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6.6 Postoperative Complications andManagement ofScleral Buckling
131
performed. When persistent subretinal uid is encountered, the peripheral retina
must be carefully examined to conrm that the primary break is completely apposed
to the buckle. If the break is well sealed and no additional breaks are identied, the
subretinal uid will typically resolve over time. Although this absorption process
may be quite slow, the patient’s visual acuity generally remains stable—as the
trapped subretinal uid can provide a relatively stable environment for neurosensory retinal metabolism—and no further intervention is required.
6.6.2 Recurrent Retinal Detachment
First, observe whether the primary break is well sealed, then determine the presence
of missed or new breaks, and nally formulate a secondary surgical plan based on
the clinical ndings. Lincoff’s Rules can be used to assess whether missed or new
breaks are present.
If the primary break is located superiorly (between the 8:00 and 4:00 o’clock
positions), intravitreal gas injection may be considered. Inject a small volume of
ltered air or an inert gas (e.g., 0.2 mL of C₃F₈), combined with appropriate head
positioning, to allow the gas bubble to seal the break and promote retinal apposition.
This method is particularly suitable for “sh-mouth” breaks that remain unclosed.
If the buckle is improperly positioned, revision surgery may be performed to
adjust the position of the silicone explant. However, due to the signicant postoperative inammatory response, attention should be paid to intraoperative analgesia
and hemostasis (Fig. 6.29). If new breaks occur or PVR develops, an internal
approach may be required to achieve retinal reattachment.
6.6.3 Elevated Intraocular Pressure
Most cases are temporary and spontaneously resolve. However, a few cases may be
pathological, generally due to the following causes: (1) Anterior chamber shallowing caused by the explant (e.g., anterior displacement of the ciliary body); (2)
Obstruction of the choroidal venous outow pathway for aqueous humor; (3)
Preexisting undiagnosed glaucoma, which may be exacerbated postoperatively;
and (4) Pupillary block from various factors (e.g., extensive posterior iris synechiae). Persistent intraocular pressure elevation can lead to irreversible visual
damage. If intraocular pressure remains uncontrolled despite appropriate measures
such as mydriatics, anti-inammatory agents, and ocular hypotensive medications,
the patient should be promptly referred to the glaucoma service for further
management.
132
ab
6 Surgical Intervention ofRhegmatogenous Retinal Detachment: Part 1 (Scleral…
c d
Fig. 6.29 Preoperative and postoperative images of secondary silicone explant adjustment. (a)
Primary retinal break located in the temporal area of the left eye. (b) Fundus examination on the
rst day after scleral buckling surgery shows that the retina remains detached and the scleral buckle
is malpositioned. (c) During revision surgery, after incising the conjunctiva, suture slippage is
noted, and the groove of the silicone explant is not aligned. Re-suturing is performed, and approximately 0.5 mL of ltered air is injected. The patient is instructed to maintain a right lateral decubitus position for one day. (d) Fundus examination on the rst postoperative day shows that the break
is well sealed and the silicone buckle is properly positioned
6.6.4 Anterior Segment Ischemia
The incidence of this complication is extremely low. To prevent it, the rectus muscles should be handled with care during surgery, and the encircling band should not
be excessively tightened. The main manifestations include a severe ischemic inammatory response in the anterior chamber, such as corneal edema, anterior chamber
are, brous exudation, and even iris neovascularization, along with acute intraocular pressure elevation. Mild cases may be managed with systemic and topical glucocorticoids; however, the prognosis for severe cases is often poor. In such instances,
thescleral explants should be removed promptly, and symptomatic treatment should
be administered.
6.6 Postoperative Complications andManagement ofScleral Buckling
Fig. 6.30 Extrusion of the
silicone tire and
encircling band
133
6.6.5 Explant Displacement andExtrusion
If the explant penetrates the conjunctiva and becomes exposed (Fig. 6.30), the
patient may complain of signicant foreign body sensation, and some cases may
present with concurrent ocular surface infection. Prompt removal of the implant is
necessary. However, due to severe scarring and bleeding during removal, careful
sharp dissection is required to maintain a clear surgical eld and avoid damaging the
extraocular muscles or the ocular wall.
6.6.6 Extraocular Muscle Dysfunction
This complication may manifest as abnormal ocular motility, strabismus, or diplopia; while these ndings are typically transient, they may become permanent in a
small number of cases. Possible causes include: (1) Severe iatrogenic injury to the
extraocular muscles during surgery; (2) Extensive adhesions forming between the
extraocular muscles, Tenon’s capsule, and the sclera; and (3) Splitting or compression of the extraocular muscles by the explant. During surgery, meticulous attention
must be paid to protecting the extraocular muscles, maintaining a clear surgical
eld, and strictly avoiding muscle damage during sharp dissection.
