• Cryotherapy and Scleral Buckling Surgery
• Gas Bubble Injection (Pneumatic Retinopexy)

Cryotherapy and Scleral Buckling

If the retina has become detached and the detachment is too large for laser treatment or cryotherapy alone, surgery is necessary to "reattach" the retina. Without some type of retinal reattachment surgery, vision will almost always be completely lost. If pneumatic retinopexy cannot be performed, a scleral buckle is usually the procedure used to repair the retinal detached retina.

The Procedure

Scleral buckling is generally performed in the operating room under local anesthesia but, in some cases, may be performed under general anesthesia. The surgeon first treats the retinal tear with cryotherapy. A cryoprobe is placed on the outside part of the eye (the sclera) as the surgeon looks into the eye. The surgeon then places the cryoprobe in the correct position and the retinal tear is treated. A piece of silicone plastic or sponge is then sewn onto the outside wall of the eye (sclera) over the site of the retinal tear. This pushes the sclera in toward the retinal tear and holds the retina against the sclera until scarring from the cryotherapy seals the tear. This surgery is called scleral buckling because the sclera is buckled (pushed) in by the silicone. The silicone buckle is left on the eye permanently. Another type of scleral buckling surgery for retinal detachment can be done with a small rubber balloon which is left on the eye only a few days and is then removed.

The silicone may also be placed all around the outside circumference of the eye. This is called an encircling scleral buckle or band. The purpose of the encircling scleral buckle is to lessen the pulling of the vitreous on the retina. During the surgery, the surgeon may drain the fluid from beneath the retina by making a tiny slit in the sclera, and then making a small puncture into the space under the retina. The fluid under the retina then drains out through the slit in the sclera.

Encircling Scleral Buckle

Occasionally, the surgeon may place a gas bubble into the vitreous cavity. When the surgery is over, the patient is positioned so that the gas bubble rises and pushes the retinal tear against the scleral buckle to help keep the tear closed.

In most cases, there is better than 80% chance of successfully reattaching the retina with one operation. But successful reattachment does not necessarily mean restored vision. The return of good vision after surgery depends on whether, and for how long, the macula was detached prior to surgery. If the macula was detached, vision rarely returns to normal. Still, if the retina is successfully reattached, vision usually improves. The best vision may not occur for many months after surgery.

Postoperative Period

Following surgery, the eye will be red and slightly sore for a month or two. Patients often feel a scratchy sensation produced by the stitches used to close the lining around the eye. Severe pain is uncommon; if it occurs, the surgeon should be told immediately. The eye will water for several weeks, and the patient may find it more comfortable to wear a patch on the operated eye. Usually, several medicines given as eye drops must be taken after the surgery. These should be continued until the surgeon asks the patient to stop. These drops are used to prevent infection and to help make the eye feel more comfortable. In most cases, the patient may leave the hospital the day of surgery.

Following the surgery, vision will be blurry; it may take many weeks for the vision to improve. During this period the main concern is that the retina remains attached. Many surgeons ask their patients to restrict their physical activity for several weeks.

Complications of Scleral Buckling

Even though the surgery for retinal detachment is generally successful, certain complications can occur. Any one of these complications can result in failure of the operations, loss of some or all vision, and, in rare situations, even loss of the eye.

Retinal detachment surgery done by scleral buckling can affect the eye muscles that move the eye and keep the eye straight. This can result in double vision, which on rare occasions is permanent. Retinal detachment surgery can also cause bleeding under the retina, cataract formation, glaucoma, retinal redetachment, proliferative vitreoretinopathy, vitreous hemorrhage, drooping of the upper lid, and infection. Although any one of these can result in the need for some surgery, or in the total loss of vision, these complications are very infrequent. Retinal redetachment is the most commonly occurring problem. If this occurs, your surgeon will discuss the chance that a reoperation will successfully reattach the retina.

Gas Bubble Injection (Pneumatic Retinopexy)

Cryotherapy or laser treatment is performed to seal the retinal tear. The surgeon, using a needle, injects a gas bubble inside the vitreous cavity of the eye. The patient is instructed to keep his head in a specific position so that the gas bubble pushes the detached retina against the back wall of the eye to seal the retinal tear. The patient is asked to remain in this position for various periods of time until the retinal tear is sealed against the back wall of the eye. The surgeon will tell you how long special positioning is necessary.

The gas bubble in the vitreous cavity of the eye expands for several days and takes six to eight weeks to disappear. During this time, airplane travel or travel to a high altitude must be avoided because high altitudes can result in an expansion of gas and an increase in pressure that can damage the eye. Your surgeon will tell you when it is safe to travel. It is also important for a patient with a gas bubble not to lie face up, as the air bubble may come to rest against the lens of the eye and cause a cataract or high pressure in the eye.

Positioning after retina surgery with gas bubble present in the eye

Outcome

The chance of successfully reattaching the retina with pneumatic retinopexy is less than with the scleral buckling surgery, but the final visual outcome is better if the pneumatic retinopexy is successful. Also, pneumatic retinopexy cannot be used, or is not effective, for every retinal detachment. The surgeon will discuss with you whether pneumatic retinopexy is feasible and the chances for successfully reattaching your retina. With pneumatic retinopexy, hospitalization, general anesthesia, and the cutting done for the scleral buckling surgery are all avoided. Complications of pneumatic retinopexy include cataract formation, glaucoma, gas getting under the retina, excessive scar tissue formation, and infection. Any one of these complications can lead to a total loss of vision, but each is rare. The most common complication is recurrence of the retinal detachment. The recurrence rate is about 25%. If the retina becomes detached again, scleral buckling surgery or vitrectomy can usually be performed to reattach it.