Lessons from our Pupils: A Reflection [Episode 3]

During Episode 142, Jay was joined by Dr. Ed Ryan of Minneapolis, MN to discuss the design of devices to improve surgical techniques, advances in vitrectomy, and scleral buckling. Central to this discussion was the idea that while scleral buckling may be falling out of favor, it is a technique that must not be forgotten and should be considered as the primary intervention in certain cases. Today’s blog post is from a new name on our team: Amy Kloosterboer, a third-year medical student at the University of Miami’s Miller School of Medicine. Today, we present the history of scleral buckling and some of the basic principles behind this surgery.  

Retinal detachment occurs when the retina separates from the underlying retinal pigment epithelium (RPE) and choroid. This can occur actively, as seen with diabetic traction retinal detachment, or passively due to accumulation of fluid between the two layers. The inner layers depend on the outer layers for delivery of nutrients and oxygen, and so this detachment can lead to damage to and even death of the cells in the neurosensory retinal layer. 

Image Credit:  (Left) http://www.shreeramkrishnanetralaya.com/retinal_detachment.html  (Top Right) https://www.lehp.org.au/Training%20Course/pages/conditions.html  (Bottom Right) http://www.fairvieweyecenter.com/Education/Conditions/RetinalDetachment/tabid/3103/Default.aspx

Image Credit:

(Left) http://www.shreeramkrishnanetralaya.com/retinal_detachment.html

(Top Right) https://www.lehp.org.au/Training%20Course/pages/conditions.html

(Bottom Right) http://www.fairvieweyecenter.com/Education/Conditions/RetinalDetachment/tabid/3103/Default.aspx

One of the options to treat retinal detachment is a scleral buckle. The principle behind this surgery is to collapse the space created between the detached retinal layer and its supporting layers. This is done by applying a band-like device onto the exterior of the globe, which causes inward indentation of the sclera to create a ridge (or buckle) that functionally closes the breaks. This allows the separated layers to come together once more.

Image Credit: https://www.texomaretina.com/services-2/common-treatments/scleral-buckle/

Image Credit: https://www.texomaretina.com/services-2/common-treatments/scleral-buckle/

The first successful treatment of retinal detachment occurred in 1920 by Swiss ophthalmologist, Dr. Jules Gonin. His technique involved closure of the break using trans-scleral cauterization. Since the patient subsequently recovered vision, this showed that retinal breaks were the main cause of retinal detachments, and that successful treatment involved sealing those breaks. Many different techniques were developed after 1920, but it was not until 1949 that the first scleral buckle surgery was reported. Dr. Erns Custodis, a German ophthalmologist and professor, performed the first scleral buckling procedure that included a retained exoplant. He sutured a polyviol material to the sclera, and effectively indented the eye wall at the area of the break to close the gap between the retinal layer and the RPE. In 1956, Dr. Charles L. Schepens, inventor of the binocular indirect ophthalmoscope, modified this technique to use an encircling polyethylene tube. With the help of the indirect ophthalmoscope, Dr. Schepens was able to localize the retinal break and correctly position this tube to seal the break between the layers. Today, there are a variety of materials can be used as a buckle, and the most common is silicone as it is nontoxic, nonallergenic, and can be molded as needed by the surgeon. This last property allows for great variability between operations, giving the surgeon the flexibility to adapt the technique to the patient and to choose between a localized scleral buckle to an encircling circumferential buckle. 

-Amy Kloosterboer

Jayanth SridharComment