157 Pak J Ophthalmol. 2022, Vol. 38 (2): 157-161 Original Article Early Removal of Scleral Buckle Nida Usman 1 , Muhammad Ali Haider 2 Department of Ophthalmology, 1-2 Al-Ehsan Welfare Eye Hospital ABSTRACT Purpose: To study the outcomes of early removal of segmental buckle on visual acuity, retinal status, and astigmatism. Study Design: Interventional case series Place and Duration of Study: Mayo hospital, from February 2018 to July 2018. Methods: Ten patients fulfilling the inclusion criteria were recruited. All the patients underwent segmental radial sponge with cryoretinopexy, with or without drain and intraocular gas tamponade as per need. Post-operative follow ups were at 1 st week, 4 th week and 6 th week. Sponge was removed at 6 th week after making sure that the retina was attached. Follow ups after buckle removal were planned at 1 st week, 1 st month and 3 rd month. Improvement in VA, retinal status and astigmatism were noted. The commonest reason for the explant removal was infection followed by pain. Normality was checked through Shapiro-Wilk’s W-test and the normality criteria was met so paired sample t-test was used to assess the significance of astigmatism pre and post-surgery. Results: The average age was 32.30 ± 16.75 years (range, 03 – 61 years). Anatomical success was achieved in 100%. Visual acuity improved in all patients. Moreover, early removal of buckle reduced astigmatism and further improvement in vision was also noted. Pre and post-surgical vision improvement was statistically significant with p-value of 0.000. After removal of buckle, improvement of astigmatism was also statistically significant p-value 0.004. Conclusion: The early removal of scleral explant not only provides symptomatic relief to the patients, but is also associated with marked improvement in visual acuity was noted. Key Words: Visual Acuity, Astigmatism, Retinal Detachment, Segmental Scleral Buckle. How to Cite this Article: Usman N, Haider MA. Early Removal of Scleral Buckle. Pak J Ophthalmol. 2022, 38 (2): 157-161. Doi: 10.36351/pjo.v38i2.1357 Correspondence: Nida Usman Al Ehsan Eye Hospital, Lahore Email: dr.nidausman@yahoo.com Received: December 11, 2021 Accepted: March 16. 2022 INTRODUCTION Scleral buckling (SB) has always been an important procedure for the management of retinal detachment and provides comparable results with primary pars plana vitrectomy. 1,2 Pars plana vitrectomy is increasingly used for repair of Rhegmatogenous retinal detachment (RRD)and is the most popular method of management nowadays. The importance of conventional method with cryotherapy and scleral implant cannot be put aside. 3 Buckling not only provides very good vision but also gives anatomical stability to the retina. 4 Scleral buckle is removed at 6 months after surgery or in some cases not removed at all. 5 Segmental scleral buckle is an extremely effective technique for the repair of retinal detachments, especially in young and phakic eyes with fresh RRD. 6 Its initial success rates are higher than pneumatic retinopexy and are comparable with vitrectomy and combined approach in selected cases. 7 Segmental buckle is a fast, simple and cost effective procedure. It eliminates the restriction of positioning and decreases risk of cataract formation with minimal astigmatism. It also reduces the risk of IOP rise and there is faster visual rehabilitation with no risk of travelling. On the Nida Usman, et al Pak J Ophthalmol. 2022, Vol. 38 (2): 157-161 158 other hand because of more chances of infection, extrusion, and astigmatism, with more implication of time and effort and more difficult training, its usage has become limited with the passage of time. 8 This study was conducted to evaluate anatomical and functional outcomes of early removal of segmental scleral buckle, chances of re-detachments and changes in the refractive status of the eye. METHODS Ten patients fulfilling the inclusion criteria were taken from the outdoor of Mayo Hospital. Phakic patients with fresh Rhegmatogenous retinal detachment, single break or multiple breaks involving 1 clock hour and PVR A or B were included. Pseudophakic patients with old RRD, multiple breaks or breaks involving 2 or more clock hours and PVR C were excluded. The data was collected from February 2018 to July 2018. Initial evaluation included: Visual Acuity (VA), Auto Refraction (AR), Intra ocular Pressure (IOP) and detailed anterior and posterior segment evaluation. All the patients underwent segmental radial sponge (507 or 509) with cryo, with or without sub-retinal fluid drainage and intraocular gas tamponade (C3F8) when needed. Post-operative visits were planned at 1 st week, 4 th week (laser augmentation if needed) and 6 th week. Removal of sponge was done at 6 th week after making sure the stability of retina. Follow up after buckle removal was planned at 1 st week, 1 st month and 3 rd month. Improvement in VA, retinal status and astigmatism were noted. Data was collected and analyzed using SPSS version 25. The Shapiro-Wilk’s W-test was applied for checking normality assumptions. Paired Sample T-test was used to check the significance of results, the p- value of ≤0.05 was considered as statistically significant. RESULTS Average age of the patients was 32.30 ± 16.75 years (range, 03–61 years). Functional success was 100% as visual acuity was improved in all the patients. Further improvement in visual acuity was observed after the removal of buckle. Anatomical success rate was also 100%. Mean duration of explant was 06 weeks and mean follow-up was 06 months. In all the 10 patients, radial silicone explants was applied. The commonest reason for the explant removal was infection. Followed by pain. Symptomatic relief was achieved in 100% of patients. No patient suffered from retinal re- detachment after removal of explant till the last followup. Normality was checked through Shapiro-Wilk’s W-test and the normality criteria was met so paired sample t-test was used to assess the significance of astigmatism pre and post-surgery and Friedman Test was applied to check the significance of visual improvement. Results showed that the pre and post- surgical vision improved significantly with p-values < 0.05. After removal of buckle, improvement in astigmatism was also significant p-value 0.004. Table 1: Pre and Post-Surgical Visual Improvement. Visual Acuity Log Units No. of Patients Percentage Pre Surgery 1.00 2 20.0 1.50 1 10.0 1.60 7 70.0 Total 10 100.0 Post Buckle (2 nd Week) 0.30 2 20.0 0.50 3 30.0 0.60 4 40.0 1.00 1 10 Total 10 100 Post Buckle Removal (6 th week) 0.10 2 20.0 0.30 2 20.0 0.40 2 20.0 0.50 1 10.0 0.60 2 20.0 0.70 1 10.0 Total 10 100.0 Table 2: Pre and Post-Surgical Astigmatism. Astigmatism Dioptres (D) No. of Patients Percentage Before Buckle Removal 0.90 1 10.0 1.20 4 40.0 1.40 1 10.0 1.70 3 30.0 2.20 1 10.0 Total 10 100 After Buckle Removal 0.40 1 10.0 0.70 1 10.0 0.90 3 30.0 1.20 2 20.0 1.40 2 20.0 1.70 1 10.0 Total 10 100.0 Early Removal of Scleral Buckle 159 Pak J Ophthalmol. 2022, Vol. 38 (2): 157-161 Table 3: Early Removal of Scleral Buckle Impacts. Total No. of Patients Minimum Maximum Mean Std. Deviation P- Value Visual Acuity VA Pre Surgery 10 1.00 1.60 1.4700 .24967 0.000* VA Post Surgery Pre-Buckle Removal 10 .30 1.00 .5500 .19579 VA Post Buckle removal 10 .10 .70 .4000 .20548 Astigmatism Astigmatism Pre Surgery 10 .90 2.20 1.4400 .38064 0.004* Astigmatism Post Surgery 10 .40 1.70 1.0700 .38312 *shows significant p-value, VA = Friedman Test was applied, Astigmatism = Paired Sample T-Test Figure 1: Functional Success. Figure 2: Post buckle improvement of astigmatism in individual patients. DISCUSSION The aim of our study was to find out the functional and anatomical success in case of early removal of scleral buckle, which was carried out at 6 th week. We had a close eye on patients on the 1 st week and kept on checking until 4 th week to see if the patient needed any laser augmentation, laser was applied to three patients who needed augmentation at the site of the break and after complete satisfaction we went for the removal of buckle at 6 th week post operative. Only two of our patients showed slight infection of the sponge in late 5 th week and their buckle was also removed at 6 th week. All of our patients showed 100% success as not only the vision of our patients improved but when these patients were followed up later at 6 th months and one year interval none of them showed any re- detachment. Not only did we measure betterment in the VA due to retinal attachment but we also calculated the degree of astigmatism induced due to buckle and when the buckle was removed astigmatism improved as well as the VA in most of our cases making it significant finding that early removal of buckle helps reduce astigmatism as well. Deokule investigated in his study that the commonest reason for explant removal was extrusion followed by pain, scleritis, infection and foreign body sensation but we only faced minor explant infection at the end of 5 th week for which we removed the implant at 6 th week. Retina was attached in 88.8% of his patients but we achieved the 100% success. He did not calculate the improvement in astigmatism after the removal of buckle but we calculated and showed significant improvement in astigmatism. 