6.6.7 Refractive Changes
Postoperative refractive changes are a frequently criticized complication of scleral
buckling, most commonly presenting as myopia progression. Some patients may
develop irregular astigmatism. For patients with poor baseline visual acuity, such
changes often do not cause signicant discomfort. However, for patients with good
baseline visual acuity, the resulting anisometropia may cause signicant discomfort, affecting work and daily life. Preoperatively, the spherical refractive power of
both eyes should be examined to determine whether scleral buckling will exacerbate
134
6 Surgical Intervention ofRhegmatogenous Retinal Detachment: Part 1 (Scleral…
the interocular refractive difference. Additionally, the external scleral explant should
not be placed too anteriorly, and the encircling band should not be excessively
tightened.
6.6.8 Common Issues ofRetinal Detachment
Complications such as choroidal detachment, epiretinal membrane, macular
edema, and PVR may occur. These should be managed with either observation or
secondary surgery, depending on the cause and severity of the condition—this
will not be elaborated further here.
6.7 Summary
“As a stone sharpens a blade, turning bluntness into sharpness.”This chapter has
provided a comprehensive overview of scleral buckling, covering its current status,
foundational principles, indications, and key surgical maneuvers. We have navigated through the diverse schools of thought and the management of potential complications, all with the goal of helping the novice surgeon broaden both the depth
and breadth of their professional knowledge. By mastering these fundamental techniques, you are not merely learning a procedure; you are sharpening your clinical
intuition to identify the most effective surgical strategy for each unique patient.The
true charm—and the persistent perplexity—of scleral buckling lies in its unpredictability. Despite our best planning and execution, the outcomes often surprise us,
reminding us of the limits of our control.
Even today, no surgeon can assert with absolute certainty that the retina will be
perfectly reattached by the rst postoperative day. Furthermore, the biological mystery remains: no one can fully explain the subtle, invisible forces that compel the
detached neurosensory retina and the retinal pigment epithelium to “embrace” each
other so tightly once again. As you rene your skills, let this blend of scientic rigor
and clinical wonder guide your growth in this intricate art.
Surgical Intervention
ofRhegmatogenous Retinal
Detachment: Part 2 (Pars Plana
Vitrectomy)
For the treatment of rhegmatogenous retinal detachment (RRD), pars plana vitrectomy (PPV) has become the mainstream approach worldwide. In a narrow sense,
PPV is often referred to as ab interno surgery, primarily to emphasize its fundamentally different approach from scleral buckling. Compared with scleral buckling,
PPV follows a relatively xed operative pattern. Intraocular illumination provides
full, clear visualization of the vitreoretinallesions.The coordinated use of various
intraocular instruments enables direct and precise relief of vitreous traction on the
retina, allowing complete closure of retinal breaks during the procedure. These
advantages largely account for its widespread acceptance among retinal surgeons.
This chapter will focus on introducing conventional surgical techniques for RRD
treatment and will incorporate complex scenarios to explore the precautions and
surgical skills essential for PPV.
7
7.1 Patient Selection forVitrectomy
The vitreous of the human eye occupies most of the volume of the intraocular contents. Vitrectomy involves removing nearly all of this tissue, which is a fundamental
difference from many other surgical subspecialties. The vitreous plays an important
physiological role in the eye. We should not regard it as an insignicant “silent
bystander”, the decision to proceed with vitrectomy must be approached prudently.
“Und wenn du lange in einen Abgrund blickst, blickt der Abgrund auch in dich
hinein (When you gaze long into an abyss, the abyss also gazes into you).” This
metaphor is likely tting here. If we treat the vitreous hastily, it may soon trouble us
in return. In RRD surgery, extensive residual vitreous can lead to serious complications. Therefore, when considering whether to perform vitrectomy, we should rst
consider the purpose of vitreous removal, then the difculty of the procedure, and
nally the potential benets and risks.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2026
Z. Zhang, U. Spandau, Vitreoretinal Surgery,
https://doi.org/10.1007/978-3-032-25271-5_7
135
136
7 Surgical Intervention ofRhegmatogenous Retinal Detachment: Part 2 (Pars Plana…
In the following RRD patients, PPV may be the preferred approach: (1) Extensive
bullous retinal detachment; (2) Older age accompanied by posterior vitreous detachment (PVD) or signicant vitreous liquefaction; (3) Obvious vitreoretinal traction;
(4) Multiple retinal breaks involving different quadrants; (5) Pseudophakic eyes; (6)
Presence of signicant proliferative changes (PVR ≥ C1) (see Sect. 11.2 of Chap.
