In this lecture Dr. Kitchens compares buckling with his favourite sport basketball. The lecture talks about the steps for a successful buckling and how to avoid failures by knowing when to buckle and when not to do a buckle.
Lecturer: John W. Kitchens, MD, Retina Associates of Kentucky, USA
Dr. Kitchens: All right, this talk is entitled, Championship Buckling. And I love giving this talk because I love basketball, and I like to compare buckling, one of my other loves, to basketball. And I was fortunate that I trained at a place that emphasized buckling, Bascom Palmer, but also I joined a practice that was very skilled at scleral buckling. And taught me how to put on really nice and amazing buckles. And how really to achieve success, like we see on the left, and avoid cases like we see on the right. Which unfortunately, is a failed buckle. And that is my failed buckle, a patient that I failed to achieve a retinal detachment on.
So I think if we’re going to have success with scleral buckling, it’s important to know when not to buckle. And the key times when not to buckle is when you need a vitrectomy. And I know that sounds simple, but in reality if you have things like retained lens fragments, a lot of macular hole that needs to be peeled, causing a detachment. A compromised view, such as vitreous hemorrhage, anything where you’re going to need to do a vitrectomy, to be able to get debris out of the eye, close the hole, or remove hemorrhage so you can have better visualization, then it’s absolutely critical that you combine this with a vitrectomy.
When you have to peel. So when there’s extensive PVR, giant retinal tears, and fixing these giant retinal tears. And then on occasion, in patients who are pseudophakic with premium IOLs, if your referring doctor’s absolutely, positively want to maintain that patient’s ametropia. That being said, many of our anterior segment colleagues now do laser treatment for these patients postoperatively. So they will have the ability to do refractive surgery and take a patient who might be a -2 or -3 from a high scleral buckle, and get them back into ametropia fairly easily.
And obviously, those patients with vascular compromise. We are worried that a encircling element might cause anterior segment ischemia, patients who have sickle cell or bad diabetics. This is an example of a patient that you would want to do a vitrectomy on, they have surface PVR. You’re going to need to peel, you might need to do a retinectomy, you’re going to have to be able to remove this traction on the surface of the retina to be able to get that retina flat. This is also a patient that would probably be a great patient for a primary vitrectomy, a superior retinal detachment with a PVD and some vitreous debris. A good patient that you could do one of those modified pneumatic-type vitrectomies. Although a scleral buckle would be highly successful in a case like this is as well. And in a phakic patient, you may choose to do a scleral buckle in this situation.
So when should you buckle? Well, I love doing scleral buckles in young, myopic patients. Patients like this often times have lots of lattice with atrophic holes, patients who have inferior detachments do great with a scleral buckle, particularly chronic detachments, thin sclera, and sclera ectasia. This may seem a little counterintuitive. Why would you want to put a buckle on thin sclera? That’s technically very difficult. And I’ll show you why in a bit.
Patients with a retinal dialysis do very well. Actually, if you can get a patient who has a schisis detachment flat with a scleral buckle, they can do extremely well. Patients that you have PVR concerns for. It’s great if you do a primary buckle if you’re worried about PVR and you can get that retina reattached, because those patients seem to be easier to fix if you have to go to a vitrectomy later on.
Phakic patients do well with scleral buckles, especially phakic patients with clear lenses. Patients who might require air travel and you can drain fluid from underneath their retina and then use an air bubble to achieve a more rapid recovery. And I feel like patients who need a rapid visual recovery, pneumatic patients always seem to do so well with their visual recovery. Followed second by scleral buckles.
And then finally, in cases of ruptured globes, particularly scleral ruptures that are more posterior, I will put a buckle on at the time of closing those posterior ruptures. Just because if we are going to salvage and save that eye, and potentially have vision, I want to be able to have that buckle on in advance, and not have to deal with scarred down conjunctiva when I go back into that eye to repair it.
