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Twenty-Year Follow-up for Scleral Buckling
Stephen G. Schwartz, MD;
Derek P. Kuhl, MD, PhD;
Alice R. McPherson, MD;
Eric R. Holz, MD;
William F. Mieler, MD
Arch Ophthalmol. 2002;120:325-329.
ABSTRACT
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Objective To the report 20-year follow-up data for patients receiving a scleral
buckle for treatment of a primary rhegmatogenous retinal detachment (RRD).
Methods Nonconsecutive, retrospective case series. We identified 227 eyes with
primary RRD who were treated with a scleral buckle, and for whom at least
20 years of follow-up data were available. Results were classified into 3
subgroups: retina reattached with 1 procedure; retina reattached with 1 or
more additional vitreoretinal procedures; or retina detached at 20 years.
Results One hundred eighty-six eyes (82%) achieved retinal reattachment with
1 scleral buckling procedure and with a median final visual acuity of 20/40
at 20 years of follow-up. An additional 30 eyes (13%) achieved retinal reattachment
after 1 or more additional vitreoretinal procedures, with a median final visual
acuity of 20/50. Eleven eyes (5%) were detached at the 20-year follow-up examination,
with a final visual acuity in all eyes of no light perception.
Conclusions Scleral buckling for primary RRD achieves anatomical efficacy and preservation
of central vision in the majority of eyes at 20 years' follow-up. The 1-operation
success rate was 82%, overall success rate was 95%, and median final visual
acuity was 20/40. This study may serve as a basis for comparison with the
long-term results of other surgical techniques used in the treatment of primary
RRDs.
INTRODUCTION
PLACEMENT of a scleral buckle (SB) is the most established technique
for the treatment of primary rhegmatogenous retinal detachment (RRD). Although
Gonin1 developed the principles of retinal
reattachment in the early 20th century, modern scleral buckling procedures
date to the 1950s and the work of Custodis,2
Schepens et al,3 and Arruga.4
There is currently a wealth of information supporting the short-term efficacy
of this procedure, but there is a relative paucity of long-term data. In a
review of 7 articles reporting on 4940 eyes, Wilkinson and Rice5
reported a 75% to 91% success rate with a single operation and an 88% to 97%
success rate with multiple procedures. Wilkinson and Rice also reported that
39% to 56% of successfully treated eyes attained a visual acuity of 20/50
or better, although this percentage decreased to between 37% and 42% when
only macula-off RRDs were considered. In both of these analyses, however,
the length of follow-up was not discussed.
Tornquist and Tornquist6 reported retinal
reattachment at 10 years' follow-up in 442 (78%) of 566 eyes predominantly
treated with encircling procedures. Reoperations were required in 130 eyes
(23%). Of successful cases, visual acuity was better than 0.5 (20/40) in 34%.
Kreissig et al7 reported that 99 (94%)
of 107 eyes treated with segmental buckling were attached after 11 years and
that 13% of eyes required reoperation during this time frame. Of the 72 eyes
available for follow-up at 15 years, mean visual acuity was 20/40.8
In this study, we report the outcomes of a retrospective, nonconsecutive
series of 227 eyes treated with a scleral buckle for a primary RRD and for
whom at least 20 years' follow-up data were available.
MATERIALS AND METHODS
The medical records at the McPherson Retina Center at Baylor College
of Medicine (Houston, Tex) were reviewed. A total of 227 eyes from 212 patients
met entry criteria for this study: primary RRD, treated with a scleral buckle
by the McPherson Retina Associates, and for which 20 years of follow-up were
available. In this retrospective, nonconsecutive study, no attempt was made
to contact or otherwise retrieve the medical records of patients who were
lost to follow-up during this period.
Eyes with proliferative vitreoretinopathy of grade C or greater, or
with a history of scleral buckle, vitrectomy, posterior segment open-globe
trauma, or significant concurrent eye disease (judged to independently compromise
the postoperative visual acuity such as amblyopia, macular disease, etc) were
excluded.
Eyes were subdivided into 4 groups: phakic macula-on RRDs; phakic macula-off
RRDs; aphakic/pseudophakic macula-on RRDs; and aphakic/pseudophakic macula-off
RRDs. The "macula-off" groups included those eyes in which the fovea was involved
in the RRD. All macula-off RRDs were treated with encircling procedures. Some
macula-on RRDs were treated with segmental procedures at the discretion of
the treating ophthalmologist, and these data were independently recorded and
analyzed.
