Exploring a new method for scleral buckling

Take home

A retinal surgeon describes a new scleral buckling device which requires less surgical dissection, has a one or two-stitch fixation, is applicable to treat pathology over 4 clock hours in any quadrant, and which can be removed in the office 3 to 4 weeks after insertion.

By Michelle Dalton, ELS; Reviewed by Paul E. Tornambe, MD

San Diego-Scleral buckling “is not dead,” nor should it be, said Paul E. Tornambe, MD. Scleral buckling (SB) indents the retina underlying a break and is believed to alter intraocular fluid currents that in turn allow the retinal pigment epithelium to remove existing subretinal fluid and reduce a retinal detachment to a mere retinal tear. The first reported procedure was in 1937, and incremental improvements in technique have rendered it a proven method for reattaching the retina, Dr. Tornambe said.

Success rates are high; complications such as endophthalmitis are low.

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“Once the subretinal fluid is removed, you should treat the retinal tear like you would any other tear not associated with subretinal fluid,” he said. Scleral buckling has lost favor by many retinal surgeons for a few reasons, he said; when compared with pars plana vitrectomy, the traditional SB procedure necessitates a more extensive preop evaluation. Conventional buckling can result in induced refractive error and sometimes muscle imbalance, discomfort, infection, and extrusion of the buckling material. Scleral buckling surgery is more time-consuming; it requires a detailed preoperative evaluation of the retina, an operating room, and may require general anesthesia. Although there have been many technological advances in the instruments and techniques we use today to treat a retinal detachment, the scleral buckling materials and procedure has not changed over the past 50 years.

“We have developed a new scleral buckling device which requires less surgical dissection, has a one or two-stitch fixation, is applicable to treat pathology over 4 clock hours in any quadrant, and which can be removed in the office 3 to 4 weeks after insertion,” he said, noting it is based on the Lincoff balloon concept that a permanent buckle in many cases is not needed. That balloon device failed to achieve commercial success, but “the concept was brilliant,” Dr. Tornambe has said.

Using a temporary buckle

The removable circumferential SB is patent-pending. The first prototype, “a compressible football simulating a balloon, was first described by us about a year ago,” Dr. Tornambe said. “The football worked in a few cases but tended to migrate and that design has been put on the back burner. However, the concept that a permanent scleral indentation is not needed excited us and kept us on the path to search for a better design for a temporary buckle.”

The group does not treat retinal tears not associated with subretinal fluid with a SB or vitrectomy, “so if we can reduce that detachment back to a flat tear we should be able to treat it with just laser or cryotherapy,” he said. The Lincoff balloon boasted a success rate of more than 90% in some studies, but shortcomings were numerous and included surgical difficulty with implantation, corneal abrasions, and patient discomfort; the occasional leak led to less-than-expected indentations, and once the U.S. manufacturer halted production availability was severely hindered.

With the Lincoff balloon, an inflatable silicone explant is inserted through the conjunctiva and expanded beneath the retinal break; the buckling effect closes the break. Adhesion is obtained by transconjunctival cryopexy and the balloon is removed after several days.

The new device is composed of a solid firm circumferential element that buckles the sclera over 3-4 clock hours and a radial element used to fix the device in position using one or two absorbable sutures, Dr. Tornambe explained. “The device can be inserted in an office ‘clean room’ or surgery center under local anesthesia.”

The conjunctiva is opened, cryopexy is appled to the tear(s) and the device is inserted beneath one or two muscles depending on the size and location of the breaks. Absorbable sutures are used to fix the implant in position and close the conjunctiva so that the exoplant can be removed in the office 2-3 weeks later. A paracentesis may be necessary, he explained.

Because the new device is removed after several weeks, “it does not induce a refractive error or muscle imbalance, the main side effects noted with a permanent buckle,” Dr. Tornambe said.

“This new SB device is a very cost-effective, minimally invasive procedure which has a place in retinal detachment surgery,” Dr. Tornambe said, re-emphasizing its ability to address retinal detachments with pathology in any quadrant subtending pathology up to 4 clock hours apart. Candidates for a temporary buckle might be the 30-year-old phakic post-LASIK myope with an inferior detachment, the phakic young patient with a break beneath a muscle, or the patient with a subclinical retinal detachment that might be treated with a laser barricade that would sacrifice peripheral vision, he said

A temporary buckle might be considered in addition to vitrectomy in eyes with inferior breaks or possible PVR where the surgeon would like the “insurance” of a buckle in the early postoperative period.

“This is clearly a work in progress, but there is no reason to believe we cannot achieve the same success rates as the Lincoff balloon,” he said. “Back to the future!”

Paul E. Tornambe, MD

E: tornambepe@aol.com

This article was adapted from Dr. Tornambe's presentation at the 2014 meeting of the  American Society of Retinal Specialists. He did not indicate any proprietary interest in the subject matter.