Disclosures Is there a role for scleral buckling in the age of sutureless vitrectomy? • None Jay M. Stewart, MD University of California, San Francisco Rhegmatogenous retinal detachment Retinal detachment Vitreous detachment 1
Scleral Buckle Scleral buckling chosen less and less Vitrectomy with gas Ramulu et al, JAMA Ophthalmology 2010 2
Phakic, superior RD Pseudophakic, superior RD ASRS PAT Survey ASRS PAT Survey Phakic, inferior RD Pseudophakic, inferior RD ASRS PAT Survey ASRS PAT Survey 3
Fellowship training Fellowship training Literature: SB vs PPV • “ SPR study ” • Heimann et al, Ophthalmology 2009 • Randomized trial • 681 patients, 45 surgeons, 25 centers 4
Heimann et al Heimann et al Outcomes: phakic group Outcomes: phakic group • Primary anatomic success • Primary anatomic success – SB: 64% – SB: 64% – PPV: 64% – PPV: 64% Retina-affecting procedures • Final success – SB: 97% Mean # 0.63 (SB) vs 0.51 (PPV) – PPV: 97% P > 0.05 VA improvements similar in both groups Heimann et al Heimann et al Outcomes: pseudophakic group Outcomes: pseudophakic group • Primary anatomic success • Primary anatomic success – SB: 53% – SB: 53% – PPV: 72% – PPV: 72% Retina-affecting procedures • Final success – SB: 93% Mean # 0.77 (SB) vs 0.43 (PPV) – PPV: 96% P < 0.05 VA improvements similar in both groups 5
Heimann study Procedure costs • Pros – Largest randomized study SB vs PPV – Only one with a phakic group • Cons – Low primary success rates – Incomplete information on re-ops – Vague re: cataract Seider et al, AJO 2013 Phakic patient Pseudophakic patient SB cheaper by 11% PPV cheaper by 12% Seider et al, AJO 2013 Seider et al, AJO 2013 6
Summary Scleral buckling: drawbacks • Good opportunity for cost-effectiveness • Intraoperative visualization analysis because final outcomes similar • Difficult to teach between groups • May take longer if surgeon is not • SB less expensive in phakic RD experienced • PPV less expensive in pseudophakic • Risks with drainage, suture passes RD • Possibly delayed reattachment 44-year-old engineer Post-op week 1 Post-op day 1 7
Post-op month 3 Post-op year 1 Vitrectomy Scleral buckle Scleral buckle Vitrectomy • Steeper initial • Easier learning curve • More difficult to teach • Easier • Mostly extraocular • Intraocular • Age-old techniques • New instruments / toys • Delayed gratification • Immediate gratification 8
Modernizing scleral buckling Potential advantages • Allows attending physician to monitor trainee • Operative microscope zoom to inspect suspicious areas Retina , 2015 Chandelier-assisted buckling • 14 patients in each group • Reduction in surgical time in chandelier group compared to standard technique (78 vs. 95 minutes) Narayanan et al, Retina 2015 9
Recent case Pediatric RD • 10-year-old boy with bilateral RD • 104 eyes – OD: 20/150 • Mean age 12 y.o. – OS: 20/30 • 80% male • Family history of RD • 60% macula-off • Optically empty vitreous • Possible dx: Stickler, Wagner Errera et al, Retina 2015;35:1441-9 10
Pediatric RD High myopia: recurrent RD • Technique: segmental element • 255 eyes (84%)+/- encircling band • Recurrent RD after: • Primary success rate: 73% – Single primary SB • Final after buckle enhancement: 86% – Single primary PPV – Multiple surgeries Ripandelli et al, Retina 2015;35:416-22 Errera et al, Retina 2015;35:1441-9 High myopia: recurrent RD High myopia: recurrent RD 88% attached after one surgery Ripandelli et al, Retina 2015;35:416-22 Ripandelli et al, Retina 2015;35:416-22 11
Wills PVR Study Group Wills PVR Study Group • 65 patients “high risk for PVR” • 36 PPV/SB • 29 PPV alone Storey et al, Retina 2014;34:1945-51 Storey et al, Retina 2014;34:1945-51 Where is buckle most helpful? Future trends • Young • Fewer primary buckles • Phakic • Skills will remain alive (sort of) through combined vitrectomy/buckle cases • Inferior pathology • Chandelier-assisted cryotherapy and • Patient cannot position face down drainage • High myopia • Proliferative vitreoretinopathy / complex cases 12
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