Each eye was classified into 1 of 3 subgroups; retina reattached with
one scleral buckling procedure ("primary" success); retina eventually reattached
with additional vitreoretinal procedures ("eventual" success); or retina detached
at the 20-year follow-up (failure). For the purposes of this report, we define
"additional vitreoretinal procedures" as those procedures that were definitely
necessary to achieve or maintain retinal reattachment. These included revisions
of the scleral buckle by repositioning the existing buckling elements or adding
new ones (to treat a recurrent or persistent detachment) pars plana vitrectomy,
drainage of choroidal detachment, and/or injection of temporary vitreous adjuncts
(air or gas).
In contrast, for the purposes of this report, "additional vitreoretinal
procedures" specifically excluded those procedures that were frequently performed
during this period but that were not definitely necessary to achieve or maintain
retinal reattachment. This included postoperative supplemental retinopexy
(photocoagulation, xenon arc coagulation, or cryotherapy) and/or loosening
or removal of the scleral buckling elements. A buckle loosening was performed
by sectioning the encircling rod or band, typically as an outpatient procedure
under local anesthesia. The buckling elements were otherwise left in position.
Buckle loosenings were performed either to ameliorate or to lessen the risk
of transcleral (internal) erosion of the encircling elements at the discretion
of the treating ophthalmologist, and in the majority of cases they were performed
as preventative measures prior to any ophthalmoscopic evidence of erosion.
However, removal of the buckling elements involved explantation of some
or all foreign material, including sutures. This procedure was typically performed
to treat an established complication of scleral buckling surgery, such as
infection, transconjunctival (external) extrusion, or ocular motility disturbances.
Preoperative and 20-year postoperative visual acuities were recorded.
When refractions were not available, best-corrected visual acuities were used.
Giant retinal tears were included in their appropriate group (phakic macula-on,
etc), although this small subgroup of patients was also analyzed independently.
Any additional procedures performed to the eye subsequent to the original
scleral buckling operation were also recorded.
RESULTS
Two hundred ten eyes (93%) were treated by cerclage, which in almost
all cases consisted of an encircling element (a silicone rod or band) with
an additional segmental sponge supporting the detached retina. The encircling
element was a rod in 94 eyes (45%), a band in 83 eyes (40%), and could not
be determined by our retrospective review in 33 eyes (16%).
In nearly all cases, cryopexy was the modality used for creating a chorioretinal
adhesion during the initial scleral buckling surgery. However, in a few operations
performed during the early 1960s, diathermy was used; we estimate this percentage
to be no greater than 3%, although we could not precisely determine this figure
with our retrospective review. The summarized data for all groups of patients
are presented in Table 1.
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Summarized Data for All Groups of Patients*
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A total of 227 eyes received treatment for a primary RRD. Of these,
210 eyes (93%) were initially treated with encircling elements. The median
preoperative visual acuity was 20/100 (range, 20/15 to light perception).
One hundred seventy-three eyes (83%) achieved retinal reattachment with 1
encircling procedure; the median 20-year visual acuity was 20/40 (range, 20/20
to light perception). Twenty-seven additional eyes (13%) achieved retinal
reattachment after a median of 1 (range, 1-3) additional vitreoretinal procedure;
the median 20-year visual acuity was 20/30 (range, 20/20 to light perception).
Ten eyes (5%) never achieved retinal reattachment despite a median of 1 (range,
0-2) additional vitreoretinal procedure, and the 20-year visual acuity was
no light perception in all of these eyes.
Seventeen eyes (7.5%) were initially treated with segmental elements.
Of these, the median preoperative visual acuity was 20/25 (range, 20/15 to
counting fingers). Thirteen of these eyes (77%) achieved retinal reattachment
with 1 segmental procedure; the median 20-year visual acuity was 20/30 (range,
20/20-20/100). Three eyes (18%) achieved retinal reattachment after 1 additional
(encircling) vitreoretinal procedure; median 20-year visual acuity was 20/200
(range, 20/20-5/400). One eye (7%) never achieved retinal reattachment despite
3 additional vitreoretinal procedures, with a final visual acuity of no light
perception.
Four eyes had giant retinal tears. No eyes achieved retinal reattachment
with 1 scleral buckling procedure. One eye never achieved retinal reattachment
despite 1 additional vitreoretinal procedure. The other 3 eyes achieved retinal
reattachment after 1 additional vitreoretinal procedure, with a median 20-year
visual acuity of 20/200 (range, 20/25 to counting fingers).
There were no important differences between the anatomical and visual
outcomes when the data were analyzed according to lens status (phakic vs aphakic/pseudophakic)
or macular status (attached vs detached).
