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.

Twenty-seven-gauge endoilluminator-assisted scleral buckling using a wide-field viewing system: Case report.

RATIONALE: We report a new scleral buckling technique using a 27-gauge endoilluminator and a wide-field viewing system to overcome the limitations of conventional indirect ophthalmoscope-methods and "chandelier-assisted" surgery. PATIENT CONCERNS: A 26-year-old female patient visited the local clinic for floaters and lower visual field defects in her left eye that had occurred 5 days prior. DIAGNOSES: On fundus examination, upper retinal detachment without macular involvement and an atrophic hole was observed in her left eye. INTERVENTIONS: Under general anesthesia and after perilimbal conjunctival incision, extraocular muscle isolation, and traction with black silk, a 27-gauge trocar-cannula was inserted 90° away from the retinal break, 4 mm away from the limbus. Under wide-field viewing using a contact lens, the fundus was observed through a surgical microscope. Retinal break was evaluated and cryopexy was performed with careful movement of the endoilluminator, paying attention to damage to the lens. The surgeon could accurately and freely control the direction of the illumination tip to obtain a brighter view of the region of interest. OUTCOMES: There were no complications associated with trocar cannula incision or the illuminator. The retina was successfully reattached. LESSONS: Twenty seven gauge endoilluminator-assisted scleral buckling is an easy and safe procedure and provides better control over and free adjustment of the light direction, thus overcoming the limitations of chandelier-assisted surgery.

Impact of contact versus non-contact wide-angle viewing systems on outcomes of primary retinal detachment repair (PRO study report number 5).

BACKGROUND/AIMS: Vitrectomy to repair retinal detachment is often performed with either non-contact wide-angle viewing systems or wide-angle contact viewing systems. The purpose of this study is to assess whether the viewing system used is associated with any differences in surgical outcomes of vitrectomy for primary non-complex retinal detachment repair. METHODS: This is a multicenter, interventional, retrospective, comparative study. Eyes that underwent non-complex primary retinal detachment repair by either pars plana vitrectomy (PPV) alone or in combination with scleral buckle/PPV in 2015 were evaluated. The viewing system at the time of the retinal detachment repair was identified and preoperative patient characteristics, intraoperative findings and postoperative outcomes were recorded. RESULTS: A total of 2256 eyes were included in our analysis. Of those, 1893 surgeries used a non-contact viewing system, while 363 used a contact lens system. There was no statistically significant difference in single surgery anatomic success at 3 months (p=0.72), or final anatomic success (p=0.40). Average postoperative visual acuity for the contact-based cases was logMAR 0.345 (20/44 Snellen equivalent) compared with 0.475 (20/60 Snellen equivalent) for non-contact (p=0.001). After controlling for numerous confounding variables in multivariable analysis, viewing system choice was no longer statistically significant (p=0.097). CONCLUSION: There was no statistically significant difference in anatomic success achieved for primary retinal detachment repair when comparing non-contact viewing systems to contact lens systems. Postoperative visual acuity was better in the contact-based group but this was not statistically significant when confounding factors were controlled for.

Wide-angle 3D viewing system with valved trocar applied to chandelier-assisted scleral buckling.

INTRODUCTION: Scleral buckling (SB) has been the first technique to repair a retinal detachment (RD) and it is still largely in use. Pars plana vitrectomy (PPV) is currently the most common technique, being more versatile and easier to approach. Here we report on a new SB variant, modified by using some of the latest technological advances borrowed from PPV. METHODS: We retrospectively reviewed all our SB cases from November 2017 to November 2018, all of them performed with a chandelier, mounted on valved trocar, to provide 3D wide-angle viewing. 107 eyes of 107 patients (mean age of 59 ± 8 years, 61 [57%] males) underwent primary uncomplicated RD surgery using this modified SB technique and were enrolled for this study. RESULTS: In this article, the technique is thoroughly described with an online video presentation. Briefly, thanks to valved trocar insertion, it combines the latest breakthroughs in the field of PPV viewing systems with traditional SB surgery. Our first-year data reveal a primary success rate of 94% (101 cases out of 107) at 3 months follow-up. A hidden retinal lesion, undetected at clinical pre-operative evaluation, was found intraoperatively in 12 (8.9%) cases. CONCLUSION: The use of a digital three-dimensional (3D) visualization system, coupled with the positioning of a single 25 gauge valved trocar with chandelier, dramatically simplifies the traditional SB and flattens its learning curve, making this procedure more accessible to young surgeons. In addition, the better visualization capability yields to higher possibility to detect and treat all retinal lesions.

