11.1 Scleral Buckle

1. Young myopic patients (without a posterior vitreous detachment), particularly those under 50 years of age
2. Phakic lens status
3. Inferior (gas or silicone oil tamponade is less effective), anterior, atrophic breaks
4. Retinal dialyses

1. Significant media opacity limiting 360° peripheral examination: corneal scar, cataract, vitreous hemorrhage
2. Proliferative vitreoretinopathy Grade B or higher
3. Special cases where vitrectomy is generally preferred (although scleral buckling has been described): giant retinal tear with detachment, macular hole retinal detachment, myopic macular detachment

Note

If undergoing a scleral buckle following a failed pneumatic retinopexy, avoid having the patient lie supine pre-operatively as this can induce a “gas cataract” that will make the surgery more difficult

1. Use conjunctival (Bonaccolto) forceps to lift the conjunctiva and Tenon’s capsule, whilst cutting it with Westcott scissors. Marking the 3 and 9 o’clock positions can assist with closure later
2. ± Create radial relaxing incisions at 3 and 9 o’clock to prevent tearing

Note

Remember that Tenon’s capsule inserts into the sclera posterior to the corneal limbus. Although the conjunctival peritomy should occur close to the corneal limbus, blunt dissection must occur posteriorly enough to capture both Tenon’s capsule and conjunctiva

Options

1. A recessed conjunctival peritomy, approximately 2mm posterior to the limbus is an alternative in young patients who are contact lens wearers. If this is performed, a continuous running suture is preferable for closure
2. If a segmental tire without circumferential band or a radial sponge is to be inserted, a full 360 degree conjunctival peritomy is unnecessary. The conjunctival peritomy can be performed in the region where the explant will be inserted. If a rectus muscle needs to be mobilised where there is no conjunctival peritomy, a 4-0 silk suture can be passed underneath it with a vascular needle

1. Use Steven tenotomy scissors in four quadrants between the rectus muscles
2. Cut Tenon’s capsule to form a “pocket”, insert the Stevens tenotomy scissors fully in, then open them to blunt dissect and remove with them still open. This breaks any remaining adhesions between Tenon’s capsule and sclera

Order: Horizontal recti muscles, inferior rectus, superior rectus.

Generally the superior rectus is left until last since it is hardest to sling given its difficult exposure and close proximity to the superior oblique. Once the horizontal rectus muscles have been slung, the silk sutures can be used to supraduct and infraduct the eye for greater exposure of the inferior and superior rectus muscles respectively.

1. Use a Jameson muscle hook to capture a muscle. Point the tip of the muscle hook radially into the fornix, sliding it along the surface of the sclera. Once deep in the fornix, rotate the hook around so that it captures the muscle. Ensure that the muscle hasn’t been split by the hook, and that all the muscle fibres have been captured
2. Angle the tip of the Jameson muscle hook away from the scleral surface, creating an opening for passage of the 2-0 black silk (or 2-0 Ethibond Excel* Polyester) suture. It is easiest to use a fenestrated (Gass) muscle hook to pass the suture in the opposite direction to which the Jameson muscle hook was passed. Alternatively, the needle can be grasped at the tip and the suture inserted “backwards”
3. Tie off the silk suture near its free ends and near the muscle. To do this, place the conjunctival (Bonaccolto) forceps over then under the suture, and grasp the free ends. To tie the suture near the muscle, keep the suture loop “open” and slide it down with the open Bonaccolto forceps before tying off (Figure 11.1.3.5)
4. Repeat for all four rectus muscles

Note

• When slinging the inferior and superior rectus muscles, push the muscle hook posteriorly to check that the inferior and superior oblique muscles have not been inadvertently captured, respectively. It should slide freely
• There may be less chance of capturing the superior oblique if the muscle hook approaches from the nasal side
  
  

Options

• If a fenestrated (Gass) muscle hook is unavailable, the suture can be passed underneath the muscle with the needle held backwards in a needle holder (driver)
  
  

Tenon’s capsule should be thoroughly cleaned off the rectus muscles. There are three ways of doing this:

1. Use conjunctival (Bonaccolto) forceps to hold up conjunctiva, then a cotton bud (q-tip) to pull Tenon’s capsule off the edge of rectus
2. Use conjunctival (Bonaccolto) forceps to strip the Tenon’s capsule posterior along the muscle
3. Use conjunctival (Bonaccolto) forceps to hold up conjunctiva, then Westcott scissors to cut off Tenon’s adherent to this. Remember that muscle doesn’t attach to conjunctiva. This is less traumatic than using a cotton bud (q-tip), but has the potential risk of cutting muscle if the anatomy is not identified correctly

Localise the retinal detachment with an indirect ophthalmoscope and lens (e.g. 20D or 30D). The indirect ophthalmoscope (“hat”) is adjusted on the surgeon’s head with a double glove or sterile bag. Use a cotton bud (q-tip) or muscle hook for indentation. The assistant holds the rectus sutures radially out perpendicular to where the surgeon is looking, and maintains the cornea moist with BSS.

1. Determine the extent (in clock hours) of the retinal detachment
2. Mark the centre of the posterior edge of the breaks (if the break is large, the entire extent may need to be marked). Use an O’Connor localiser to mark the sclera, dry the area with a cotton bud (q-tip), then re-mark with a fine point permanent marking pen. The mark can be re-checked with the O’Connor localiser or wooden end of a cotton bud (Figure 11.1.3.7)