Outcomes of Scleral Buckle Removal: Experience from the Last Decade

Early Postoperative Conjunctival Complications Leading to Exposure of Surgically Implanted CorNeat EverPatch Devices

PURPOSE

To compare the early exposure and surgical revision rates between a new synthetic tissue substitute (CorNeat EverPatch) with that of human donor cornea after placement onto the scleral surface during ophthalmic surgery and study the biomaterial properties of the synthetic patch material.

DESIGN

Retrospective comparison study and biomaterial analyses of new and explanted synthetic patch material.

PARTICIPANTS

All consecutive patients who underwent ophthalmic surgery with implantation of the CorNeat EverPatch at the Wilmer Eye Institute (occurring from February through August 2024) and a comparison group who underwent ophthalmic surgery with implantation of irradiated donor cornea, matched 1:2 with patients receiving EverPatch for age, type of glaucoma, and surgeon.

METHODS

Retrospective review of clinical electronic medical records of patients who underwent surgery at the Wilmer Eye Institute. Materials characterization of EverPatch, including morphologic features, surface roughness, wettability, thermal stability, elemental analysis, and physical properties.

MAIN OUTCOME MEASURES

Early exposure (within 5 months of surgery) and surgical revision rates after CorNeat EverPatch or irradiated human donor cornea implantation during ophthalmic surgery.

RESULTS

Thirty patients undergoing ophthalmic surgery in 2024 received EverPatch implantation during primary tube shunt placement (n = 27), tube shunt revision (n = 2), or covering of exposed suture used for scleral fixation of an intraocular lens (n = 1). During the early postoperative period, the rate of EverPatch exposure was 48.3% and the rate of surgical revision was 27.9%. In case-matched control participants (n = 58), the rate of patch graft exposure was 1.7% (P < 0.0001) and the rate of surgical revision was 1.7% (P < 0.0001). EverPatch devices constituted a randomly aligned fibrous mesh with an average fiber diameter of 1.36 ± 0.78 μm, surface roughness of 1.3 ± 0.1 μm, pore size of 3.7 ± 0.4 μm2, and percent porosity of 37 ± 3%. Explanted EverPatch devices demonstrated varying degrees of tissue integration with significantly increased wettability and changes in thermal stability and elemental composition.

CONCLUSIONS

The rate of early conjunctival complications leading to exposure of the CorNeat EverPatch was higher than that of irradiated human donor corneal patch grafts.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

A SCLERAL BUCKLE INFECTION CAUSED BY CUTIBACTERIUM ACNES (FORMERLY PROPIONIBACTERIUM ACNES ) AN ATYPICAL, INDOLENT COURSE

PURPOSE

To report a case of atypical, indolent presentation of scleral buckle infection, caused by Cutibacterium acnes (formerly known as Propionibacterium acnes ).

METHODS

Observational case report.

RESULTS

A 44-year-old healthy woman with a history of scleral buckling procedure for retinal detachment repair 16 years before presentation was admitted with pain and redness in her left eye for 6 weeks. Conjunctival hyperemia and vascular congestion were noted over the scleral buckle in a circular manner without signs of exposure. After removal of the scleral buckle, culture analysis revealed C. acnes. Systemic amoxicillin was administrated. Over a six-month follow-up, the retina remained attached.

CONCLUSION

Cutibacterium acnes , known to be associated with chronic postoperative endophthalmitis after cataract surgery, may also lead to scleral buckle infection with an indolent, chronic course.

Scleral Buckle Removal: Long-Term Patient Outcomes

PURPOSE

Scleral buckling has been a reliable treatment option in the repair of primary rhegmatogenous retinal detachments. Occasionally, patients require scleral buckles (SBs) to be removed for various reasons. While outcomes of SB removal have been investigated in this subset of patients, there has not been any large patient series to reach any conclusions. Long-term sequelae of SB removal are debated in the literature, specifically around the risk of redetachment.

DESIGN

We performed a retrospective, observational study to evaluate the clinical indications for, and outcomes of, SB removal.

PARTICIPANTS

No control patients in this retrospective, observational study.

METHODS

Eighty-six individuals with a history of SB removal from June 1, 2000, to January 1, 2021, were followed from a large academic center and a private, retina-only practice in Chicago. Exclusion criteria were age of < 18 years and unplanned or self-explanted SB removal.

MAIN OUTCOME MEASURES

Data extracted included patient symptoms before SB removal, indications for removal, resolution of symptoms following removal, rate of redetachment, and rate of additional ocular surgery. Secondary outcomes included identifying factors associated with poorer outcomes.

