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6.4 Basic Steps andPrecautions ofScleral Buckling
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Fig. 6.22 Changes in the shape ofocular wallby silicone explants. (a) The ocular wall is nearly
circular when the silicone explant is not tightened. (b) After tightening the encircling band, the
anteroposterior diameter of the vitreous cavity increases, and the anterior chamber becomes
slightly shallower. (c) When suturing the silicone explant, a small suture span produces a ridgewith
a low height and gentle slope. (d) A larger suture span creates a ridgewith greater height and a
steeper slope
8. Close the conjunctival incision:Align the conjunctival incision edges and close
with interrupted or continuous 8–0 absorbable sutures. If tension is high, place a
xation suture at the limbus to prevent slipping. Wounds heal quickly, typically
within 2 weeks, but avoid rough alignment to prevent excessive postoperative
edema and scarring. Conjunctival sutures may be removed promptly to reduce
ocular foreign body sensation.
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6 Surgical Intervention ofRhegmatogenous Retinal Detachment: Part 1 (Scleral…
6.5 Different Operations inScleral Buckling
As noted above, there are considerable variations in the specic techniques of
scleral buckling, and particularly in recent years, several new surgical approaches
have emerged. We will discuss these objectively to broaden our knowledge and
facilitate the more effective application of scleral buckling in addressing practical
clinical challenges.
6.5.1 Break Localization andSealing Under Indirect
Ophthalmoscope andMicroscopes
1. Indirect ophthalmoscope: It provides a three-dimensional, clear fundus image,
facilitating dynamic observation of the cryotherapy effect. It offers advantagein
locating small peripheral breaks undermoderatescleral indentation.
However, the biggest disadvantage of the indirect ophthalmoscope is its
steep learning curve and reverse imaging. It is difficult for beginners to
master it proficiently in a short time. Many beginners often lose confidence
after failing to locate breaks with the indirect ophthalmoscope and then turn
to learning break localization under microscope. This choice is reasonable,
but it does not diminish the importance and necessity of the use ofindirect
ophthalmoscope—especially when diagnosing and treating pediatric
vitreoretinaldisorders.
2. Microscope: Moststeps ofare performed undermicroscope. The surgeon does
not need to use an indirect ophthalmoscope for break localization or cryotherapy, ensuring theprocedural consistency. This technique is particularly
useful in medical institutions that lack access to an indirect
ophthalmoscope.
Because the procedure is performed under the microscope, the highest
point of the peripheral retina must be depressed to bring it close to the visual
axis. This is difcult to achieve without scleral drainage. Therefore, this technique places high demands on drainage. However, beginners should avoid
pursuing maximal efcacy of subretinal drainage at the expense of
safety.Additionally, for some small breaks, if the neurosensory retina is not
frozen to bewhite enough, the break may be difcult to visualize clearly. As
a result, the total cryoenergy delivered during break localizationand cryotherapymay be excessive.
Mastering the indirect ophthalmoscope requires overcoming a steep learning
curve. However, if we approach it as an essential career skill and actively learn
6.5 Dierent Operations inScleral Buckling
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it—just as no novice ophthalmologist would give up learning slit-lamp biomicroscopy despite similar difculty—the lasting and profound sense of fulllment it brings will be well worth the effort. At the same time, microscopic scleral
buckling also offers distinct advantages. Beginners should remain objective and
open-minded, trying different techniques in clinical practice to nd the approach
that best suits you.
6.5.2 Subretinal Fluid Drainage
From the surgeon’s perspective, the decision to perform subretinal uid drainage
depends on two major factors: (1) The specic surgical philosophy the surgeon
follows; and (2) The clinical balance between its potential advantages and inherent risks. All other secondary considerations revolve around these two fundamental pillars. By carefully examining these factors from both the patient’s clinical
status and the surgeon’s technical perspective, a well-informed nal decision can
be reached.
(1) Concepts
The Custodis–Lincoff school has demonstrated through long-term practice that
scleral buckling can achieve a high success rate without subretinal uid drainage—
even when the retinal break remains unclosed at the end of the procedure. As
explained earlier by Bernoulli’s equation, the buckling effect around the break promotes retinal reattachment. If the buckle is placed appropriately, subretinal uid
will be gradually absorbed over one or several days after surgery (Fig.6.23).
Based on the principle of maximizing benets while minimizing risks—although
the probability of choroidal hemorrhage caused by subretinal uid drainage is low
(approximately 10%)—this school emphasizes that it should be avoided whenever
possible.
The Schepens school believes that subretinal uid drainage enables more accurate sealing of the retinal break during surgery, results in more denitive scar formation, and does not require an excessively high buckle to seal the break. Especially in
patients with relatively viscous subretinal uid, drainage promotes complete retinal
reattachment. Regarding potential complications, this school believes that the benets signicantly outweigh the risks. As long as proper surgical techniques are followed, the probability of complications such as choroidal hemorrhage remains
low—there is no need to “abandon eating for fear of choking.”
