retrospective noncomparative case series study of the outcomes of SB technique for RRD repair performed from 1 st March 2008 to 28 th February 2009 at Gartnavel General Hospital, Glasgow. Inclusion criteria included RRD requiring surgery using SB. Patients with any previous RRD surgery, pseudophakic patients, aphakic patients, patients with giant retinal tears, posterior breaks, proliferative vitreo-retinopathy (PVR) grade C, retinal detachment (RD) with vitreous hemorrhage, RD with choroidal detachment and patients who had a history of strabismus surgery were excluded. The study included mostly adults with the age of presentation ranging from 15 to 75 years with a mean age of 47.44 years. Cases were identified from the operating theatre logbook at Gartnavel General Hospital. Case notes were then retrieved with the help of the medical records department. Patient demographics, visual outcome, complications and failure rates were identified and recorded. The data collection sheet was completed, and results analyzed. All the patients had documented posterior vitreous characterized by a Weiss ring detected on fundoscopy.
| Results|| |
The total number of primary SB repair surgery performed during the 12-month period was 65 patients of which 38 were female. The age of presentation varied from 15 to 75 years with a mean age of 47.44 years. The right eye was involved in 40 patients. Five surgeons were involved with Surgeon 1 performing 30 surgeries. The duration of symptoms ranged from 1 day to 3 months. Three patients presented within 24 h, 12 within 1-2 days, 18 within 3-7 days, while 32 presented with symptoms of >7 days duration. Forty-three patients (66%) underwent surgery within 2 days of the presentation. Twenty-two patients had surgery after 3 or more days. The maximum waiting time for surgery was 6 weeks because the patient had a previous operation on the other eye for RRD. More than half of the patients were myopes (54%), of which 23% were high myopes (>−6 D) (n = 15) and 31% were low myopes (n = 20), emmetropia in 24 (37%) and hypermetropia in 6 (9%). History of trauma was elicited in four patients including one patient who was a rugby player presenting with retinal dialysis. Treated RD in the fellow eye was seen in three patients. Presenting symptoms are summarized in [Table 1].
The presenting visual acuity (VA) was 6/6 in 16 (24.67%) patients, 6/9-6/18 in 25 (38.5%) patients, 6/24-6/36 in 8 (12.3%) patients, 6/60 and less in 13 patients, hand movements (HMs) in three patients. Two patients were amblyopic in the affected eye with VA 6/60 and counting fingers.
Of the 41 patients with VA better than 6/18, 37 patients had macula-on RD at presentation. Seven patients had macula-on RD by ultrasound, in which the detached retina was folded over the front of the macula. The rest (32%) had macula-off RD (n = 21). All the patients who underwent an operation were phakic. Sixteen patients (25%) had retinal dialysis on presentation. The refractive status of most of the patients with dialysis was emmetropia (n = 11) with the rest having low myopia (n = 5). The RDs resulting from dialysis was found in 16 cases (24.6%) and those resulting from tears/breaks in 21 cases (32.3%), while holes were responsible in 28 cases (43.1%). Two patients had suspicious breaks, but no clearly defined breaks/holes were identified. It was interesting to note that there is area specific predilection for the tears, dialysis and holes in this series of RD, highlighted in [Figure 1], [Figure 2], [Figure 3]. Moreover, some patients had more than one quadrant involved.
|Figure 1: Frequency of quadrant involvement in tears/breaks (UT = upper temporal; UN = upper nasal; LT = lower temporal; LN = lower nasal; RE = right eye; LE = left eye)|
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General anesthesia was used in 64 patients while one patient with near term pregnancy was done under local (sub-tenon) anesthesia. The variations in surgical technique used are shown in [Table 2].
The buckles used were mostly segmental in 59 patients, and radial buckles were performed in five, while one patient had a circumferential buckle. All buckles were made of silicone. Prophylactic treatment with cryotherapy in the fellow eye was required in 15 patients for suspicious areas, while one patient had bilateral detachment. The buckles when placed radially were at 10 o'clock, 11 o'clock, and 2 o'clock hours in three patients. The choice of buckles used, is shown in [Table 3].
The intraoperative complications included vitreous hemorrhage (n = 1), sub-retinal hemorrhage, while draining sub-retinal fluid (SRF) (n = 4), choroidal hemorrhage (n = 1), and tyre displaced posteriorly (n = 1). Fifty-eight patients had no complications intraoperatively [Table 4].