RESULTS

Eighty-six eyes with history of SB removal were included with an average follow-up of 4 years. Approximately 60% were males and the mean age at the time of SB removal was 59 years. Leading indications for removal were exposure (61.63%), infection (20.93%), and diplopia/strabismus (19.77%). The average time from SB placement to removal was 12.28 ± 11.16 years. Most patients requiring SB removal presented with symptoms, specifically of pain and discomfort (65.12%), diplopia (22.09%), and drainage/discharge (18.60%). Of these patients, 86.59% experienced symptom resolution following SB removal. Notably, 6.56% (4 eyes) of all eyes with at least 1 year of follow-up experienced a redetachment requiring surgery. Within this subset, the average time from SB placement to removal was 2.05 ± 2.01 years and time to redetachment following removal was 15.95 ± 25.71 months. Nine percent of all eyes required additional strabismus or oculoplastic surgery.

CONCLUSIONS

Scleral buckle removal provides a high rate of symptomatic relief and low risk of subsequent detachment. Nevertheless, close monitoring is warranted to monitor for recurrent retinal detachments.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

A comparative study of strabismus surgery with retained or removed scleral explant after retinal detachment surgery

PURPOSE

To compare, in a larger study population, the outcomes of strabismus surgery in patients who either had the scleral explant (EX) retained or removed after surgery for retinal detachment.

METHODS

A comparative retrospective study includes data from 2 centres. Surgical outcome, motor success, sensory success, the number of secondary operations for strabismus and complications were compared between the two groups. Motor success was defined as horizontal deviation of ≤6 prism diopters (PD) and vertical deviation of ≤6PD. Sensory success was defined as no diplopia without use of prism.

RESULTS

Forty-seven patients were included in the study; 70% had retained the EX and 74% had vertical strabismus. Horizontally, the final alignment was equal between the 2 groups, 4 PD vs.5 PD in the EX removed group. The patients with retained EX were referred with a significant lower mean vertical deviation and had a significant lower post-operative mean vertical deviation of 2 PD vs. 3 PD in the EX-removed group. The rates of motor success (76% vs. 71%) and sensory success (79% vs. 93%) did not differ significantly between the EX-retained and EX-removed groups. No patients underwent more than 2 operations. Two complications occurred in the EX-retained group: a subconjunctival cyst and an exposed EX. In the EX-removed group, 2 patients with retinal re-detachment were found in the follow-up period.

CONCLUSION

Good surgical outcomes including high motor and sensory success were obtained regardless of the presence of the EX. Retinal re-detachment was observed in two patients with previously removed EX.

Scleral Buckling: A Review of Clinical Aspects and Current Concepts

Scleral buckling represents a valuable treatment option for rhegmatogenous retinal detachment repair. The surgery is based on two main principles: the closure of retinal breaks and the creation of a long-lasting chorioretinal adhesion. Buckles are placed onto the sclera with the purpose of sealing retinal breaks. Cryopexy is usually performed to ensure a long-lasting chorioretinal adhesion. Clinical outcomes of scleral buckling have been shown to be more favorable in phakic eyes with uncomplicated or medium complexity retinal detachment, yielding better anatomical and functional results compared with vitrectomy. Several complications have been described following scleral buckling surgery, some of which are sight-threatening. Expertise in indirect ophthalmoscopy is required to perform this type of surgery. A great experience is necessary to prevent complications and to deal with them. The use of scleral buckling surgery has declined over the years due to increasing interest in vitrectomy. Lack of confidence in indirect ophthalmoscopy and difficulties in teaching this surgery have contributed to limiting its diffusion among young ophthalmologists. The aim of this review is to provide a comprehensive guide on technical and clinical aspects of scleral buckling, focusing also on complications and their management.

Scleral Buckle Removal: Indications, Timing, Complications, and Long-Term Outcomes

BACKGROUND AND OBJECTIVE

To report indications, timing, complications, and outcomes of scleral buckle (SB) removal surgery.

PATIENTS AND METHODS

Retrospective observational case series. Eyes that underwent SB removal between 2010 and 2016 with greater than 1 year of follow-up were included. Main outcome measures were post-SB removal complications and best-corrected visual acuity (BCVA).