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6 Surgical Intervention ofRhegmatogenous Retinal Detachment: Part 1 (Scleral…
a
b
c
Fig. 6.23 Preoperative and postoperative fundus images of scleral buckling without subretinal
uiddrainage. (a) Preoperative oval hole and multiple degenerative lesions in the superotemporal
area; corrected visual acuity was 0.1. The patient was monocular, so it was ultimately decided not
to perform subretinal uid drainage. (b) Twelve hours after scleral buckling, subretinal uid was
partially absorbed; the silicone buckle was faintly visible, and the break was located above the
buckle. (c) Half a month after surgery, the retina was completely attached, the break was fully
apposed to the silicone buckle, and corrected visual acuity was 0.8
(2) Advantages and Disadvantages
1. Advantages of subretinal uid drainage: (1) Directly reduces the volume of
subretinal uid, thereby enhancing its absorption; (2) Brings the retinal break
into closer proximity with the underlying retinal pigment epithelium (RPE),
thereby facilitating the effective application of cryotherapy; and (3) Lowers
intraocular pressure, which can aid in the precise localization and effective
sealing of small peripheral retinal breaks.
2. Disadvantages of subretinal uid drainage: (1) Signicant increase in the risk
of choroidal hemorrhage, where small hemorrhages outside the macula generally resolve spontaneously, but severe hemorrhage can result in devastating
visual loss and make secondary surgery extremely challenging (Fig.6.24); (2)
High risk associated with the drainage site selection, as drainage from areas
with limited subretinal uid or proximity to high-risk structures like vortex
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6.5 Dierent Operations inScleral Buckling
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veins remains hazardous regardless of surgical skill; (3) High incidence of
complications secondary to a sudden drop in intraocular pressure, including
globe collapse and choroidal detachment; (4) Potential for retinal perforation
leading to iatrogenic breaks, though the incidence remains low; and (5) Risk of
retinal incarceration or vitreous prolapse, which occurs with very low
frequency.
(3) Selection of DrainingLocation
If the surgeon decides to perform subretinal uid drainage, a 2-mL syringe needle may be used to puncture the sclera, or a sharp blade may be used for oblique
puncture. When subretinal uid is observed to ow out, a cotton swab or forceps
can be used to gently depress the ocular wall to facilitate further uid egress. If
no uid ows out after puncture, do not manipulate the incision signicantly to
avoid choroidal hemorrhage. Indirect ophthalmoscopy can be used to reassess
the location of subretinal uid elevation, and an alternative safe drainage site
may be selected for puncture.
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Fig. 6.24 Postoperative fundus images of choroidal hemorrhage during scleral buckling. (a)
Intraoperative fundus examination revealed subretinal hemorrhage. The patient was immediately
instructed to maintain a left lateral decubitus position after surgery. On the rst postoperative day,
fundus examination showed that the retina was essentially attached, the break was well sealed, and
the hemorrhage was predominantly in the temporal area. As the hemorrhage did not signicantly
involve the macula, the patient’s vision recovered well (corrected visual acuity 0.5), although the
patient complained of a xed black scotoma. (b) Fundus reexamination six months after surgery
showed complete retinal attachment and complete resolution of the subretinal hemorrhage.
Because a 6/0 absorbable suture was used to secure the silicone explant, the silicone buckle had
completely disappeared after the suture degraded (corrected visual acuity 1.0). (c) OCT at six
months postoperatively revealed an intact and continuous ellipsoid zone in the macular area, but
the ellipsoid zone was absent in the slightly temporal region (red arrow), which was attributed to a
toxic reaction caused by the subretinal hemorrhage
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6 Surgical Intervention ofRhegmatogenous Retinal Detachment: Part 1 (Scleral…
Regardless of the drainage method used, the following principles should be followed to select the optimal drainage site: (1) The drainage point must be located
within the area of greatest subretinal uid detachment; (2) Avoid the 3 o’clock and
9 o’clock positions to protect the long posterior ciliary arteries and long ciliary
nerves; (3) Avoid the areas surrounding the vortex veins to minimize hemorrhagic
risk; (4) The zones one clock hour above and below the medial and lateral rectus
muscles are considered the safest for drainage (Fig.6.25); (5) Maintain an appropriate distance from the limbus, as being too close results in low drainage efciency
while being too far increases the risk of choroidal hemorrhage—a distance of
10–12mm from the limbus is generally preferable; and (6) Prioritize safety above
all, and do not persist with the attempt if signicant technical difculties arise.
6.5.3 Scleral Encircling
For patients with extensive retinal degeneration—particularly adolescents with
underlying conditions such as familial exudative vitreoretinopathy (FEVR) or
Stickler syndrome—the risk of peripheral vitreous traction and contraction is relatively high. Scleral encircling may be considered in such cases (Fig. 6.26).
Alternatively, peripheral retinal laser photocoagulation can be performed preoperatively or postoperatively to seal the degenerative areas and prevent the formation of
new breaks.
