Temporary scleral buckling performed with a removable external device provides the benefits of scleral buckling while addressing its downsides as surgery for a detached retina.
Reviewed by Paul E. Tornambe, MD
Dr. TornambeTemporary scleral buckling performed with a removable external device provides the benefits of scleral buckling while addressing its downsides as surgery for a detached retina.
For about six years, Paul E. Tornambe, MD, and colleagues have been working to develop a temporary scleral buckle that is inserted and removed in an office-based “clean room.” The idea is based on the premise that retina reattachment only requires a temporary plombage and recognizes the advantages and disadvantages of scleral buckling along with other surgical alternatives.
Dr. Tornambe noted that pars plana vitrectomy (PPV) has seen growing in popularity for the repair of retinal detachments (RDs), but there are many reasons to consider scleral buckling instead.
“Scleral buckling has an equal or possibly higher single operation success rate than PPV and is less invasive, especially if subretinal fluid is not drained,” said Dr. Tornambe, Retina Consultants of San Diego, Poway, CA. “In addition, scleral buckling is much less costly because scleral buckling does not require expensive equipment or single-use packs. It results in fewer return trips to the operating room for failed reattachment or inevitable surgery-induced cataract progression.”
Side effects of scleral buckling with a permanent device include discomfort, myopia, astigmatism, muscle imbalance, chronic macular edema, and risks of buckle infection and extrusion.
“A temporary external scleral buckle represents a better mousetrap because the procedure is minimally invasive and induced refractive errors, muscle imbalance, and discomfort all go away after the buckle is removed,” Dr. Tornambe added. “Scleral buckling with a removal device is not a step backwards, but rather a step back to the future.”
Figure 1. The removable buckle is placed between two rectus muscles and temporarily fixed to the globe with two 5-0 Chromic Sutures. The bites are placed 8 mm apart. Note the AP wing, which prevents rotation of the circumferential element and the positioning hole which facilitates insertion and removal. (Image courtesy of Paul E. Tornambe, MD)
It is also worth noting that in 2017, reimbursement for scleral buckling was about the same as for PPV. Because scleral buckling has a higher single operation success rate than PPV, its use has implications for assessments of surgeon outcomes, Dr. Tornambe pointed out.
“The government is looking at our costs and outcomes, and no return to the operating within 90 days of surgery is a quality measure for retinal detachment surgery,” Dr. Tornambe explained. “According to IRIS registry data, the rate of return with PPV is 29%, which is probably for cataract surgery, whereas it is only 2% for scleral buckling. The removable device can be inserted and removed in an office-based ‘clean room,’ and therefore would avoid all operating room-related costs.”
The device consists of a firm segmental circumferential element that subtends four clock hours and a radial wing plate that prevents rotation and facilitates removal in the office. It requires only two absorbable chromic sutures to fixate, making implantation faster than a conventional sponge or circumferential element. (See Figure 1.)
Cases worth considering
Dr. Tornambe suggested there are several situations where a temporary scleral buckle is worth considering because of its advantages for preserving the crystalline lens, leaving the refractive state unaltered, or avoiding permanent field loss. They include phakic eyes with a traumatic or congenital dialysis that would be expected to respond nicely to temporary scleral buckling.
Young phakic myopes with a history of LASIK also are good candidates for a temporary scleral buckle because the procedure would avoid induction of refractive errors or compromise of the crystalline lens, Dr. Tornambe added.
Consideration of temporary scleral buckling is worthwhile in an eye with a subclinical RD, where laser barricade might be considered but would cause peripheral field loss. A temporary scleral buckle also is a good choice for phakic eyes with an inferior RD, especially for surgeons who are not performing pneumatic retinopexy.
“Pneumatic retinopexy has a lower single-operation success rate compared with other reattachment procedures,” Dr. Tornambe said. “When properly performed and assuming failed cases are re-operated promptly, pneumatic retinopexy is associated with the best visual result. That is important because the goal of RD surgery should be to restore predetachment vision and not to reattach the retina in one operation.”
He added that the downside of pneumatic retinopexy is that it is limited to superior pathology.
Temporary scleral buckling could be considered as a supplement to vitrectomy in a case where the surgeon has concern that proliferative vitreoretinopathy (PVR) might develop or progress. “If PVR does not progress, the buckle can be removed, possibly in the office,” Dr. Tornambe added.
“It is not unreasonable to predict that in the near future, the majority of retinal detachments may be repaired in an office-based clean room, avoiding the operating room completely,” Dr. Tornambe concluded. “This would have an enormous impact on the cost of delivering care for patients with RDs.”
Paul E. Tornambe, MD
This article is based on a presentation given by Dr. Tornambe at the 2017 Retina World Congress. Dr. Tornambe holds a patent on the removable scleral buckling device and founded Poway Retinal Technologies to develop it for commercialization.