Indications and outcomes of scleral buckle removal in a tertiary eye care center in South India.

PURPOSE: To study the clinical profile of patients undergoing scleral buckle removal (SBR) surgery.
MATERIALS AND METHODS: All consecutive patients undergoing SBR surgery following scleral buckle for retinal detachment repair between January 2002 and December 2011 with a minimum postSBR follow-up of 6 months were included in this study. A record based on analysis of indications, methods, complications, and outcomes of the eyes was performed.
RESULTS: One hundred and two eyes of 101 patients (men = 77; 76.24% and women = 24; 23.76%) belonging to the age group of 15-78 years (mean 50 ± 15 years) were included in this study. Time gap between scleral buckle and SBR ranged from 2 to 216 months (mean 61 ± 51 months). Buckle exposure with clinical infection (81; 79.41%) was the most common indication. Of 90 (88.2%) eyes with positive culture, 75 (83.3%) revealed single and 15 (16.6%) revealed multiple microorganisms. Staphylococcus epidermidis (42; 41.2%), was the most common isolate. Fungus was isolated in 3 (2.94%) eyes. Globe perforation (14; 13.7%) and recurrent retinal detachment (7; 6.9%) were the commonest complications. Time gap between SBR and recurrent retinal detachment ranged from 15 days to 50 months (mean 12.2 ± 18.3 months).
CONCLUSIONS: Most of the exposed scleral buckles developed clinical infection few months to years after surgery, ultimately requiring SBR. Recurrent retinal detachment after SBR may appear from few days to years later warranting a long-term follow-up.

Introduction

Scleral buckling (SB) as a method of retinal reattachment can provide comparable results with primary pars plana vitrectomy.[123] With the change in the technique and material for SB the rate of complications has been minimized but still a small number of patients require scleral buckle removal (SBR) during the follow-up.[4567]

Indications of SBR are diverse.[58] Buckle infection, which is one of the most common indications of SBR has been noted to have variable presentation in different climatic condition.[58910] Though commensal microorganisms are responsible for most of the buckle infection cases, Pathengay et al. have reported higher prevalence fungus, acid fast organisms and polymicrobial infection in Indian scenario.[10] Recurrent retinal detachment is the most feared complication of SBR and varies widely in its incidence and management.[56711] In literature review of SBR, Tsui I has reported the incidence to vary between zero to 33%.[5] Management of recurrent retinal detachment varies from pneumatic retinopexy to repeat SB and vitrectomy.[6811]

The present study intends to present indications, microbiological profile and outcome of patients undergoing SBR surgery in south India. This seems pertinent in the current times as scleral buckle procedure and its outcome are being re-evaluated in view of advancement in vitrectomy techniques and instrumentation.[123]

Materials and Methods

All consecutive patients who underwent SBR surgery following scleral buckle for retinal detachment repair between January 2002 and December 2011 with a minimum postSBR follow-up of 6 months were retrospectively reviewed following approval of the Institutional Review Board. Patients with previous vitrectomy or previous retinal detachment surgery on the same eye were excluded from study. Eyes with belt buckling for retinopathy of prematurity were not included. Cases in which buckle sutures were trimmed or removed without removal of buckling material were not included in the study. Eyes which had penetrating injury after SB were not included in the study.

Demographic data were obtained from medical records. Time gap between SB and SBR was noted for all eyes. Visual acuity was measured with Snellen's chart before the surgery and at the final follow-up. Type of SB (explant vs. implant), materials removed and indication for removal were recorded. Scleral buckle exposure and infection were noted separately.[7] Exposed buckles were further analyzed based on presence and absence of clinical infection. Removed materials after surgery were sent for bacterial and fungal cultures. Complications after SBR were noted with consequent management. Favorable anatomical outcome was defined as attached retina with quiet eye. Favorable functional outcome was defined as maintained or improved vision by one line on Snellen's visual acuity chart.

Results

One hundred and two eyes of 101 patients were included in the study. Of them 77 (76.24%) were men and 24 (23.76%) were women in an age group of 15–78 years (mean 50.1 + 14.99 years). One patient had SBR in his both eyes. Time gap between SB and SBR was 2–216 months (60.79 + 50.78 months). The follow-up of SBR ranged from 6 to 108 months (32.43 + 27.07 months).