The following points should be noted during xation of the encircling band: (1)
Ensure that the encircling band passes completely under the rectus muscles;
Fig. 6.25 Subretinal uid drainage. (a) Puncture slightly above the lateral rectus muscle using
oblique needle insertion; the chord length from the puncture site to the limbus is approximately
12mm (green line). (b) Successful drainage of subretinal uid: gently depress the scleral wound
with the needle to facilitate further uid egress; no signicant bleeding is observed during the
procedure
6.5 Dierent Operations inScleral Buckling
Fig. 6.26 Fundus image after scleral buckling. The patient underwent encircling with scleralbuckling for retinal detachment in the right eye over 30 years ago (at age 20). The surgical ridge is well
in position. No recurrent retinal detachment was observed during long-term follow-up.
Subsequently, his daughter developed the same type of retinal detachment, and genetic testing
conrmed that both were diagnosed with Stickler syndrome(COL2A1 gene mutation)
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carefully verify that it does not compress any portion of the muscles; (2)Adjust the
anteroposterior suture distance according to the position of the silicone explant to
ensure that the encircling buckle remains parallel to the limbus; (3) Reasonably
adjust the tightness of the encircling band based on the band’s position and the axial
length of the surgical eye. A mild scleral indentation is preferred; excessive tightening may cause axial elongation, adversely affecting anterior segment perfusion and
potentially progressing myopia; (4) If intraocular pressure becomes excessively
elevated, perform anterior chamber paracentesis promptly to maintain normal intraocular pressure.
6.5.4 Modified Methods inScleral Buckling
In recent years, several modied scleral buckling techniques have emerged, including the following: (1)Using a 25G endoilluminator to visualize the break position,
assess the degree of cryopexy, and verify the correct placement of the silicone
buckle from an internal approach; (2)Using a 25G light ber combined with an
external scleral cryoprobe to localize and seal the break; (3) Internal buckling: incising the sclera beneath the break and injecting viscoelastic material into the subscleral space to create a temporary buckling ridge under the break (this method
typically requires internal illumination). These modied techniques have enriched
the scope of scleral buckling. However, because they involve entry into the vitreous
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cavity, attention must be paid to incision maintenance during surgery to prevent
complications such as wound leakage and vitreous incarceration.
6 Surgical Intervention ofRhegmatogenous Retinal Detachment: Part 1 (Scleral…
6.5.5 Modified Suturing Technique toProduce Temporary
Scleral Buckling Effect forNoncomplex Rhegmatogenous
Retinal Detachment
The modied buckling technique was proposed by the author (Zhang) in 2024.
It uses both nonabsorbable and absorbable sutures to create a temporary scleral
buckling effect for noncomplex rhegmatogenous retinal detachment. This technique provides an adequate buckling effect while inducing minimal permanent
refractive changes. Figure6.27 shows the main steps of this technique.
This technique offers a distinct advantage: it does not cause signicant changes
in axial length or refractive power. After the absorbable suture has been absorbed,
the shape of the eyeball remains essentially unchanged (Fig.6.28), and the risk of
inducing or exacerbating anisometropia is relatively low. However, its long-term
efcacy, safety, and optimal indications require further validation.
ef
6.5 Dierent Operations inScleral Buckling
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d
Fig. 6.27 Key steps of the technique using a combination of nonabsorbable and absorbable
sutures to produce a temporary buckling effect. (a) The segmental silicone tire is xed to the sclera
with a 5-0 nonabsorbable suture (green arrow). (b) After the 5-0 nonabsorbable suture is tied
(green arrow), 6-0 absorbable sutures are added to tighten the silicone tire and create a scleral ridge
(white arrow). (c) One end of the silicone tire is xed to the sclera with a 5-0 nonabsorbable suture
(green arrow). (d) The other end of the silicone tire is xed to the sclera with a 5-0 nonabsorbable
suture (green arrow). (e) A silicone sleeve (green arrow) is used to hold the two ends of the encircling band, which are then tightened with a 6-0 absorbable suture. (f) After a 5-0 nonabsorbable
suture is tied to secure the band in place (green arrow), the silicone sleeve is removed. The 6-0
absorbable suture then becomes the only element tightening the two ends of the band
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6 Surgical Intervention ofRhegmatogenous Retinal Detachment: Part 1 (Scleral…
Fig. 6.28 Typical case who underwent the suturing technique with both segmental silicone tire
and encircling band. (a) Before surgery, a retinal tear (white arrow) and supercial macula-off retinal detachment were observed, with an axial length 26.97 mm. (b) One day after the surgery, retinal reattached, with an obvious scleral ridge. (c) One month after surgery, the ridge was still
present and in situ.(d) Three months after surgery, the retina remains attached, the scleral ridge is
basically resolved, axial length 26.99mm, corrected visual acuity 1.0
6.6 Postoperative Complications andManagement
ofScleral Buckling
Aside from choroidal hemorrhage, scleral buckling is generally safe when proper
surgical techniques are followed; however, several postoperative issues still warrant
close attention.
6.6.1 Persistent Subretinal Fluid
Subretinal uid may persist for an extended period in certain patients, particularly
in cases involving: (1) Adolescents; (2) Chronic retinal detachment; and (3)
Situations where no drainage or insufcient drainage of subretinal uid was