Outcomes of primary rhegmatogenous retinal detachment repair with extensive scleral-depressed vitreous removal and dynamic examination.

There are multiple surgical approaches to the repair of rhegmatogenous retinal detachment (RRD). Here, we evaluated the outcomes of small-gauge pars plana vitrectomy (PPV), alone or in combination with scleral buckle (SB-PPV), for RRD repair using a standardized technique by 3 vitreoretinal surgeons: "extensive" removal of the vitreous with scleral depression and dynamic examination of the peripheral retina. One hundred eighty seven eyes of 180 consecutive patients treated for primary RRD by three vitreoretinal surgeons at a tertiary academic medical center from September 2015 to March 2018 were analyzed. Most RRDs occurred in males (134 [71.3%] eyes), affected the left eye (102 [54.3%]), and were phakic (119 [63.3%]). PPV alone was performed in 159 eyes (84.6%), with a combined SB-PPV used in the remaining 29 eyes (15.4%); focal endolaser was used in all (100%) cases. The single surgery anatomic success rate was 186 eyes (99.5%) at 3 months, and 187 (100%) at last follow up. Overall best-corrected visual acuity (BCVA) had significantly improved at 3 months ([Snellen 20/47] P<0.00005) and last follow up ([Snellen 20/31] P<0.00005), as compared to day of presentation ([Snellen 20/234]). Our findings suggest that "extensive" removal of the vitreous and dynamic peripheral examination with scleral depression may lead to high single surgery success in primary uncomplicated RRD repair.

To remove the buckle or watch?

Scleral buckling is one of the most effective modality for treatment of rhegmatogenous retinal detachment and in selected cases of retinopathy of prematurity. Although quite safe, it has its own set of associated morbidities. This report presents an interesting case, where the scleral buckle migrated posteriorly reaching up to the optic nerve.

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.

New Scleral Depressor Marker for Retinal Detachment Surgery.

PURPOSE: To report the efficacy of the use of a new scleral depressor marker during scleral buckling surgery for retinal detachment. DESIGN: Noncomparative, consecutive case series study. PARTICIPANTS: Eleven patients (11 eyes) with rhegmatogenous retinal detachment who underwent scleral buckling surgery performed by 2 experienced vitreoretinal surgeons. METHODS: The prototype of a new indenter marker was used during scleral buckling surgery. MAIN OUTCOME MEASURES: The possibility of performing simultaneous indentation and selected marking of the desired area was assessed. Additionally, the precision of the fiber light-assisted indentation as well as force of indentation were evaluated. RESULTS: The use of a new depressor marker facilitated a quick and effective flow of the standard surgery for retinal detachment. It was possible to perform indentation and marking as separate steps of 1 session. Only desired areas of the sclera were marked during the same indentation session. The indentation required less force. When combined with chandelier light, the precision of the marking was improved as demonstrated by a light from the chandelier indicating the highest point of the indentation area. There were no complications related to the use of the new instrument. CONCLUSIONS: The newly developed scleral depressor marker facilitated simultaneous indentation and marking on the sclera. The new instrument allowed for the selective marking of the desired areas during the same session of indentation. Additionally, it can be combined with chandelier fiber light, which improves the precision of the marking.

A new instrument to simplify encircling buckle placement.