Postoperative complications included raised intraocular pressure (n = 4), re-detachment (n = 6) and PVR grade C with vitreous hemorrhage and new breaks in one patient. Epiretinal membrane developed in two patients. Residual SRF at macula was observed in two patients [Table 4]. Squint (hypertropia) developed in one patient, but was successfully treated with Fresnel prism and subsequently resolved after 2 months.
Postsurgical follow-up is vital in that it ensures that the retina is in place and at the same time, it also helps to identify unsuccessful cases for repeat surgery. Anatomical success was defined as a reattached retina at the last postoperative visit. The shortest postoperative follow-up period was 2 weeks, while the longest postoperative follow-up period was 6 months. Forty-two patients were followed-up for 2 months after which they were discharged. Eleven patients were discharged at 3 months. Six patients were followed-up for 4-6 months. The postoperative best-corrected VA (BCVA) was included for 58 patients and is shown in [Table 5].
The follow-up results excluded the six patients who underwent repeat surgery. One patient failed to attend for further follow-up and another one attended follow-up in another hospital.
[Figure 4] shows the presenting VA, and VA after one successful operation and subsequent repeat surgery for those who were unsuccessful after the first operation. Out of the 65 patients, six needed repeat surgery with vitrectomy for persistent RD. Five of the six patients had good visual outcome and only one developed PVR.
|Figure 4: Graph illustrating the presenting visual acuity, and visual acuity after one successful operation and subsequent repeat operations for those who were unsuccessful after the first operation|
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Six patients who underwent repeat surgery for the persistent detachment were aged between 15 and 63 years, with a mean age of 35.16 years. All patients were operated within 6 days of presentation. Four of the six patients were emmetropic, while the other two were low-myopes. The presenting VA was 6/9-6/18 in three patients, 6/24-6/36 in two patients, and HMs in one patient. Four of the six patients had retinal dialysis (3 in 7-8 o'clock). One patient had retinal holes (3 holes 6-8 o'clock) and another patient had a horseshoe retinal tear (10 o'clock). Two patients had macula-off RD, while three were macula-on RD with the retina folded in front of the macula. The final visual outcome after repeat surgery was 6/6 in two patients, 6/9 in one patient, while two patients achieved 6/12 VA improvement. The patient who had a horseshoe retinal tear did not attend for follow-up.
| Discussion|| |
Scleral buckling is a very effective procedure in selected cases of RRD such as in uncomplicated phakic patients. Unfortunately, this technique is performed less frequently due to the introduction of PPV in early 1970s. However, SB has multiple advantages over PPV, including reducing the risk of cataract formation and endophthalmitis. It has faster visual rehabilitation compared to PV, which requires intra-vitreal gas or silicone oil.  Furthermore, in certain cases like retinal dialysis, SB is the treatment of choice, with a better prognosis and success rate. 
However, SB technique is more difficult to learn and teach compared to PV. It is also demands more surgical expertise compared to PPV, which has the advantage of intraoperative visualization of retinal breaks.
In our study, the primary outcome (primary anatomical success following index surgery) is far better than that reported in the national average, although the secondary outcome (anatomical success following repeat surgery) is more or less the same as that reported by the national average.  The postoperative BCVA was 6/6 in 37 patients (56%). Thirteen patients achieved 6/9-6/18, while four had VA between 6/24 and 6/36. Thus, 76.9% patients achieved a VA better than 6/18 postoperatively after the primary procedure. The VA of <6/60 was seen in three patients. Of those, two had preexisting amblyopia. One patient was left with VA of HM only. Moreover, one patient failed to follow-up, while six patients required repeat surgery.
In our study, only one patient experienced double vision (1.5%) due to exotropia. This was treated conservatively by prism and resolved in 2 months. In a study of 821 patients who underwent SB, 12 developed diplopia lasting >3 months. Six of the SB operations were vertical, three horizontal, and three oblique. Examination of the 12 patients showed seven cases of hypertropia, two cases of hypertropia associated with esotropia, one case of hypertropia with exotropia, and two cases of exotropia. The SB was removed in all 12 patients; binocular single vision was restored in six cases. Secondarily, prism correction restored binocular vision in three additional patients. Strabismus surgery was necessary for the remaining three patients. 