RESULTS

Fifty eyes that underwent SB removal met the inclusion criteria. Indications include exposed SB (54%), infection (26%), diplopia (16%), and recurrent retinal detachment (4%). Mean and median intervals between SB placement and removal were 65 months and 30 months. Complications include recurrent retinal detachment (12%), transient ocular hypertension (6%), and persistent diplopia (4%). There was no significant change in mean BCVA after SB removal (P = .979).

CONCLUSIONS

Exposed SB, infection, and diplopia are the most common indications for SB removal. The single-surgery success rate is high and the risk for complications is relatively low. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:138-144.].

Recurrence of Retinal Detachment after Scleral Buckle Removal

Purpose

To investigate the indications for scleral buckle removal and the risk factors for the recurrence of rhegmatogenous retinal detachment after scleral buckle removal.

Methods

In this retrospective study, the medical records of all patients who underwent scleral buckle removal for the treatment of rhegmatogenous retinal detachment were reviewed.

Results

Forty eyes (40 patients) were included in this study. The indications for scleral buckle removal included exposure without infection in 23 eyes (57.5%), exposure with infection in seven eyes (17.5%), elevated intraocular pressure in six eyes (15.0%), strabismus or diplopia in three eyes (7.5%), and migration of buckle material in one eye (2.5%). After the removal of the scleral buckle, the recurrence of rhegmatogenous retinal detachment was observed in four eyes (10.0%) during follow-up, and the retina was successfully reattached after pars plana vitrectomy in all the eyes. Most clinical and ocular factors of the eyes with and without the recurrence of retinal detachment during follow-up were not different, but the eyes that underwent encircling removal were more likely to have retinal detachment recurrence during follow-up than those that underwent segmental buckle removal (n = 4 / 16 [25.0%] vs. n = 0 / 24 [0.0%]; p = 0.020).

Conclusions

Scleral buckle removal can result in the recurrence of retinal detachment. The benefits and risks of scleral buckle removal should be carefully considered before surgery, and extensive monitoring during follow-up after scleral buckle removal is important, especially for patients who underwent encircling removal.

Rhegmatogenous retinal detachment: a review of current practice in diagnosis and management

Rhegmatogenous retinal detachment (RRD) is a common condition with an increasing incidence, related to the ageing demographics of many populations and the rising global prevalence of myopia, both well known risk factors. Previously untreatable, RRD now achieves primary surgical success rates of over 80%-90% with complex cases also amenable to treatment. The optimal management for RRD attracts much debate with the main options of pneumatic retinopexy, scleral buckling and vitrectomy all having their proponents based on surgeon experience and preference, case mix and equipment availability. The aim of this review is to provide an overview for the non-retina specialist that will aid and inform their understanding and discussions with patients. We review the incidence and pathogenesis of RRD, present a systematic approach to diagnosis and treatment with special consideration to managing the fellow eye and summarise surgical success and visual recovery following different surgical options.

Hemorrhagic complications associated with suprachoroidal buckling

Background

Multiple surgical techniques exist for the repair of rhegmatogenous retinal detachments (RRD). Suprachoroidal buckling (SCB), consisting of injecting viscoelastic material in the suprachoroidal space to allow chorioretinal apposition, has been recently described in the repair of RRD. The aim of this study is to report the complications of SCB and to propose measures to decrease their incidence during the learning curve.

Methods

A total of 26 eyes of 26 patients who underwent a SCB procedure for the management of RRD secondary to a single or multiple retinal breaks were enrolled. Patients were operated between January 2014 and March 2017 at two academic institutions. Patient and retinal detachment characteristics were obtained from the charts. Surgical videos were reviewed for every case and intraoperative complications were recorded. Complications observed postoperatively were obtained from the charts.

Results

Sixteen eyes (62%) underwent SCB alone, 5 eyes (19%) underwent additional gas tamponade and 5 eyes (19%) had combined pars plana vitrectomy. The most common complication was hemorrhage (6 cases, 23%). There were no cases of ischemic choroidal changes or hyperpigmentation at the edge of the dome. All six complications occurred in phakic patients who had inferior RRD with retinal breaks in the inferior quadrants. Isolated subretinal hemorrhage occurred in 4 patients and isolated suprachoroidal hemorrhage in 1 patient, and those did not affect final visual outcome. Extensive combined subretinal and suprachoroidal hemorrhage occurred in one case, and was complicated by phthisis bulbi. Re-detachment occurred in 4/6 (67%) of patients, and 5/6 (83%) of patients required a secondary procedure. Three out of 6 patients (50%) had at least 2 lines of visual acuity improvement.