9 There are other studies which showed some of the major complications following scleral buckling. 10-13 These included extrusion, 10 fistula formation, 11 rejection 12 and intrusion of the sponge. 13 However, in our study only two patients got minor infection in the 5 th week which came better as soon as we removed the sponge by the end of 6 th week. By early removal of buckle we can avoid all of these complications and relieve our patients from the complications of buckle. 14 In previous studies, the usual time of removal of scleral buckle ranged from 03 – 80 months. 15,16,17 Moisseiev et al, studied the effects and indications of implant removal. 16 He experienced explant extrusion as the commonest reason for buckle removal. However, in our study infection was the commonest reason and we did not have extrusion in any case. In his study the improvement in VA was not significant but our patients showed marked improvement in VA. It might be because of the different patient selection criteria as we included only fresh detachments in our study. Different types of explants were studied by different authors but we used only radial silicone sponge. 18,19 Singh S has shown a rare case of buckle infection with Curvularia species. 19 Park SW et al. described Nida Usman, et al Pak J Ophthalmol. 2022, Vol. 38 (2): 157-161 160 that patient selection was a very important criteria in case of scleral buckling in the management of rhegmatogenous retinal detachment and its outcomes. 20 Limitations of our study was that it was a case series with only limited follow up. Large number of patients with longer follow ups and multi-center data are required to further prove the results of this particular study. CONCLUSION Early removal of scleral buckle at 6 weeks not just gives anatomical but functional success as well with minimal chances of post-operative infections. The discomfort that patients experience in case of buckle (sponge) is also reduced. Ethical Approval The study was approved by the Institutional review board/ Ethical review board (COAVS/817/2020). Conflict of Interest Authors declared no conflict of interest. Disclaimer This research study was conducted at KEMU and all authors were present in the said place during the conduct of the study. REFERENCES 1. Schwartz SG, Flynn HW. Pars plana vitrectomy for primary rhegmatogenous retinal detachment. Clin Ophthalmol. 2008; 2 (1): 57-63. Doi: 10.2147/opth.s1511. 2. Falkner-Radler CI, Myung JS, Moussa S, Chan RV, Smretschnig E, Kiss S, et al. Trends in primary retinal detachment surgery: results of a Bicenter study. Retina. 2011; 31 (5): 928-936. Doi: 10.1097/IAE.0b013e3181f2a2ad. 3. Heimann H, Bartz–Schmidt KU, Bornfeld N, Hilgers RD, Nodov M, Weiss C, et al. Results of the Scleral Buckling versus Primary Vitrectomy in Rhegmatogenous Retinal Detachment Study (SPR Study). Invest. Ophthalmol. Vis. Sci. 2006; 47 (13): 2690. 4. Kazi MS, Sharma VR, Kumar S, Bhende P. 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Singh S, Shrivastav A, Agarwal M, Gandhi A, Mayor R, Paul L. A rare case of scleral buckle infection with Curvularia species. BMC Ophthalmol. 2018; 18: 35. https://doi.org/10.1186/s12886-018-0695- 4 20. Park SW, Lee JJ, Lee JE. Scleral buckling in the management of rhegmatogenous retinal detachment: patient selection and perspectives. Clin Ophthalmol. 2018; 12: 1605-1615. Published 2018 Aug 30. doi:10.2147/OPTH.S153717 Authors’ Designation and Contribution Nida Usman; Consultant Ophthalmologist: Concepts, Design, Literature search, Data acquisition, Manuscript Preparation. Muhammad Ali Haider; Assistant Professor: Data acquisition, Data analysis, Statistical analysis, Manuscript preparation, Manuscript editing, Manuscript review. .…  ….