Buckle-related complications following surgical repair of retinal dialysis has been reported in a study of 28 cases. Anatomical success was achieved with a single procedure in 26 cases (92.9%). Compared to our study, the primary success rate for related cases was lower at 75%. However, the secondary success rate is almost similar.  Postoperative complications were seen in 20 cases (71.4%), with complications attributable to the buckle noted in 19 cases (67.9%).  Buckle-related complications included exposure (n = 7; 25%), strabismus (n = 5; 17.9%), and infection (n = 3; 10.7%).  In contrast, the complications attributable to SB in our study, were minimal with only one patient developing a strabismus, which was treated with prisms. None required removal of buckle, although the follow-up of the patient is shorter.
The case has been reported of a patient with visual field defect after retinal reattachment using the encircling procedure for RRD. However, it improved after relaxation of the buckle, which restored the ocular blood flow.  The report suggested that the choroidal circulation disturbance, which was found following the encircling procedure, had a plausible role in the development of the visual field defect.  We did not notice any visual field related complications in our series.
Sub-macular fluid was seen in two patients (3%) in our case series, one of which resolved in the follow-up. The incidence, pattern, duration, and clinical consequences of persistent, localized sub-macular fluid after SB surgery for RD has been reported in the literature in a prospective observational cohort series.  Ninety-eight patients had an optical coherence tomography (OCT) scan of the macula preoperatively and at 6 weeks postoperatively. Of the 98 patients recruited in the study, 54 (55%) had SRF on OCT 6 weeks after surgery. Fluid was associated with delayed visual recovery. Of those with SRF, 78% had persistent fluid at 6 months, and resolution of fluid took a median of 10 months and was associated with an improvement in vision.  The study concluded that persistent SRF 6 weeks following SB, occurs in approximately half of patients. Furthermore, this may persist for many months and cause delayed visual recovery.  In our case series, two patients had residual SRF, which was absorbed in the subsequent follow-up of 2 months.
A retrospective, noncontrolled case series study was conducted in 93 patients (93 eyes) to evaluate the outcome of patients who had previous macula-off RRD treated with SB.  Patients with low-grade myopia (<−6 D) regained significantly better mean postoperative VA as compared with high myopia (>−6 D) and emmetropic eyes (0 to + 3 D) (ANOVA, P < 0.001). In this series, SRF drainage procedure did not affect postoperative visual outcome. Multivariate logistic regression analysis revealed that the duration of macular detachment was the only variable affecting the visual outcome. 
A study of eyes with primary, uncomplicated, macula-off RD repaired with SB, concluded that eyes achieve excellent postoperative VA if repaired within the first 10 days of macular detachment.  Patient age did not significantly affect anatomical outcomes. 
In a large case series of 186 eyes, 82% achieved retinal reattachment with one SB procedure and with a median final VA of 20/40 at 20 years of follow-up.  An additional 30 eyes (13%) achieved retinal reattachment after one or more additional vitreo-retinal procedures, with a median final VA of 20/50. Eleven eyes (5%) developed RD at the 20-year follow-up examination, with a final VA in all eyes of no light perception. This study may serve as a basis for comparison with the long-term results of other surgical techniques used in the treatment of primary RRDs.  Our success rate is comparable to the above study, as we have achieved success after one procedure of 90.77% and 98.46% after two procedures.
The National RD Audit, UK reported primary reattachment in 82% and the final reattachment as 91%.  In a randomized controlled trial of 546 patients, favorable surgical outcomes for primary RRDs with SB alone was achieved in 97.8% of the patients. 
From the results of our study, we observed that there are few factors that may be contributing toward the failure of the minority of cases reported in this study. Patients with dialysis were noted to have a higher incidence of failure rate after first surgery. The sample size of our study is too small to draw a significant correlation between success rate and duration of symptoms of RRD. However, the latter appears to have some bearing on the overall success of a first RRD repair using the SB technique. Persisting RD will eventually develop into PVR, which can further reduce the chance of a successful first-time operation.
| Conclusion|| |
Scleral buckling is still a very effective technique to treat selected cases of RD, and as such should not be a neglected skill for present and future vitreo-retinal surgeons, despite in the advent of advancing techniques and technology of PPV.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]