PURPOSE: The purpose of this study is to describe a new surgical instrument that simplifies 360° silicone band placement, alone or in combination with pars plana vitrectomy, for the treatment of rhegmatogenous retinal detachment. METHODS: The instrument has a straight shank and a curved component in the form of a partial helix, whose purpose is to encircle the perimeter of the eye globe below the rectus muscles. The distal tip of the helix is inserted through a small conjunctival incision in the superior temporal quadrant, and the shank is rotated 360° on its axis until the tip emerges from the insertion point. One end of the silicone band is sutured to the tip, and the instrument is rotated in the opposite direction until both ends of the band are positioned in the same scleral quadrant. The band is sutured to the sclera and the conjunctival incision is closed. Pars plana vitrectomy can then be performed using transconjunctival microincision techniques through the intact conjunctiva. RESULTS: Our experience using the instrument in more than 100 procedures has shown that the new technique considerably reduces surgical trauma: wide opening of the conjunctiva is obviated, there is little manipulation of the extraocular musculature, and only a few sutures are needed. The duration of the procedure is considerably shorter because of the smaller number of surgical maneuvers. CONCLUSION: We describe a new scleral technique facilitated by this surgical instrument, whose objective is safe and effective placement of an encircling silicone band with minimum trauma and a reduction in operating time.

[Buckling Surgery: Old Fashioned or Cutting Edge?] / Buckelchirurgie: Old Fashion oder Cutting Edge?

For many decades, scleral buckling surgery was the only reasonable surgical procedure in eyes with primary rhegmatogenous retinal detachment. In recent years, primary vitrectomy has apparently become the treatment of choice, although evidence from comparative clinical trials is missing. In this article, data from clinical trials and indications for buckling surgery are presented.

Scleral Buckling Using a Non-contact Wide-Angle Viewing System with a 25-Gauge Chandelier Endoilluminator.

PURPOSE: To report the outcome of scleral buckling using a non-contact wide-angle viewing system with a 25-gauge chandelier endoilluminator. METHODS: Retrospective analyses of medical records were performed for 17 eyes of 16 patients with primary rhegmatogenous retinal detachment (RRD) without proliferative vitreoretinopathy who had undergone conventional scleral buckling with cryoretinopexy using the combination of a non-contact wide-angle viewing system and chandelier endoillumination. RESULTS: The patients were eight males and five females with a mean age of 26.8 ± 10.2 (range, 11 to 47) years. The mean follow-up period was 7.3 ± 3.1 months. Baseline best-corrected visual acuity was 0.23 ± 0.28 logarithm of the minimum angle of resolution units. Best-corrected visual acuity at the final visit showed improvement (0.20 ± 0.25 logarithm of the minimum angle of resolution units), but the improvement was not statistically significant (p = 0.722). As a surgery-related complication, there was vitreous loss at the end of surgery in one eye. As a postoperative complication, increased intraocular pressure (four cases) and herpes simplex epithelial keratitis (one case) were controlled postoperatively with eye drops. One case of persistent RRD after primary surgery needed additional vitrectomy, and the retina was postoperatively attached. CONCLUSIONS: Scleral buckling with chandelier illumination as a surgical technique for RRD has the advantages of relieving the surgeon's neck pain from prolonged use of the indirect ophthalmoscope and sharing the surgical procedure with another surgical team member. In addition, fine retinal breaks that are hard to identify using an indirect ophthalmoscope can be easily found under the microscope by direct endoillumination.

[Mo-dified scleral buckling for additional fixation of the retina with endovitreal magnetic implant (experimental study)]. / Modifikatsiia épiskleral'nogo plombirovaniia dlia dopolnitel'noi mekhanicheskoi fiksatsii setchatki magnitnym implantatom so storony vitreal'noi polosti (éksperimental'noe issledovanie).

