Retina Today - Controversies in Vitreoretinal Surgery: Is Scleral Buckling an Important Mainstay in the Treatment of Retinal Detachment in 2014? (January/February 2014)

摘要

These articles are based on the debate-style presentations at the American Academy of Ophthalmology Retina Subspecialty Day in New Orleans November 15-16, 2013. The arguments presented by the authors, affirmative or negative, were assigned to them and do not necessarily reflect their own opinions and practices. Scleral Buckle for Retinal Detachment: Pro By Gaurav K. Shah, MD; and Baseer Ahmad, MD Is scleral buckling surgery for retinal detachment (RD) repair here to stay? We believe the answer is “yes,” but only if ophthalmologists continue to perform and teach these procedures. If we do not, scleral buckling procedures will pass into history. There is no doubt that pars plana vitrectomy (PPV) is an effective procedure, valued day in and day out. So are scleral buckling procedures, however, for appropriate cases. Even so, scleral buckling procedures have become eclipsed by PPV. A PubMed search revealed the following: since 1956, 2745 articles have been published on scleral buckling; since 1970, 12 341 articles have been published on PPV; since 1972, 1073 articles have been published on scleral buckling plus PPV. In the past 5 years, the difference is even more pronounced, with 395 articles on scleral buckling, 3126 on PPV, and 234 on both procedures. Medicare claims data (Figure 1) also reflect this trend. From 2000 to 2011, use of the PPV code has more than doubled, from about 15 000 annual procedures to about 32 000. Meanwhile, the use of scleral buckling has declined, from 6000 to 2000 procedures per year. Several factors may be responsible for these changes. The availability of small-gauge instrumentation, wide-angle viewing systems, high-speed cutters, and better illumination have made PPV much easier. Surgeons may also lack confidence in their skills with indirect ophthalmoscopy, and there is less time spent on scleral buckling by mentors and training programs. Economic and time factors play a role. In addition, there is no industry support of scleral buckling at this point. At the same time, there is a growing list of misconceptions about scleral buckling. These include the following: The success rate with scleral buckling is lower than that with PPV; The choice of initial treatment does not make a difference in failure outcomes; Scleral buckling has a high incidence of complications; There is a significantly higher amount of myopia after scleral buckling compared with PPV; Rates of proliferative vitreoretinopathy (PVR) are higher after scleral buckling than after PPV. MISCONCEPTIONS EXAMINED A look at the relevant literature shows that all of the above are incorrect assumptions. Success rates. Reviewing the published results of retrospective and prospective comparative case series from 2000 to the present,1-15 the single-operation success rate is better with PPV in some papers and with scleral buckling in others, with no preponderance of greater success with PPV or scleral buckling. However, when results are broken down into phakic and pseudophakic groups, it becomes clear that in pseudophakic eyes PPV is the more common procedure with the higher success rate. Conversely, in phakic eyes, single-operation success with scleral buckling seems to be equivalent, and in some cases superior, to PPV. A recent multicenter study16 reached a similar conclusion. This nonrandomized retrospective study assessed success and failure of the primary procedure in the treatment of 7678 rhegmatogenous RDs by 176 surgeons on 5 continents. Final success rate in phakic eyes was higher with scleral buckling than with PPV (99.5% vs 98.7%; P = .028). The study authors concluded that, in the treatment of uncomplicated phakic RD, repair using scleral buckling is at least equivalent to PPV. Initial treatment does not matter. In a retrospective study including 1402 eyes,17 those who failed initial treatment with scleral buckling required approximately 30% fewer secondary retinal pro