Eighty-one (79.41%) eyes had undergone scleral buckle explant while 21 (20.58%) eyes had undergone implant surgery. The best corrected visual acuity was <20/400 at presentation in 37 (36.3%) eyes [Table 1]. General anesthesia was used in 79 cases (77.45%) while 23 (22.54%) eyes were operated under local anesthesia. Both solid silicon tire and band were removed from 92 (90.19%) eyes. Sponge was removed from 6 (5.88%) eyes and silicon encircling band alone was removed from four (3.92%) eyes. Buckle exposure with clinical infection (81; 79.41%) and buckle exposure without clinical infection (11; 10.78%) were the most common indications of buckle removal [Table 2, Figures 1 and 2]. Of 93 eyes with exposed buckles, 81 (87%) had clinical infection, 11 (10.78%) did not have clinical infection and 1 (1.07%) eye had anterior migration of buckle. Three (2.9%) eyes with intraocular infection had buckle intrusion causing endophthalmitis.

Table 1

Initial and final visual acuity in eye undergoing scleral buckle removal

Table 2

Indications of scleral buckle removal

Figure 1

Buckle exposure without clinical infection

Figure 2

Buckle exposure with clinical infection

In 90 (88.23%) eyes identification of microorganism on culture was possible while cultures were negative in other 12 (11.76%) eyes. Single microorganism was identified in 75 (73.52%) eyes whereas culture from remaining 15 (14.70%) eyes yielded more than one microorganism. Of the 90 eyes, scleral buckle material was the source of identification of microorganism is 83 (90.22%) eyes; buckle sutures were the source in 76 (84.44%) and conjunctiva in 9 (10%) eyes. Overall culture revealed bacterial infection in 87 eyes (85.29%) and fungal infection in three eyes (2.94%). Gram-positive bacteria (76; 74.50%) outnumbered Gram's-negative (11; 10.78%) bacteria. S. epidermidis (42; 41.17%) and Staphylococcus aureus (15; 14.70%) were the most common isolates [Table 3]. In three eyes with intraocular infection, the culture isolates from scleral buckle material and vitreous were identical. Two of these eyes had S. aureus and one eye had Pseudomonas aeruginosa grown in culture. All these three eyes needed vitrectomy with intraocular antibiotics along with SBR.

Table 3

Isolated microorganisms (n=105)

All patients undergoing SBR were treated postoperatively with oral ciprofloxacin (500 mg twice daily for 5 days). Scleral perforation (14; 13.72%) and recurrent retinal detachment (seven; 6.86%) were the most common postoperative complication. Scleral thinning was noted in 8 (7.84%) eyes. Scleral abscess, choroidal detachment, vitreous hemorrhage and accidental extraocular muscle disinsertion were noted in 1 (0.98%) eye each. All eyes with scleral perforation had buckle exposure with clinical infection and 8 (57.14%) of them had previously undergone intrascleral implant. Scleral perforation was managed with cadaveric scleral patch graft in 6 (42.85%) eyes. Scleral suturing with 7–0 vicryl suture was done in other 6 (42.85%) eyes and cynoacrylate glue was used in 2 (14.28%) eyes. Time gap between SBR and recurrent retinal detachment ranged from 15 days to 50 months (mean 12.21 + 18.28 months). Out of seven eyes with recurrent retinal detachment 4 (57.14%) had developed retinal detachment before 1-month, 2 (28.57%) in the 2nd year and 1 (14.28%) in the 5th year after SBR. All eyes with recurrent retinal detachment had buckle exposure with clinical infection as the indication for buckle removal. A new retinal break in the reattached retina was the cause of recurrent retinal detachment in 4 (57.14%) eyes. In 1 (14.28%) case, in which scleral buckle was done for partial retinal detachment; new break occurred in the part of retina which was never detached. In remaining 2 (28.57%) eyes the cause of recurrent retinal detachment could not be identified. Vitrectomy and endotemponade was done in 4 (57.14%) eyes. One (14.28%) eye with retinal detachment was managed with laser barrage while 2 (28.57%) eyes did not undergo any treatment. Favorable anatomical outcome was achieved in 92 (90.19%) eyes after the SBR procedure and favorable functional outcome was achieved in 90 (88.23%) eyes.

