Although scleral buckling is more effective than vitrectomy for repairing retinal detachments, many younger surgeons do not have much experience with this traditional technique because it is difficult to teach, observes María H. Berrocal, MD, FASRS. However, recent technological advances can be utilized to reduce visualization-related complications and make it easier to teach the procedure to others in the operating room, she said during the 2024 American Academy of Ophthalmology annual meeting.

The medical literature indicates that surgeons get the best visual acuity outcomes when performing a scleral buckle to repair a phakic retinal detachment, with a success rate of 91% compared to 83% for vitrectomy in most published series, said Dr. Berrocal during the vitreoretinal surgery session of Friday’s Retina Subspecialty Day program. Scleral buckle has many advantages, she noted: no need to position, faster recovery of visual acuity, convalescence time is reduced, and there is no cataract progression. Despite this, today over 80% of all retinal detachments worldwide are treated with vitrectomy, and in the United States that figure is more than 90%.

“Young surgeons prefer vitrectomy, partly because they have limited exposure to scleral buckling techniques during training,” explained Dr. Berrocal. “This is because it is very difficult to learn something that you cannot really see, and poor visibility during surgery is a real issue with traditional scleral buckle.” Many surgeons still rely on loupes and the indirect ophthalmoscope when performing scleral buckle surgery, which gives a limited view, particularly in pseudophakic eyes. Because the assistant has no view of what’s going on, it’s hard to teach them how to identify the breaks or where to apply cryotherapy. And because the surgeon must stand while doing most of the procedure, it’s inconvenient and uncomfortable.

The solution, she said, is to improve the visibility by using a chandelier endoillumination system, which allows better visualization of the posterior segment. For teaching purposes and surgeon comfort, a wide-angle viewing platform can be used with the microscope; in her practice Dr. Berrocal uses the BIOM indirect ophthalmomicroscope (Oculus Surgical) and the Ngenuity 3D visualization system (Alcon). This approach allows the surgeon to take advantage of direct visualization to locate breaks, apply cryotherapy, and drain fluid, with an ergonomic advantage because the surgeon can perform the procedure while seated. Showing a surgical video, Dr. Berrocal described her technique to a captivated audience. (Figure 1, Video1).

“A meta-analysis of 30 publications and 1,133 eyes showed primary reattachment rate of 91.7%, with surgical time reduced 19 minutes on average vs a conventional scleral buckle,” she concluded. “There is no difference in attachment between phakic and pseudophakic eyes, no cases of endophthalmitis. This approach reduces complications due to poor visibility, optimizes teaching capabilities, it’s ergonomic, it may reduce retinal displacement in cases that are macula-off, and as we can see it may improve outcomes.” RP