This is an ideal type of patient for a scleral buckle, if they were to develop a retinal detachment. You can see they do not have a posterior vitreous separation, they have multiple areas of lattice with large atrophic holes. It is incredibly difficult to achieve a vitreous separation in a young patient who looks like this. And you’re likely going to cause more tears and more damage in the patient like this that has a detachment, than you would by doing a buckle.
This is a patient that has failed a primary vitrectomy. And I show this picture only to show the fact that these patients who fail primary vitrectomy have a different type of PVR. It’s more of an intrinsic PVR, it’s more of a PVR that’s difficult to peel, it tends to result in greater numbers of inferior retinectomies, greater amounts of silicon oil, greater numbers of lensectomy cases done. And so a patient who fails at buckle, tends to have an easier fix when you go back in to do the vitrectomy, secondarily. Versus a patient who fails a vitrectomy and then you have to put a buckle and do a vitrectomy secondarily.
Now some would look at this case and say, well, this is obviously someone you need to do a vitrectomy on, because you have to get that subretinal band out of this patient’s eye. Further complicating this young man’s detachment is he had a full thickness macular hole. My partner, Dr. Rick Isernhagen, did a beautiful scleral buckle on this patient. And you can see the subretinal bands settled nicely. This patient did not have a vitrectomy until the retina was reattached. Then Rick went in and did a vitrectomy to fix the macular hole. My point is, subretinal bands actually will flatten nicely if they are not circumferential, if they’re not a napkin ring type band. You can get a big enough buckle to support many, many subretinal bands and get them flat. Particularly those in young patients with chronic detachments.
Now I mentioned thin sclera and we can see thin sclera in clinic, through the conjunctiva, we certainly can see it in the operating room. Why does thin sclera do better with a buckle? And I always tell our fellows, when you see a patient, you’re thinking about a pneumatic or primary vit, look at their sclera. And if you can see the choroid through it, then we want to do a buckle. And the reason is that these patients, over time, develop scleral ectasia.
So actually what happens is, is that their sclera starts to bulge out, almost like a staphyloma, but off to the, usually, temporal side of the globe. And the retina does not follow that sclera, it does not have any elasticity. And so the sclera moves away, but the retina doesn’t. And you can make this retina attach under gas or air to that ectatic sclera, but eventually that retina will pull away. And the number one reason I see patients fail primary vitrectomies, is because of this scleral ectasia. And eventually once the air or gas goes away, the retina will come back off because there’s just no apposition.
So by putting a buckle on the eye, you’re actually able to move that sclera back into relative apposition with the retina, and eliminate this foreshortening, and reoppose the retina to that eye wall. So in those cases, I put a nice broad element.
So back to our basketball analogies. I love certain scleral buckles. And my go-to scleral buckle, the greatest of all time in my mind, is the 41 band. And that is such a multipurpose band, it’s very easy to tunnel. The 42 band is very similar, but bigger. It tends to be better off sutured and a 4050 band certainly sutured. And this is one that’s great for a large, broad encircling element. It is the Shaquille O’Neal of scleral buckles. And the very small and nimble John Stockton of buckles is the 240 band. And this really requires precise and accurate placement.
So the 41 band, I put it on with scleral tunnels, making this cut down with a 64 blade. And I make it about 70% of the scleral thickness. And then I use a Castroviejo Scleral Dissector. I really love these scleral tunnels to be able to attach a scleral buckle. And you can see here how that works.
As far as the bands are concerned, you can see we can suture them or tunnel them, for the most part, although the 42s and 4050s work best when suturing. The role players, the sleeves, the wide grooves, the meridional elements are all very, very critical. When I look at a few of these, the sleeve, obviously, tightening your buckle is an art. I take two needle drivers and I pull the buckle up and away from the eye, and then I tighten it down to just the right adjustment. Our fellows always ask, “How much do you tighten this down to?” And it’s just a feel that you get. And I always like to snug it up so that I can pull it just a little bit away from the globe. But I get a good indentation.