Overall, 186 eyes (82%) achieved retinal reattachment with 1 scleral
buckle procedure (encircling or segmental); the median 20-year visual acuity
was 20/40 (range, 20/20 to light perception). Thirty additional eyes (13%)
achieved retinal reattachment with a median of 1 (range, 1-3) vitreoretinal
procedure; the median 20-year visual acuity was 20/50 (range, 20/20 to light
perception). Eleven eyes (5%) never achieved retinal reattachment despite
a median of 1 (range, 0-3) additional vitreoretinal procedures, and the 20-year
visual acuity in all of these eyes was no light perception.
A total of 210 eyes (93%) received 1 or more supplemental treatments
following the initial scleral buckle, with the most frequently employed modalities
being adjunctive photocoagulation or xenon arc therapy in 124 eyes (55%) and
cryotherapy in 28 eyes (12%). Additional procedures included loosening of
the buckling element in 123 eyes (54%), revision of the scleral buckle in
37 eyes (16%), removal of the elements in 20 eyes (9%), and cataract extraction
in 56 eyes (25%).
Of the 56 eyes that underwent subsequent cataract extraction, 3 (5%)
developed recurrent retinal detachment. One was successfully repaired with
1 additional vitreoretinal procedure, and 20-year postoperative visual acuity
was 20/20. The other 2 eyes remained detached at the 20-year follow-up examination
despite 1 additional vitreoretinal procedure each. Visual acuity was no light
perception in both.
Of the 210 eyes initially treated with cerclage, the buckling elements
were loosened in 123 eyes (59%) and removed in 20 eyes (10%). Of the 123 eyes
that underwent loosenings, 53 (43%) showed ophthalmoscopic evidence of transcleral
(internal) erosion at the time of loosening. Median visual acuity at 20 years'
follow-up was 20/40 in the eyes that underwent loosening for erosion, 20/30
in eyes that underwent loosening without prior evidence of erosion, 20/40
in eyes that underwent removal of elements, and 20/40 in eyes that did not
undergo loosening or removal.
No eyes developed a recurrent retinal detachment, vitreous hemorrhage,
or endophthalmitis as a result of the loosening or removal procedures. One
eye (0.8%) developed a choroidal detachment, which was successfully drained,
and 1 eye (0.8%) developed orbital cellulitis, which was managed by removal
of the buckling elements, along with local and systemic antibiotics.
COMMENT
This report is limited to a specific subset of eyes with primary RRD
that was without evidence of preexisting advanced proliferative vitreoretinopathy,
treated with scleral buckling, and with 20 years of available follow-up data.
Because of the specialized nature of this series, direct comparison with other
reports is not possible, but certain comparisons may be made.
The aforementioned rates of retinal reattachment are consistent with
previously published studies. Wilkinson and Rice5
found that, in the short term, 75% to 91% of eyes were reattached with 1 procedure,
and 88% to 97% were reattached with 1 or more reoperations. We report that,
at 20 years' follow-up, 82% of eyes were reattached after 1 operation and
95% were reattached after multiple procedures. It was very rare for a recurrent
retinal detachment to occur beyond 1 year following the initial procedure.
The implication, then, is that a successful scleral buckle procedure tends
to remain stable in the long-term. This finding is consistent with previously
reported data. Tornquist and Tornquist,6 with
a follow-up of 10 years, reported a reoperation rate of 23%, while Kreissig
et al,7 with a follow-up of 11 years, reported
a reoperation rate of 13%. In this study, the rate was 18%.
Regarding visual function, Wilkinson and Rice5
reported that 39% to 56% of eyes achieved a visual acuity of 20/50 or better
in the short-term. Kreissig et al8 reported
a mean visual acuity of 20/40 at 15 years' follow-up in successfully treated
eyes; we present an identical median acuity at 20 years' follow-up. Our visual
acuity data appear to be better than those of Tornquist and Tornquist,6 who found that only 34% of successful cases had visual
acuities better than 0.5 (20/40) at 10 years' follow-up. The conclusion, therefore,
is that a scleral buckle offers long-term stabilization or improvement of
central vision in the majority of eyes with primary RRD. The caveat, however,
is that a significant proportion of eyes may require additional surgical procedures
to maintain this acuity. For example, in our study, 56 eyes (50% of the phakic
eyes and 25% of the total) required cataract extraction during the 20-year
follow-up examination. This of course, is not unexpected, in view of the fact
that these patients were elderly.
