Scleral Buckling

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Mueller introduced shortening of the sclera in 1903 for reducing the volume of the globe [79]. Lindner, in 1931, revived this technique by performing a perforating sclerectomy and removing a meridional section of sclera [9]. Due to its difficulty and high complication rate it was replaced by lamellar scleral resection that was originally introduced by Blascovics in 1912 and later popularized by Shapland (1951-1953), Dellaporta (1951-1957), and Paufique (1952) [47,48,61,80,81].Using this technique, two-thirds of the out-

Fig. 1.2. Ernst Custodis. (Reproduced with permission; Wilkinson CP, Rice TA (1997) Michels retinal detachment, 2nd edn. Mosby St. Louis MO. pp 241-333 [10])

er sclera over the retinal breaks was dissected in a circumferential direction and removed. The edges were opposed with sutures and the inversion of the scleral bed caused by the sutures created a scle-ro-choroidal ridge. Diathermy was applied to the retinal hole, but was later replaced by cryotherapy or photocoagulation. This procedure not only induced shortening of the sclera but also induced a buckling effect that led to the later development of encircling scleral buckles.

In 1937, Jess was the first to use a foreign substance to create a scleral buckle when he inserted a temporary tampon of gauze beneath Tenon's capsule over the retinal break [82]. Lindner in 1949 and Weve in 1949-1950 used a reefing stitch in the sclera to induce a similar effect [83,84]. The first scleral buckling procedure with a retained exoplant was performed by Custodis in 1949 (Fig. 1.2) [85].

Fig. 1.3. Charles L. Schepens. (Reproduced with permission; Wilkinson CP, Rice TA (1997) Michels retinal detachment, 2nd edn. Mosby St. Louis MO. pp 241-333 [10])

After applying surface diathermy to the full-thickness sclera over the break, he sutured a polyviol material to the sclera. The eye wall was indented at the area of the break so that the retina would appose the RPE and close the break. In 1956, he reported his experience with 515 consecutive patients with an 83.3% successful reattachment rate [85]. He did not believe that subretinal fluid needed to be drained and, if the subretinal fluid was not absorbed by day 4, he recommended re-operation. Schepens in 1951 performed the first scleral buckling procedure with an exoplant in the United States (Fig. 1.3) [86-93]. In 1956, he described the use of an encircling polyethylene tube that was placed under the flap of a lamellar scleral dissection [88]. Using the indirect ophthalmoscope introduced by Schepens, he and his colleagues were able to identify and meticulously localize the posterior edge of retinal breaks [94]. The midpoint of the scleral dissection was slightly posterior to the breaks and surface diathermy was placed in the bed of the lamellar dissection along this line at the posterior edge of the breaks and extended anterior, at each end of the retinal detachment. The goal of the operation was to form a permanent barrier with the buckle and the diathermy-induced adhesion to prevent residual anterior sub-retinal fluid from extending posteriorly. Contrary to the practice of Custodis, Schepens and his colleagues would drain the subretinal fluid. The rigid polyethylene tubes, though effective, sometimes eroded through the sclera into the eye. Schepens further modified the scleral buckling procedure using silicone rubber implants, originally recommended by McDonald, that were less likely to erode because they were softer and less rigid than the polyethylene tubes, but retained the barrier concept [93]. Because the anterior edge of the breaks often remained open, subretinal fluid would sometimes leak anteriorly and extend through the barrier to detach the posterior retina. Their next step was to modify the encircling procedure to close the retinal breaks. In 1965, Brockhurst and colleagues described the now-classic scleral buckling technique of lamellar dissection, diathermy of the scleral bed, and the use of sili-cone buckling materials of various shapes, widths and thicknesses in conjunction with an encircling band to close the breaks [95].

In 1965, Lincoff modified the Custodis procedure using silicone sponges instead of polyviol explants, better needles for scleral suturing, and cryopexy instead of diathermy (Fig. 1.4) [96]. Lincoff became the major advocate of non-drainage procedures and led the movement from diathermy to cryotherapy for retinopexy. By Kreissig in subsequent years, the non-drainage technique with segmental buckling was further refined to so-called minimal surgery for retinal detachment [97].

A number of absorbable materials, such as sclera, gelatin, fascia lata, plantaris tendon, cat gut, and collagen were introduced [98108]. However, some absorbable materials were complicated by erosion, intrusion, and infection and none is currently used. Sili-cone rubber and silicone sponges have proven reliable and safe for

Fig. 1.4. Harvey Lincoff. (Reproduced with permission; Wilkinson CP, Rice TA (1997) Michels retinal detachment, 2nd edn. Mosby St. Louis MO. pp 241-333 [10])

many years and are the standard for scleral buckles. However, another material that was used for scleral buckles proved problematic. A form of hydrogel, co-poly (methylacrylate-2-hydroxyethyl acrylate) (MAI) (Miragel) can undergo microstructural change of the architecture of the porous material when left in place for 5 years or more and require removal [i09].MAI can swell, fragment and cause a granulomatous foreign body reaction. A patient can develop irritation, disturbance of ocular motility, an extraocular mass and rarely intrusion of the buckle through the sclera. It has been necessary to remove many MAI scleral buckles.

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