Irmak Karaca, MD, FEBO, FICO, MRCSEd:

Hi, I am Irmak Karaca, a second year vitreoretinal surgery fellow at Manhattan Eye and Ear Hospital and Columbia University in New York. Our study evaluated the outcomes of scleral buckle revision for the repair of recurrent or persistent rhegmatogenous retinal detachment following the primary scleral buckle failure. In today's practice, when the buckle fails, most of the time these patients undergo pars plana vitrectomy. However, especially in young phakic patients, vitrectomy may not be the ideal next step because these patients have formed attached vitreous, putting them at higher risk of iatrogenic retinal breaks, challenging PVD induction, PVR risk, cataract progression, and long-term vitreoretinal changes.

We reviewed eight patients who underwent scleral buckle revision following primary buckle failure, and these patients were young with the mean age of 33 and all eyes were phakic with a macula-on retinal detachment. What we found was the most buckle failures were due to localized correctable problems, and most common cause for the buckle failure was actually inadequate buckle support, meaning that the breaks were not properly indented under the scleral buckle, which was seen in five eyes. Two eyes had new or missed retinal breaks, and importantly, these mechanisms do not necessarily mandate the vitreous removal with vitrectomy. Revision surgery typically included either the augmenting existing buckle with the additional segmental element or modifying the original buckle configuration to provide a better support to the retinal breaks.

One practical lesson from this series is that revision surgeries can technically be challenging because of the significant scarring from the primary buckle surgery. Therefore, careful conjunctival dissection, meticulous dissection of the fibrous tissue around the extraocular muscles, and opening of capsular sheet around the encapsulated buckle element with sharp dissection are critical steps for the successful revision surgery. Also, general anesthesia is often helpful to facilitate these complex dissections.

We achieved successful [inaudible] reattachment at six months in all eyes with the preservation of phakic status and the visual acuity at the mean of 20/22, and no intraoperative complications was seen.

So the take home message is that not every failed buckle requires vitrectomy and understanding why the buckle failed is critical. And in appropriately selected group of patients, scleral buckle revision surgery still remains a valuable and underutilized option in modern vitreoretinal surgery. Thank you very much.