The wide groove gives you tons of support, it needs to be sutured. And the 287WG will actually go under a 41 or a 42, as we see it here. I sutured on with 5-0 nylon sutures, and it gives this really nice imbrication. And here we can see that in that temporal area. It can give you a really nice, broad support.
And then finally, the role players. This is a 106 and I love it because it has a little ledge and you can just slide it underneath the scleral buckle and it locks into place. You can put a couple of these on, separated by the tunnels, and get really nice posterior kick and good imbrication. This is what one of those looks like in the eye. Right here as we can see temporally. It gives you really just a nice, good imbrication.
I also like a 106, sutured posteriorly. So you can see the little notch that we’ll oftentimes lock the buckle into place. Well, you can use this little notch or footplate, to actually pull the buckle back most posteriorly. So if you have a very posterior break, you can really put a vertical mattress suture on the eye, and you can pull that more posteriorly and imbricate.
And then I love efficiency. So one thing I’ll do, and Larry Bird’s a great, efficient basketball player, is I’ll actually use my CryoProbe under the biome, to mark and cryo my break. So I use the CryoProbe, I identify the breaks by depression. And then as soon as I’m cryoing, it freezes my probe to the eye, I’m able to then rotate the eye around, with the probe frozen to the eye. There’s a little ice ball right there and I can then mark my break.
One of the things I absolutely love to do is guarded needle drainage. This really involves placing a traction suture around the buckle, 180 degrees away from where you’re going to drain, and away from your sleeve. You don’t want to put it in the same quadrant as your sleeve. Guarding the 26 gauge 3/8 inch needle, with a 270 or 70 sleeve, so you have a couple millimeters showing. You put it on an open-ended 3CC syringe, and you actually are about to slide it right in, into the subretinal space, direct the bevel away from the retina. And then you use that traction suture to just simply pull an increase pressure in the eye. You can also achieve this with the infusion line.
And if I have a very superior bullous detachment, when I’m doing a buckle vitrectomy, I’ll go ahead and put my buckle on, I’ll drain the subretinal fluid with the needle drainage by elevating the pressure to 80. To avoid bleeding and encourage fluid to flow out through the drainage site, and then that gives me a flat retina to actually operate and do the vitrectomy on.
Here’s what this looks like. This 26 gauge ⅜ inch needle is really great. And you place it on the anterior crest of the buckle. The sleeve simply prevents you from over penetrating, which when you’re learning is something that’s very easy to do. Once again, it’s for use with a bullous retinal detachment. The 26 gauge ⅜ inch needle is on an open-ended 3ml syringe. You want the pressure to be up, because that will encourage fluid to flow out of the eye, and it will actually avoid choroidal bleeding as you enter. You want to place your needle bevel away from the retina on the anterior crest of the buckle, and make sure that it’s guarded. That elevated pressure is really critical and you can achieve that with either infusion or you can achieve that with the traction suture.
Also, I use gas or air at the end of almost all my cases. Just to give me a little margin of error and I usually inject an equal amount of gas or air from what I’ve drained from the subretinal space. I love marking the conjunctiva, it’s all about the details that matter. And marking the conjunctiva helps to assure that I put it back into place. I think some of the reason why we have buckles that are exposed is, is we don’t close tenons properly, that we don’t reapproximate the conjunctiva into the right orientation, and that gives a chance for those sutures to break down.
I would show a two minute buckle surgery here, but I know I’ve gone over. In closing, part of buckling is knowing how to deal with the complications. And indeed you will get complications such as choroidal subretinal bleeding, or preretinal bleeding, and then obviously, reattachment. But the biggest thing is don’t give up on trying. As Vince Lombardi said, “The greatest accomplishment is not in never failing, but in rising again after you fall.” So greetings from Kentucky. And please continue to try buckling and work to be better bucklers, as it is a fantastic surgery for many of our patients. Thank you.