Scleral buckling (SB) has been regaining its popularity in the treatment of retinal detachments. On large clinical material, it has been proved to be the technique of choice in phakic patients with retinal detachment of moderate severity. A combined procedure that incorporates features of episcleral as well as intravitreal surgeries has also become widely used. Aim - to investigate the prospects for increasing technical potential of SB, particularly, to investigate the possibility of additional atraumatic mechanical fixation of the retina from within the vitreous cavity. The proposed device consists of an episcleral magnetic buckle and endovitreal magnetic buckles (endobuckles). The episcleral magnetic buckle is made of medical grade silicone and cannot be distinguished from common buckles, except that it contains one or more permanent magnets on the basis of neodymium-iron-boron powders. Endobuckles are small flat elastic elements made of silicone elastomer filled with magnetic particles. Еndobuckles are implanted into the vitreous cavity through a small pars plana incision and placed on the retina at the projection of the scleral magnetic buckle. Thus, in experiments with cadaver eyes, the authors have showed the principle feasibility of retinal fixation by the force of magnetic interaction between the magnetic scleral buckle and endobuckles. The described technique of additional mechanical fixation of the retina provides wider surgical opportunities in the management of retinal detachments.

Scleral buckling with a noncontact wide-angle viewing system in the management of rhegmatogenous retinal detachment.

PURPOSE: To introduce a modified scleral buckling surgery using noncontact wide-angle viewing system and intraocular illumination in the treatment of rhegmatogenous retinal detachment (RRD) without proliferative retinopathy. METHODS: A modified scleral buckling surgery using noncontact wide-angle viewing system with a 25-G optic fiber through sclerotomy site was performed in 22 eyes of 22 patients with RRD. Twelve women and 10 men were included. The mean age was 49.23 ± 15.19 years. The mean refraction of myopia was -4 D (range -3 to -7 D). The mean duration of RRD was 6.64 ± 3.14 days. The preoperative best-corrected visual acuity (BCVA) ranged from 0.02 to 0.8. Mean follow-up was 9.59 ± 2.24 months. Proliferative retinopathy was grade A in 8 eyes and grade B in 14 eyes. RESULTS: This surgery was performed successfully and retinal attachment was achieved in all eyes at the final follow-up. The postoperative BCVA increased in all eyes. No complication was encountered related to this technique. CONCLUSIONS: This modified scleral buckling surgery brings a panoramic and upright view and easy surgical maneuvers. It may be an additional approach for the management of RRD.

Catheter-guided suprachoroidal buckling of rhegmatogenous retinal detachments secondary to peripheral retinal breaks.

PURPOSE: To evaluate functional and anatomic outcomes of eyes undergoing suprachoroidal buckling (SCB) using a specially designed catheter for the management of rhegmatogenous retinal detachment (RRD) secondary to peripheral retinal breaks. METHODS: Retrospective cohort study of 62 eyes of 62 patients. Subjects underwent SCB for the management of RRD secondary to single or multiple retinal breaks. Suprachoroidal indentation was achieved through the introduction of viscoelastic material in the suprachoroidal space overlying the break using an illuminated, 450 µm-wide, flex-tip catheter. This allowed for the creation of a suprachoroidal dome and chorio-retinal apposition. Forty-seven eyes (80 %) underwent SCB alone, while 15 eyes (20 %) were combined with 25-G pars-plana vitrectomy. Cryopexy and laserpexy were used in 38 (61 %) and 24 of eyes (39 %) respectively. RESULTS: Mean pre-operative best-corrected visual acuity (BCVA) improved from logMAR 0.82 (20/132) to 0.22 (20/33) (p < 0.0001). The single surgery reattachment rate was 92 % (57/62.) Final retinal reattachment was achieved in all eyes (100 %). No significant difference was observed in single-surgery anatomic success rates when stratified by lens status, macular involvement, or break location. There were no major intra- or post-operative complications. CONCLUSION: Suprachoroidal buckling using a special-design, flexible catheter is a safe and effective procedure for the management of RRD secondary to peripheral retinal breaks.