11 for grading); (7) Severe pre- and subretinal proliferative retinopathy; (8) Giant
retinal tears (GRTs); (9) Macular hole retinal detachment (MH-RD); and (10)
Coexistence of clinically signicant vitreous hemorrhage.
The above relative indications generally align with one of the following three
major principles: (1) The overall surgical difculty and potential risk associated
with achieving an adequate vitrectomy are relatively low; (2) The pathological
changes within the vitreous are sufciently severe to render its pathological impact
greater than its physiological value; and (3) Vitrectomy stands as an unavoidable
clinical measure for the effective management of complex retinal pathologies.
7.2 Why YouShould BeFamiliar withtheUnderlying Logic
ofParameters Settings onVitrectomy Machine
Using 23G and 25G vitrectomy platforms as examples, the main parameters and
precautions are set as follows (Table7.1). The surgeon should adjust them dynamically based on the specic intraoperative conditions.
Beginners must master the parameter settings for infusion, endoillumination, and
vitrectomy, and deeply understand the underlying physical principles and design
logic in order to adapt exibly to special situations.
Table 7.1 Common parameter settings and precautions for vitrectomy
Item
Intravitreal
perfusion
Vacuum 0~500mmHg
Parameter
20~30mmHg
Details
(1) For children and patients with diabetic retinopathy,
hypertension, and glaucoma, the perfusion pressure must
be strictly controlled, and attention must be paid to the
perfusion of the optic disc blood vessels throughout the
process
(2) Notice the hanging height of the liquid bottle and
prevent additional intraocular pressure due to hanging too
high
(3) First, empty the air in the entire perfusion line before
connecting to the infusion trocar
(4) Prevent excessive curling and folding of the perfusion
line
(1) The vacuum level is typically set to increase linearly
with foot-pedal depression depth
(2) Maintaining a large vacuum difference makes it easier
for beginners to adjust precisely through the pedaling
depth
(continued)
7.3 Fundamental Steps andKey Precautions 138
137
Table 7.1
Item
Cutting rate 5000~2500cpm
Endoilluminator 30%~40%
Diathermy 10%~20%
(continued)
Parameter
Details
(1) Under constant vacuum, vitrectomy with higher speed
is safer to remove the peripheral vitreous
(2) Under constant vacuum, vitrectomy with a relatively
lower speed is more effective to remove the vitreous; the
surgeon can adjust the vacuum level to shave the central
vitreous but must be careful to avoid iatrogenic retinal
breaks
(3) Beginners can fix the speed at 5000cpm. At this time,
they only need to pay attention to controlling the vacuum,
which will make things simpler for beginners
(1) Pay attention to the bulblife. The maximum
illumination brightness of a newly replaced bulb is
relatively high (when set to 100%). At this time, do not
increase the illumination brightness at will to avoid retinal
phototoxicity
(2) Avoid direct exposure to the macular for a long time
(3) If the bulb is aging, the parameters can be
appropriately increased, but not arbitrarily increased to a
higher level. The surgeon can first shine the light on
himself to test the brightness. If there is a glare like the
direct exposure of a car’s high beam, the brightness must
be reduced
(1) Should be prepared at all times, because if bleeding
occurs during surgery, it must be stopped in time
(2) The diathermy pen is a fragile accessory, so it can be
checked before use and must be equipped with sufficient
supplies
(3) Always begin with the lowest energy setting
7.3 Fundamental Steps andKey Precautions
For noncomplextRRD surgery, as long as the surgeon strictly adheres to standard
surgical protocols, the surgical success rate will be satisfactory.Anesthesia and trocar insertion techniques have been described in detail in previous chapters; therefore, this section will focus only on otherbasic steps.
7.3.1 Cutting Central Vitreous
First, insert the cutter and endoilluminator into the vitreous cavity. Hold the intraocular instruments rmly with both hands to avoid iatrogenic damage. Adjust the
microscope (rst focus, then magnication). The surgeon can simultaneously assess
whether the vitreous adheres tightly to the underlying retina (i.e., whether a Weiss
ring is present), thereby roughly predicting the difculty and planning the following
steps(e.g., whether to prepare triamcinolone acetonide for vitreous staining). First,
insert the cutter and endoilluminator into the vitreous cavity.
7 Surgical Intervention ofRhegmatogenous Retinal Detachment: Part 2 (Pars Plana…
7.3.2 Confirming or Creating Posterior Vitreous Detachment
In younger patients or those with high myopia, posterior vitreous detachment (PVD)
is often deceptive. Triamcinolone acetonide (TA) can be used to repeatedly conrm
the presence of PVD and to identify any residual vitreous.
