Disclosures Is there a role for scleral buckling in the age of - - PowerPoint PPT Presentation

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Disclosures Is there a role for scleral buckling in the age of - - PowerPoint PPT Presentation

Apr 02, 2024 205 likes •334 views

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

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Jay M. Stewart, MD University of California, San Francisco

Is there a role for scleral buckling in the age of sutureless vitrectomy? Disclosures

  • None

Rhegmatogenous retinal detachment

Vitreous detachment Retinal detachment

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Scleral Buckle Vitrectomy with gas Scleral buckling chosen less and less

Ramulu et al, JAMA Ophthalmology 2010

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Phakic, superior RD

ASRS PAT Survey

Pseudophakic, superior RD

ASRS PAT Survey

Phakic, inferior RD

ASRS PAT Survey

Pseudophakic, inferior RD

ASRS PAT Survey

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Fellowship training Fellowship training Literature: SB vs PPV

  • Heimann et al, Ophthalmology 2009
  • “SPR study”
  • Randomized trial
  • 681 patients, 45 surgeons, 25 centers
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Heimann et al Outcomes: phakic group

  • Primary anatomic success

– SB: 64% – PPV: 64%

Heimann et al Outcomes: phakic group

  • Primary anatomic success

– SB: 64% – PPV: 64%

  • Final success

– SB: 97% – PPV: 97%

Retina-affecting procedures Mean # 0.63 (SB) vs 0.51 (PPV) VA improvements similar in both groups

P > 0.05

Heimann et al Outcomes: pseudophakic group

  • Primary anatomic success

– SB: 53% – PPV: 72%

Heimann et al Outcomes: pseudophakic group

  • Primary anatomic success

– SB: 53% – PPV: 72%

  • Final success

– SB: 93% – PPV: 96%

Retina-affecting procedures Mean # 0.77 (SB) vs 0.43 (PPV) VA improvements similar in both groups

P < 0.05

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Heimann study

  • 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

Procedure costs

Seider et al, AJO 2013

Phakic patient

SB cheaper by 11% Seider et al, AJO 2013

Pseudophakic patient

PPV cheaper by 12% Seider et al, AJO 2013

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Summary

  • Good opportunity for cost-effectiveness

analysis because final outcomes similar between groups

  • SB less expensive in phakic RD
  • PPV less expensive in pseudophakic

RD

Scleral buckling: drawbacks

  • Intraoperative visualization
  • Difficult to teach
  • May take longer if surgeon is not

experienced

  • Risks with drainage, suture passes
  • Possibly delayed reattachment

44-year-old engineer Post-op day 1 Post-op week 1

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Post-op month 3 Post-op year 1

  • Steeper initial

learning curve

  • More difficult to teach
  • Mostly extraocular
  • Age-old techniques
  • Delayed gratification
  • Easier
  • Easier
  • Intraocular
  • New instruments / toys
  • Immediate gratification

Scleral buckle Vitrectomy Scleral buckle Vitrectomy

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Modernizing scleral buckling

Retina, 2015

Potential advantages

  • Allows attending physician to monitor

trainee

  • Operative microscope zoom to inspect

suspicious areas

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

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Recent case

  • 10-year-old boy with bilateral RD

– OD: 20/150 – OS: 20/30

  • Family history of RD
  • Optically empty vitreous
  • Possible dx: Stickler, Wagner

Pediatric RD

  • 104 eyes
  • Mean age 12 y.o.
  • 80% male
  • 60% macula-off

Errera et al, Retina 2015;35:1441-9

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Pediatric RD

  • Technique: segmental element

(84%)+/- encircling band

  • Primary success rate: 73%
  • Final after buckle enhancement: 86%

Errera et al, Retina 2015;35:1441-9

High myopia: recurrent RD

  • 255 eyes
  • Recurrent RD after:

– Single primary SB – Single primary PPV – Multiple surgeries

Ripandelli et al, Retina 2015;35:416-22

High myopia: recurrent RD

Ripandelli et al, Retina 2015;35:416-22

High myopia: recurrent RD

Ripandelli et al, Retina 2015;35:416-22 88% attached after one surgery

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Wills PVR Study Group

  • 65 patients “high risk for PVR”
  • 36 PPV/SB
  • 29 PPV alone

Storey et al, Retina 2014;34:1945-51

Wills PVR Study Group

Storey et al, Retina 2014;34:1945-51

Where is buckle most helpful?

  • Young
  • Phakic
  • Inferior pathology
  • Patient cannot position face down
  • High myopia
  • Proliferative vitreoretinopathy / complex

cases

Future trends

  • Fewer primary buckles
  • Skills will remain alive (sort of) through

combined vitrectomy/buckle cases

  • Chandelier-assisted cryotherapy and

drainage