MODIFICATION OF ADJUSTABLE MACULAR BUCKLING WITH 29-G CHANDELIER LIGHT FOR OPTIMAL POSITIONING IN HIGHLY MYOPIC EYES WITH MACULAR HOLE.

PURPOSE: To evaluate the efficacy of the modification of Adjustable Macular Buckling device in the treatment of myopic macular hole retinal detachment with posterior staphyloma. METHODS: Four consecutive patients suffering from myopic macular detachment with macular hole were treated using the macular buckling procedure. An Adjustable Macular Buckling device was used in all four cases and was modified using a 29-gauge optical fiber to illuminate its macular plate. RESULTS: Optical coherence tomography showed successful retinal reattachment and closure of the macular hole after the buckling procedure. The macular plate of the buckling device was properly positioned in all four patients. No complications were observed. CONCLUSION: The modification of the macular buckling device improves the accuracy of its positioning by illuminating its macular plate.

Outcomes of scleral buckling using chandelier endoillumination.

PURPOSE: To report the results and complications of scleral buckling for the treatment of rhegmatogenous retinal detachment (RRD) using 25-gauge chandelier endoillumination. METHODS: A total of 61 patients (61 eyes) with RRD were treated with scleral buckling. For the sclera buckling procedure, a 25-gauge chandelier was inserted through the pars plana for intra-ocular illumination, and retinal tears were identified and treated with episcleral cryotherapy under surgical microscope. On postoperative days 1, 3 and 7, the intra-ocular pressure was measured by a non-contact tonometer. On postoperative months 1 and 3, ultrasound biomicroscopy was used to examine the pars plana incision. RESULTS: In the surgical procedure, there was no lenticular or retinal damage due to the chandelier insertion. There was no conjunctival bleb formation at pars plana incision and no incidence of endophthalmitis after surgery. The mean intra-ocular pressure was 15.74 ± 2.98, 15.83 ± 2.76 and 16.14 ± 2.52 mmHg on postoperative days 1, 3 and 7, respectively. The one-time retinal reattachment rate was 93.4%. No visible vitreous incarceration was found in the incision of the pars plana. CONCLUSION: There was no complication found due to the chandelier insertion in early postoperative period. Chandelier endoillumination is a feasible method for retinal visualization under surgical microscope during scleral buckling.

MIRAgel: the immunohistochemical expression of CD3, CD34, and CD68 in the surrounding capsule.

PurposeTo study the immunohistochemical features of the capsule tissue surrounding MIRAgel episcleral buckles.Patients and methodsThis Institutional interventional clinical cohort study examined a consecutive series of 21 referred patients who required MIRAgel removal from July 2009 to July 2013. All patients with hydrated and fragmented MIRAgel episcleral buckles were included in this study. Capsule biopsies from MIRAgel episcleral buckles were obtained from all patients. Capsule specimens of seven patients with extruded silicone bands were processed as controls. Paraffin-embedded specimens were examined using light microscopy and immunohistochemistry (via the PAP horseradish peroxidase technique) to detect the expression of CD3, CD20, CD34 and CD68, and S-100 protein.ResultsInflammation with granuloma, which was primarily related to sutures, was found in all (n=36) of the MIRAgel specimens and foreign body granulomas with multinucleated giant cells, histiocytes, and macrophages (CD68+ cells) surrounded the MIRAgel fragments. Average number of CD68+ cells was higher (P<0.001) for MIRAgel than for silicone rubber. The lymphocytic inflammatory infiltrate related to the MIRAgel fragments was CD3+ and CD20- (delayed T cell-mediated immune response). Moderate neoangiogenesis was indicated by the presence of CD34+ cells.ConclusionsThe immunohistochemical analysis revealed that the immune system is able to identify the fragments of MIRAgel (after its hydrolytic degradation) as a foreign body during a delayed T cell-mediated immune response. The phagocytosis by macrophages likely triggers and perpetuates local disease. Removal of MIRAgel explants before hydrolysis should be considered.