We did not find a substantial difference in anatomical nor visual outcomes
if eyes were treated with segmental buckling rather than encircling elements.
In our study, all macula-off RRDs were treated with an encircling element.
While the majority of eyes with macula-on RRDs also received an encircling
element, the percentage of primary successes in phakic macula-on RRDs was
86% in both groups, and the median 20-year postoperative visual acuity was
likewise equal at 20/30 in both groups. Although the percentage of primary
successes in aphakic macula-on RRDs treated with a segmental buckle was 33%,
the sample size of 3 cases in this subgroup analysis is far too small to draw
any valid conclusions. We therefore agree with the work of Kreissig et al7-8 that, in carefully selected patients,
segmental buckling procedures seem to be as efficacious as encircling procedures.
We believe that our report, however, does provide support that the encircling
technique can offer both anatomical and visual stability for the majority
of eyes.
The 4 eyes with giant retinal tears had relatively poor outcomes compared
with the results of the 223 eyes with smaller retinal breaks. Today, giant
retinal tears would most likely undergo vitrectomy, with or without simultaneous
scleral buckling. However, prior to 1980, vitrectomy was not widely used,
and scleral buckling alone would likely have been considered the standard
of care. Therefore, we have included these eyes in this report despite the
relatively poor results.
A weakness of this study is its retrospective and, more importantly,
nonconsecutive nature. These 227 eyes represent only those patients who were
available for follow-up after 2 years, and no attempt was made to contact,
or otherwise retrieve the medical records of patients who were lost to follow-up.
Therefore, these 227 eyes comprise only a subset of all eyes undergoing scleral
buckling during this period, and thus, they may or may not be representative
of the total. It is possible that patients who have good surgical outcomes
(anatomical and/or visual) are more likely to keep long-term follow-up appointments
than patients with poor outcomes; therefore, these data may represent a "best-case"
scenario. Nevertheless, we believe that these results are important because
they illustrate the potential for long-term anatomical and visual successes
from scleral buckling procedures.
An additional point of consideration is the relatively high percentage
of eyes receiving postoperative supplemental retinopexy with photocoagulation
(55%) or cryotherapy (12%) during the first several months following the initial
surgery. This was a common practice of the McPherson Retina Associates during
the 1960s and 1970s, but is performed only infrequently today. The treatment
was applied to reinforce the original chorioretinal adhesion (generally cryopexy,
but rarely diathermy), rather than in response to new postoperative retinal
breaks or detachments. It is therefore not known what the effect would have
been had this supplemental treatment not been administered.
Of interest, Kreissig et al7 subdivided
redetachment into early (occurring 2-4 months after surgery) and late (occurring
3-7 years after surgery). They found that early redetachments were due to
proliferative vitreoretinopathy, and that late redetachments were due to formation
of new retinal breaks. It is possible that postoperative supplemental retinopexy
may have decreased the rate of redetachment in our series, as this problem
was very rare. Of note, only 5% of all eyes undergoing subsequent cataract
extraction during the 20-year follow-up period developed recurrent retinal
detachment, indicating that in carefully selected eyes, cataract surgery following
successful scleral buckling seems to be a fairly safe procedure.
However, the true effect of these supplemental, postoperative retinopexy
treatments cannot be precisely determined. Therefore, these treatments were
excluded from our definition of "additional vitreoretinal procedures."
A related point is the relatively high percentage of eyes undergoing
loosening (54%) or removal (9%) of the buckling elements. The rationale for
loosening of the scleral buckle was at least partly due to the fact that at
least 94 eyes in this series received encircling silicone rods, which have
since been abandoned because of their high rate of transcleral (internal)
erosion. Similarly, almost all eyes undergoing encircling procedures received
silicone rubber sponge exoplants. As compared with hard silicone elements
(eg, tires), sponges have a higher rate of extrusion (external erosion),9-12 though
there is no definite evidence of a higher rate of transcleral (internal) erosion.
A mitigating factor is that of the 123 eyes treated with loosening of
the encircling buckling element, 70 were loosened prior to any ophthalmoscopic
evidence of transcleral (internal) erosion or any other complication. These
preventative procedures, performed at the discretion of the treating ophthalmologist,
involved sectioning of the encircling rod or band under local anesthesia and
without removal of any buckling components. As noted previously, this technique
was commonly performed by the McPherson Associates during the 1960s and 1970s,
but is only rarely used today.
In contrast, removal of the elements involved explantation of some or
all foreign material, including sutures, and this was typically performed
to treat an established complication of the original scleral buckling surgery,
such as a buckle infection, external extrusion, or ocular motility disturbance.
