What is a scleral buckle?

A scleral buckle is a procedure performed for the repair of a retinal detachment. The term, “scleral buckle,” describes both a procedure and a piece of hardware that is placed on the eye. The procedure, itself, is a method of reattaching the retina without placing instruments inside the eye. If you think of a detached retina as wallpaper that has come off the wall, a scleral buckle is like pushing the wall in toward the wallpaper. This, of course, is not very practical in the case of wallpaper, but it works quite nicely for the eye.

Scleral buckling is performed in an operating room, under local or general anesthesia. The procedure generally lasts about an hour. A patch is placed over the eye at the end of surgery and removed the next morning. The patient takes eye drops for several weeks following surgery. These drops are usually intended to decrease inflammation, prevent infection, and minimize discomfort. If a gas bubble is placed in the eye, the patient may be instructed to maintain a certain head position for several days after surgery while the retina becomes more firmly attached.

The procedure typically involves several steps:

1. Cryopexy
A freezing probe is placed against the white of the eye. The probe freezes all layers of the eye, from the white of the eye (the sclera) all the way in to the retina. The purpose of cryopexy is to create a scar around any tears in the retina. Using the analogy to wallpaper, cryopexy is like placing staples around a hole in the wallpaper so that nobody can put his/her hand through the hole and pull the wallpaper off the wall.

2. Placement of a band around the eye
This band is usually made of soft silicone and resembles a fetuccini noodle (it is nearly flat and only a few millimeters wide). The band is placed around the eye and attached to the white of the eye using small sutures. Its ends are fastened together so that it stays on the eye. This band is sometimes referred to as “the buckle.” Its purpose is to indent the wall of the eye, similar to pushing the wall toward the wallpaper, in order to reattach the retina to the inner wall of the eye. In some cases, larger scleral buckles are placed around the eye, depending on the preference of the surgeon. These larger buckles are sometimes described as “tires”. In some cases, especially if the retinal detachment only involves one quadrant of the retina, a small sponge is placed against the sclera to indent the eye wall beneath the retinal tear. These are known as “segmental” buckles. Whether an encircling or segmental buckle is used, the band, tire or sponge is fastened to the sclera with sutures to hold it in the appropriate position.

3. Drainage of fluid from beneath the retina
This step is sometimes omitted, based on the surgeon’s preference. It involves creating a small hole in the sclera to allow the fluid behind the retina to drain out, accelerating the reattachment of the retina. In some cases, a blade is used to make a tiny incision in the sclera, while some surgeons prefer to place a needle through the sclera to drain the fluid.

4. Injection of a gas bubble inside the eye
Like drainage of fluid from beneath the retina, this step is also sometimes omitted, depending on the circumstances. The purpose of such a bubble is to cover the tear in the retina, thereby facilitating reattachment of the retina, as in pneumatic retinopexy.

What is the success rate of a scleral buckle?

There is approximately a 90% chance of successfully reattaching the retina with a scleral buckle. In cases when the retina does not reattach after the first procedure, other options exist for reattaching the retina. Sometimes, a gas bubble can be injected into the eye in the office to complete the reattachment. In other cases, vitrectomy surgery is needed.

Some patients have a tendency to develop scar tissue on the surface of the retina, even if it is successfully reattached. This scar tissue, known as proliferative vitreoretinopathy (PVR), develops in sheets on the retinal surface and can pull on the retina, causing it to re-detach. Vitrectomy would be needed to re-attach the retina in such a case. Sometimes, the PVR is so severe that several procedures are necessary to re-attach the retina, and in rare cases, the retina cannot be successfully re-attached despite extensive surgical intervention. Fortunately, PVR is uncommon.

What is the visual outcome of scleral buckling?

We describe retinal detachments as “macula-on” or “macula-off”. A macula-on retinal detachment has not yet involved the central part of the retina (the macula). If the macula never detaches, the chance of regaining good visual acuity after surgery (assuming that the retina is successfully re-attached) is better than if the macula has become detached. Patients can usually tell if the macula has become detached. If the central, detailed vision is still fairly good, the macula is probably still attached. On the other hand, if the central vision has become quite blurred, the macula is probably detached.

A patient who has undergone a scleral buckle will eventually need an adjustment in the prescription for his/her glasses, because the encircling band lengthens the eye slightly. Think of a water balloon. If you were to place a tight rubber band around the middle of the balloon, the water would be pushed to either side of the rubber band and the balloon would lenghthen. A scleral buckle has a similar, but much more subtle, effect on the eye. When the eye becomes longer, it becomes more near-sighted. For this reason, a new prescription is almost always needed following a scleral buckle. The doctor typically waits a few months after surgery to recommend an adjustment in the prescription, as the prescription can change slightly within a couple of months of scleral buckling.

How much pain should you expect after surgery?

A scleral buckle can cause pain, but it is usually controlled by prescription medication. Although the pain can be fairly severe, it is quite variable; some patients feel almost no discomfort. If there is severe pain, it is usually more tolerable by the day after surgery and often resolves within a week.