7.3.3 Relieving Traction onPrimary Retinal Breaks
After removing the central vitreous, the vitreous around the retinal breaks should
be removed with the cutter while maintaining a high cutting rate and low vacuum. The vitreous between the anterior edge of the breaks and the ora serrata
must be removed as completely as possible, as it is the most direct factor in the
formation of retinal tears. This maneuver helps restore retinal mobility. If the
breaks are located peripherally, the procedure must be performed under scleral
indentation with bimanual instrument exchange; otherwise, lens injury is very
likely (Fig.7.1).
ab
Fig. 7.1 Relieving vitreous traction on retinal aps. (a) Without scleral indentation, the peripheral
vitreous on the anterior ap of the tear could not be well visualized. (b) Under scleral indentation,
the peripheral vitreous was well exposed to the surgeon
7.3 Fundamental Steps andKey Precautions
139
7.3.4 Examination ofthePeripheral Retina (Generally
Performed Simultaneously withStep 5)
We must apply a “zero-tolerance” principle to peripheral retinal abnormalities in
order to maximize the long-term postoperative success rate. We recommend performing a 360° peripheral inspection with scleral indentation. For beginners, scleral
indentation must be applied to 100% of retinal detachment cases.
“Snatching defeat from the jaws of victory.” Why must we be so persistent?
Because in vitrectomy, the tolerance for missed retinal degenerative areas or breaks
is extremely low.
7.3.5 Removing Peripheral Vitreous
While exploring the peripheral retina, the “skirt” of peripheral vitreous can be
removed simultaneously. This maximizes the restoration of retinal mobility and
helps prevent traction and breaks caused by postoperative vitreous contraction
(Fig.7.2).
All efforts are not in vain; hardships temper one into success. The inferior vitreous deserves special attention: if not adequately removed, RPE cells dispersed into
the vitreous cavity can accumulate there under gravity, eventually becoming a nidus
for proliferation.
ab
Fig. 7.2 Exploring peripheral retina under scleral indentation. (a) Identifying small inferior
breaks andapplying laser photocoagulationto the peripheral break. (b) Discovering multiple inferior RPE cell deposits
140
7 Surgical Intervention ofRhegmatogenous Retinal Detachment: Part 2 (Pars Plana…
7.3.6 Reattaching theRetina
Since a detached retina cannot reattach spontaneously, external forces are required
to reattach it. For beginners, this is the step where complications are most likely to
occur during the entire procedure. The two most commonly used methods for retinal reattachment are uid/air exchange and heavy liquid tamponading.
Before performing retinal reattachment, do not rush. First, patiently remove the
vitreous and maximize retinal mobility. Strictly speaking, the retina is not “blown”
back by air or “pressed” back by heavy liquid; these methods only “squeeze” subretinal uid out through the breaks. Good retinal mobility is an important
prerequisite.
With a wide-eld surgicallens, retinal reattachment can generally be achieved
through uid/air exchange. A small amount of residual subretinal uid at the posterior pole can be completely absorbed within a short period. In most cases, there is
no need to inject heavy liquid or create a hole for subretinal draining. Beginners are
prone to hesitation at this stage. As long as the retinais well attached with the underlying RPE,wecanproceed to the next step without overdoing it.
7.3.7 Sealing Retinal Breaks
(1) Laser and Cryotherapy
Retinal laser photocoagulation is typically used to close breaks due to its precision
and mild inammatory response. Cryotherapy in PPVis rarely used today, but it
remains highly effective—especially for small peripheral breaks that are difcult to
fully expose.
(2) Role of Laser
Laser photocoagulation relies on the photothermal effect. When the target tissue
absorbs intense light, the local tissue temperature rises sharply, denaturing proteins and inducing scar formation. Excessive laser energy causes photovaporization, leading to the evaporation of intracellular and extracellular water and
potentially resulting in iatrogenic small retinal breaks. This should be avoided
whenever possible. If it occurs, laser energy must be reduced immediately, and
a small number of laser spots should be placed around the small breaks to
seal them.
Substances in fundus tissues that absorb laser energy include: (1) Melanin, present in retinal pigment epithelium (RPE) cells and the choroid, which primarily
absorbs wavelengths between 400 and 700 nm; (2) Lutein, concentrated in the macula, which protects photoreceptor cells by ltering short-wavelength light; and (3)
Hemoglobin, whose laser absorption characteristics depend primarily on its oxygen
saturation levels.