Conclusion

SCB performed for RRD can be associated with hemorrhagic complications. The hemorrhages are usually self-limited but may occasionally result in severe visual compromise when involving the suprachoroidal space. Specific surgical measures need to be undertaken in order to decrease the likelihood of complications and further studies are needed to assess the safety and efficacy of this technique.

Infectious conjunctivitis caused by Pseudomonas a eruginosa in infected and extrused scleral buckles

Extrusion of the scleral buckle is one of the complications patients may encounter undergoing the surgical treatment for retinal detachment. We present two cases of persistent Pseudomonas a eruginosa-related conjunctivitis which infected the silicone explant after retinal surgery. One of them is a 73-year-old Caucasian female patient with hyperaemia, intense pain and mucopurulent discharge. After the conjunctival swabs detected a P. aeruginosa infection, she started both topical and systemic treatment without any results; for this reason we opted for the buckle removal always under systemic therapy. The second case is an 84-year-old Caucasian female patient with fever, periorbital oedema, chronic ocular pain, hyperaemia and purulent discharge. P. aeruginosa has also been detected in this case. No improvement with topical and systemic treatment, so this convinced us to remove patient's buckles and to continue systemic therapy. Both cases had the complete resolution after surgery. It is important to quickly recognise exposed scleral buckles because they can be a source of infections and a rare but threatening cause of endophthalmitis.

Microbiological profile and antibiotic susceptibility of scleral buckle infections in North India

Purpose:

The aim of this article to study causative organisms for scleral buckle (SB) infections in North India.

Methods:

A retrospective review of records was done for all patients who have undergone SB removal at our institute between January 2009 and December 2017. The records were analyzed for etiological agent of the infected buckle and its antibiotic sensitivity.

Results:

A total of 43 samples were analyzed and a positive culture was noted in 35 (81.40%) cases. The buckle infection rate at our institute was noted to be 2.53%. The commonest organism causing SB infections was Staphylococcus – 15 (42.6%) cases, followed by Pseudomonas – 6 (17.14%) cases and Fungi – 6 (17.14%) cases. The median interval between retinal detachment surgery and buckle explantation was 3 years.

Conclusion:

A large variety of organisms may cause SB infections. The commonest organism found to cause buckle infections in our study was Staphylococcus sp.

Early Buckle Migration and Restrictive Strabismus after Successful Medical Management of Scleral Buckle Infection

We report a case of restrictive strabismus caused by early scleral buckle (SB) migration within 1 month of surgery after successful medical management of SB infection. A 24 year-old man underwent scleral buckling surgery for left eye inferior retinal detachment (RD). A solid silicone buckle element was placed inferiorly along with an encircling silicone band. Two days after surgery, he presented with SB infection. Methicillin resistant Staphylococcus aureus was cultured from the exudate at conjunctival suture sites. Since the retina was well attached and it was only the second postoperative day, it was decided to retain the buckle. SB infection was treated with intravenous cefotaxime and topical fortified cefazolin and successfully eradicated. One month thereafter, anterior SB migration was noted on slit lamp biomicroscopy. Restrictive strabismus and diplopia were also noted. Eventually, SB removal was performed at 2 months. This case report highlights the role of infection and subsequent inflammation as a cause for buckle migration and restrictive strabismus in the early post-operative period. These changes can be seen as early as 1 month after primary surgery and may occur even after successful medical management of the SB infection.

Partial scleral buckle removal during strabismus surgery after retinal detachment repair

PURPOSE

To describe outcomes after partial scleral buckle removal at the time of strabismus surgery.

METHODS

The medical records of consecutive patients with symptomatic diplopia who underwent strabismus surgery after scleral buckling by two surgeons were reviewed retrospectively. All patients underwent forced duction testing and had a segment of the scleral buckle removed intraoperatively. Pre- and postoperative ocular motility and alignment were compared. The outcome was considered successful if residual horizontal deviation was ≤8^Δ, vertical deviation ≤2^Δ, and cyclotropia <5°.

RESULTS

A total of 12 patients (mean age, 51 years; range, 14-71 years) with a mean horizontal deviation of 16^Δ (range, 2^Δ-40^Δ) and mean vertical deviation of 10^Δ (range, 2^Δ-20^Δ) were included. Three patients underwent 2 strabismus surgeries. All patients underwent intraoperative removal of a segment of the scleral buckle near a muscle being advanced or recessed at the time of surgery. An adjustable suture technique was used in 13 of 15 surgeries (86%). Orthotropia was achieved in 7 patients (58%); surgical success, in 11 (92%). Subjective resolution of diplopia was achieved in all patients, in 2 with the aid of prisms. Mean follow-up was 12.4 months (range, 1-75). No patient had retinal redetachment.

