The lost art in Ophthalmic surgery! Scleral Buckling

1. Scleral buckling
The lost art in
Ophthalmic surgery!
Dr. Mahmoud Medhat El Gammal
MSc., FRCS.

2. Dr. Mahmoud Medhat El Gammal; MSc., FRCS.

3. Single operation
Final visual acuity
Dr. Mahmoud Medhat El Gammal; MSc., FRCS.

4. Options for management of RD
• Scleral buckling.
• PPV.
• Pneumatic retinopexy.
• Laser barricade.
• Observation!
• Lincoff-Kreissig peribulbar balloon.
• INS37217 [Denufosol].
Dr. Mahmoud Medhat El Gammal; MSc., FRCS.

5. The cause of late failure
• Treatment of ALL breaks.
• Relief of vitreous traction.
Dr. Mahmoud Medhat El Gammal; MSc., FRCS.
The cause of early failure
Goal of RD surgery
• PVR.
• NO treatment of ALL breaks.
• NO relief of vitreous traction.

6. • Posterior break.
• Giant retinal tear.
• Thin sclera.
Dr. Mahmoud Medhat El Gammal; MSc., FRCS.
Technically difficult scleral buckling

7. • Number of the breaks.
• Size of the breaks.
According to the Scleral buckling Vs primary
vitrectomy in rhegmatogenous retinal
detachment study (SPR study)these factors were
common among patients undergoing SB and
PPV as well.
Dr. Mahmoud Medhat El Gammal; MSc., FRCS.
Predictors of primary anatomical
success

8. PPV Vs SB
• Lens status.
• Size and location of breaks.
• Patient compliance, and individual preference.
Scleral buckling is usually employed for primary
phakic RRD, with the exception of GRT.
Nonetheless, recent evidence suggest that PPV is
useful in phakic RRD.
Dr. Mahmoud Medhat El Gammal; MSc., FRCS.

9. Dr. Mahmoud Medhat El Gammal; MSc., FRCS.

10. Dr. Mahmoud Medhat El Gammal; MSc., FRCS.
• Old technique employed scleral implants.
• Recently: Scleral explants are employed:
Encircling band.
Local explant.

11. Preoperative assessment
• Features suggestive of non-rhegmatogenous
RD.
• Ocular co-morbidity affecting visual outcome
Macular involvement.
Glaucomatous optic neuropathy.
Hx of strabismus surgery.
• Localization of ALL retinal breaks.... Careful
documentation by a retinal drawing chart.
Dr. Mahmoud Medhat El Gammal; MSc., FRCS.

12. Retinal drawing
Dr. Mahmoud Medhat El Gammal; MSc., FRCS.

13. Lincoff’s rule
Dr. Mahmoud Medhat El Gammal; MSc., FRCS.

14. Dr. Mahmoud Medhat El Gammal; MSc., FRCS.
• Aneasthesia:
Local: Peribulbar – Subtenon.
General.
• Head positioning.
• Preparation and draping.
• Lateral canthotomy – if necessary.

15. • Conjunctival opening can
be performed either at the
limbus or 4 to 8 mm
posterior to the limbus.
• Radial relaxation incisions
are essential.
• Is it always 360 ̊peritomy?
Dr. Mahmoud Medhat El Gammal; MSc., FRCS.
Peritomy

16. Isolation of the recti
Dr. Mahmoud Medhat El Gammal; MSc., FRCS.
• Isolate the SR from the temporal side.
• Isolate the LR from the superior side.

17. Isolation of the recti
Dr. Mahmoud Medhat El Gammal; MSc., FRCS.
• Isolate the SR from the temporal side.
• Isolate the LR from the superior side.

18. Localization of the breaks
Dr. Mahmoud Medhat El Gammal; MSc., FRCS.
• Careful examination of the peripheral retina is
performed to localize ALL breaks.
• Peripheral retinal examination with
indentation is carefully performed at this step.
• Scleral marking of retinal breaks is a crucial
step in the surgery.

19. Dr. Mahmoud Medhat El Gammal; MSc., FRCS.
Schepens scleral depressor Gass scleral marker
Schocket scleral depressor & marker
O’Conner scleral depressor & marker

20. Localization of the breaks
Dr. Mahmoud Medhat El Gammal; MSc., FRCS.
Parallax effect:
In bullous RRD, retinal
breaks are more
posteriorly localized
than they truely are.

21. Retinopexy
Dr. Mahmoud Medhat El Gammal; MSc., FRCS.
1. Diathermy: The prototype of retinopexy.
2. Cryotherapy: Widely accpeted – avoids the
drawbacks of diathermy.
3. Laser:
Intraoperative diode laser.
Postoperative photocoagulation.

22. Cryotherapy
Dr. Mahmoud Medhat El Gammal; MSc., FRCS.

23. Dr. Mahmoud Medhat El Gammal; MSc., FRCS.