Discussion

The present study describes the various indications and outcome of SBR surgery in south India. It describes the microorganisms involved in buckle infection cases as well as complications of SBR. We have found that scleral buckle exposure with clinical scleral buckle infection was the most common indication of buckle removal in our group of patients while buckle exposure alone was the second most common indication. None of the eyes undergoing SBR had clinical infection without exposure. Han et al. and have reported buckle exposure without clinical infection (16; 44%) as the most common indication and clinical buckle infection with and without exposure (six; 17% each) as next two common indications for SBR.[8] In their group of patients out of 22 eyes which had buckle exposure, 16 (72.72%) had clinical buckle infection. Patients with exposed buckles in our group were more likely to develop clinical infection (81 clinical infection eyes out of 93 buckle exposure eyes, i.e., 87%). In fact we have obtained positive culture results in eyes which did not present with clinical buckle infection (90 positive culture reports). Hence, our group of patients were more likely to harbor buckle infection even if there was no discernible clinical infection. The reason behind these may be explained by relatively warmer climatic conditions in India. It is also imperative that patients presenting late after onset of buckle exposure would be more likely to present with buckle infection as well, however ours and study by Han et al. have not dealt with duration of exposure in such patients. The maximum time gap of 216 months (18 years) between SB and SBR stresses that eyes undergoing SB should undergo regular ocular examination even if they were asymptomatic so that asymptomatic buckle exposures may not be missed out until they become infected.

There has been multitude of reports on indication of SBR in literature.[6789101112] Nuzzi et al. and Deokule et al. have noted pain alone as the first and second most common indication respectively for buckle removal in their group of patients.[1314] We have not noted pain alone as the indication of buckle removal in our patients. Though complications like direct optic nerve injury, anterior segment ischemia, and macular distortion have been reported to need SBR as well; across the studies buckle exposure and infection remain the most common causes of removal.[6789101112131415] On the other end of clinical spectrum, not every eye with buckle exposure may warrant a removal. Schmidt and Cohen have followed an one eyed patient with buckle exposure in seeing eye for 11 years without removing the explant.[16] The decision to remove the scleral buckle may rely on the patient characteristics like age, comorbid conditions and status of other eye.[5] We have used general anesthesia in most of our patients for buckle removal as it is safer than local anesthesia in an eventuality of globe rupture during surgery. However that also means increased anesthesia related complications for the patients especially in older age group. Therefore stabilization of systemic parameters prior to SBR would seem wise unless there was compelling urgency like intraocular infection. We had seen three such patients who had presented with endophthalmitis with buckle intrusion and were operated on emergency basis and were managed later with intravitreal antibiotics.

We have found S. epidermidis as the commonest microorganisms isolated from removed scleral buckles which is in keeping with study by Pathengay et al. and Smiddy et al. however prevalence of polymicrobial infection in our patients was less than that reported by Pathengay et al.[1012] Acid fast organisms were not isolated from our group of patients. We also report that though buckle material and sutures were the most common source of isolation of microorganism; conjunctival bits obtained during the surgery should also be cultured as they were the sole source of identification of microorganisms in 10% of our culture positive cases.

Scleral perforation during buckle removal noted in our patients may be attributable to the fact that all such eyes had buckle exposure with infection and probably harbored some degree of scleral thinning. Keeping cadaveric scleral patch graft ready during removal of implants and when scleral buckle surgical details are unknown would be a wise move to save the eyes in case of perforation. We also report use of cyanoacrylate glue in two of our patients which was hitherto not reported to the best of our knowledge. Rate of recurrent retinal detachment (6.86%) after SBR was less in our patients compared to Schwartz and Pruett (14.5%) and Han et al. (11.8%).[817] Recurrent retinal detachment developed in 1st month in most of our patients which was similar to Han et al. who noted it to develop as early as 2 days of SBR.[8] This may mean that eyes undergoing SBR should undergo retinal examination at short intervals during first few months after the surgery.

The present study describes the clinical profile of patients undergoing SBR in India. Regular ocular examination is necessary in patients treated with SB for retinal detachment as such eyes may develop buckle exposure and infection long after the primary surgery. Most of the exposed buckles ultimately developed clinical infection. Further eyes undergoing SBR should have regular ophthalmoscopic examination to look for recurrent retinal detachment; more so if the indication for removal was exposure with clinical infection.

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Conflicts of interest

There are no conflicts of interest.