CONCLUSIONS

In this case series, removal of a segment of the scleral buckle facilitated advancement or recession of a rectus muscle and was associated with good outcomes without retinal redetachment.

The evaluation of ocular refractive error and axial length changes after scleral buckle removal

Purpose:

The present study aimed to evaluate refractive error and axial length changes after buckle removal due to buckle complications.

Methods:

A total of 15 patients involved in this study. The enrolled patients who had history of scleral buckling (SB) for rhegmatogenous retinal detachment referred to clinic for buckle removal due to buckle-related complications. Complete ophthalmic examinations and IOLMaster (Carl Zeiss) device performed prior and 3 months after buckle removal. Also best corrected visual acuity (BCVA), refractive error and axial length changes evaluated after buckle removal.

Results:

BCVA, refractive error, and axial length changes were not statistically significant (P value: 0.24, 0.23, 0.33, respectively). No redetachment or any other complication was observed after buckle removal.

Conclusion:

The study displayed induced globe shape changes due to SB are irreversible after buckle removal. In addition, it is a safe procedure and does not raise any risk of retinal redetachment.

Ocular movement disorders following scleral buckling surgery: A case series study

Purpose

To evaluate ocular movement disorders after scleral buckling surgery (SBS) for retinal detachment.

Methods

In this prospective, observational, case series, 206 patients (206 eyes) with rhegmatogenous retinal detachment who underwent SBS and investigated at the strabismus ward of Farabi Eye Hospital in Iran between November 2011 and November 2014 were assessed. Patients were followed from 6 to 36 months after SBS to evaluate for strabismus. Logistic regression analysis test and SPSS software version 20 were used for statistical analysis.

Results

From 206 patients, 56.8% were male, and 33.2% were female. For scleral buckle in 44.7% of patients, silicone band and tire (SBT) was used, and in 55.3%, a sponge. Among all patients, seven (3.39%) exhibited ocular movement disorder. There was no significant relation between type of buckle (P = 0.65) or the location of buckle (P = 0.56) and movement disorder.

Conclusion

Ocular movement disorder is one of the main complications after SBS without specific association between the type and location of exoplanet.

Strabismus surgery outcomes without removal of scleral buckle in patients with previous retinal detachment repair

PURPOSE

To report the motor and sensory outcomes of strabismus surgery following scleral buckle procedure for retinal detachment (RD) without removal of the scleral buckle.

METHODS

The medical records of patients who underwent strabismus surgery without removal of scleral buckle following RD surgical repair at a tertiary referral center between 2002 and 2015 were reviewed retrospectively. Demographic data were recorded, and rates of surgical motor success (defined as horizontal deviation of ≤10^Δ and vertical deviation of ≤4^Δ) and sensory success (resolution of diplopia) were calculated.

RESULTS

A total of 23 patients (mean age, 58.4 ± 24.4 years; 12 males) were included. The average time between the RD surgery and onset of strabismus was 11.05 ± 10.95 months (range, 1-42 months). The strabismus was horizontal in 6 patients, vertical in 2, and combined in 15. Eighteen patients (78%) presented with diplopia. Adjustable sutures were used in 18 patients. Final motor surgical success was achieved in 17 of 23 patients (74%), and diplopia improved in 17 of 18 patients (94%) who had preoperative fusional capability. There was no statistically significant difference in age, number of RD surgeries, macular status, time to strabismus surgery, visual acuity in the worse eye, or magnitude of preoperative horizontal and vertical deviation with regard to motor success rate and with persistence of diplopia postoperatively.

CONCLUSIONS

In our study cohort, strabismus surgery without removal of the scleral buckle resulted in motor success and alleviated diplopia in the majority of patients with prior RD repair.

Postoperative Complications of Scleral Buckling

Scleral buckling has an important role in the repair of certain categories of rhegmatogenous retinal detachments. These include detachments in young phakic patients, detachments associated with dialysis, and also in conjuction with vitrectomy in patients who have sustained trauma or have developed proliferative vitreoretinopathy. However, it can be associated with significant postoperative complications. The most important ones are refractive change, intrusion or extrusion, infection, globe ischemia, and choroidal detachments, amongst others. Careful planning, appropriate patient selection, and good intraoperative technique can reduce the rate of these complications.