PRESENTATIONS FROM THE RETINA SOCIETY

Is Scleral Buckling on the Endangered Species List?

Retinal specialist argues that PPV is making this procedure obsolete.

One of the more amusing and controversial papers presented at the recent Retinal Society meeting in Boston was one given by Dwain G. Fuller, MD, of Texas Retina Associates of Dallas entitled "Scleral buckles and the dodo bird." In the presentation, Dr. Fuller argued that scleral buckling will eventually become obsolete.

SCLERAL BUCKLES FOR THE BIRDS?

Dr. Fuller began by showing that the percentage of all OR cases that used stand-alone scleral buckles has fallen from 5% in 2001 to 1% in 2007 among the thirteen active surgeons in his group. The percentage of all OR cases that used any kind of scleral buckle has fallen from 12% to less than 9% during that same period. Two key questions arise from these observations, Dr. Fuller said: (1) Is scleral buckling a dying technique? and (2) Do current retinal fellows have sufficient scleral-buckling training?

In answer to the second question, Dr. Fuller reported that the Association of University Professors of Ophthalmology guidelines for retinal fellows is that they perform 75 scleral-buckle procedures during fellowship training. Then Dr. Fuller presented several slides with quotes from retinal surgeons throughout the country indicating that the use of scleral buckles has declined. "Buckles are not extinct," one said, "but they are on the endangered species list." Another said, "The art of doing a good scleral buckle is diminishing, and learning how to find a retinal break with a large drawing is definitely on the wane." A third said, "I remember how excited and frightened a recent fellow was when I suggested we actually do such a bizarre thing as a scleral buckle with external drainage."

One thing made very clear by Dr. Fuller is that, while scleral buckling may continue to be used in conjunction with vitrectomy for the immediate future, as a stand-alone procedure, its use is rapidly diminishing. Using data from the large Royal Oak retina group in Michigan, Dr. Fuller demonstrated that while vitrectromy with scleral buckling among those surgeons is up 79% from 2001 to 2006, scleral buckling alone is down 29%. He also turned to the medical literature, citing, among other studies, two 2006 articles from Ophthalmology, one that found that pars-plana vitrectomy with or without scleral buckle is more likely to achieve a favorable outcome than scleral buckle alone, and the other that found that patients with retinal detachments had better outcomes when a scleral buckle was not done.

ALTERNATIVE SURGICAL STRATEGIES

Dr. Fuller stated that his personal indication list for a stand-alone scleral buckle has shrunken to include only patients with an inferior dialysis, some high myopes with multiple breaks, and young phakic patients with non-complex retinal detachments.

Dr. Fuller concluded, using amusing animations, that showed the "I-Mo-Lester," representing scleral buckling, defeating the "gremlin," a demon-like character causing detachment. The I-Mo-Lester is eventually succeeded by "Captain Vitrector," depicted as a superhero, who defeats the gremlin but with fewer adverse side effects. RP