Long-term complications of encircling scleral buckling elements may
include myopia, strabismus, transcleral (internal) erosion, and potentially,
retinal and choroidal ischemia. These risks may be higher in cases requiring
a high buckle effect to reattach the retina (this was more frequent in the
previtrectomy era) and in younger patients, in whom the elements will remain
for many years. Loosening of the elements may prevent many of these complications.
We were unable to demonstrate a significant difference in visual acuity between
eyes that underwent loosening of the elements, removal of the elements, or
neither. However, we believe that loosening of the encircling elements may
provide a more stable long-term anatomic result. Additionally, when the buckle
was loosened or removed, there appeared to be no significant increased risk
of recurrent retinal detachment or other complications. Nevertheless, since
the true effect of these procedures is unknown, they were excluded from our
defined "additional vitreoretinal procedures."
Despite these considerations and potential limitations, this study represents
the longest reported follow-up period for patients receiving a scleral buckle
in the treatment of primary RRD. All patients were followed for at least 20
years, and with the total of 227 eyes, this represents 4540 "buckle years."
This article documents the stability that can be achieved in the majority
of patients receiving this type of treatment.
While surgical techniques are constantly evolving over the years and
buckling materials are also changing, we believe that this article documents
the anatomical and visual stability that can be achieved in this setting.
The results of this study should serve as a useful comparison with future
studies using alternative surgical techniques, including pneumatic retinopexy
and/or pars plana vitrectomy surgery in the management of primary RRD.
AUTHOR INFORMATION
Submitted for publication April 3, 2001; final revision received October
3, 2001; accepted November 16, 2001.
Corresponding author: William F. Mieler, MD, 6565 Fannin St, NC-205,
Houston, TX 77030 (e-mail: wmieler{at}bcm.tmc.edu).
From the McPherson Retina Center and Cullen Eye Institute, Baylor College
of Medicine, Houston, Tex. Dr Schwartz is currently with the Department of
Ophthalmology, Medical College of Virginia Campus of Virginia Commonwealth
University, Richmond, Va. Dr Kuhl is currently with Austin Retina Associates
and is practicing in Bryan, Tex.
REFERENCES
| |
1. Gonin J. La pathogenie du decollement spontane de la retine [in French]. Ann Ocul (Paris). 1904;132:30.
2. Custodis E. Bedeutet die Plombenaufnahung auf die Sclera einen Fortschritt in der
operativen Behandlung der Netzhautablosung? Ber Zusammenkunft Dtsch Ophthalmol Ges. 1953;58:102-105.
3. Schepens CL, Okamura LD, Brockhurst LJ. The scleral buckling procedures, I: Surgical techniques and management. Arch Ophthalmol. 1957;38:797-811.
4. Arruga H. Modalidades tecnicus de las operaciones del desprendimiento de la retina. Arch Soc Oftalmol Hisp Am. 1958;18:55-65.
5. Wilkinson CP, Rice TA. Results of retinal reattachment surgery. In: Wilkinson CP, Rice TA, eds. Michels Retinal
Detachment. St Louis, Mo: Mosby; 1997:935-977.
6. Tornquist R, Tornquist P. Retinal detachment: a study of population-based patient material in
Sweden 1971-1981, III: surgical results. Acta Ophthalmol (Copenh). 1988;66:630-636.
7. Kreissig I, Rose D, Jost B. Minimized surgery for retinal detachments with segmental buckling and
nondrainage: an 11-year follow-up. Retina. 1992;12:224-231.
PUBMED
8. Kreissig I, Simader E, Fahle M, Lincoff H. Visual acuity after segmental buckling and non-drainage: a 15-year
follow-up. Eur J Ophthalmol. 1995;5:240-246.
PUBMED
9. Hilton GF, Wallyn RH. The removal of scleral buckles. Arch Ophthalmol. 1978;96:2061-2063.
ABSTRACT
10. Hahn YS, Lincoff A, Lincoff H, Kreissig I. Infection after sponge implantation for scleral buckling. Am J Ophthalmol. 1979;87:180-185.
PUBMED
11. McMeel JW, Naegele DF, Pollalis S, Badrinath SS, Murphy PL. Acute and subacute infections following scleral buckling operations. Ophthalmology. 1978;85:341-349.
ISI
| PUBMED
12. Russo CF, Ruiz RS. Silicone sponge rejection: early and late complications in retinal
detachment surgery. Arch Ophthalmol. 1971;85:647-650.
PUBMED
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