Scleral Buckling (Retinal Detachment)

Anesthesia Implications

Position: Supine, arms tucked, Bed turned 90 degrees
Time: 1-2 hours (average)
Blood Loss: Zero
Post-op Pain: Minimal (1-3)
Maintenance Paralytic: with GETT approach

Approach – These can be done as a MAC though many opt to perform as a general anesthetic. MAC is often chosen as a great option for patients at a higher risk for anesthetic complications or those that cannot tolerate being awake for the procedure. If performing as a MAC, a propofol bolus is given to allow the surgeon to give a retrobulbar block. Thereafter, as the patient wakes up, a series of drugs may be given to keep the patient comfortable for the rest of the procedure (e.g. versed, precedex, fentanyl). If performing as a general anesthetic, GLMA will usually be sufficient, but some prefer the GETT approach. 2 mg preoperative versed is common. Fentanyl throughout the case to keep the patient comfortable.

Extraocular Muscles (EOM) – when surgeon begins pulling on EOMs, HR will decrease. Have glycopyrrolate and/or atropine ready and don’t be afraid to tell the surgeon to stop if HR is going too low.

Surgeon Requests – The surgeon may request solu-cortef (if pt is not diabetic) and Diamox (Acetazolamide), to reduce inflammation and keep intraocular pressures down respectively. They will also request to keep BP on lower side (SBP 90s-110s). Ask for the surgeons preferred range.

Tucked Arms (general considerations): Consider a second IV – once the procedure has started, it’s going to be VERY difficult to handle IV issues – especially if your only IV has problems. Ensure the IV is running and monitors are still functioning after tucking the patient’s arms

Scleral buckling is used to treat retinal detachments. Retinal detachment happens when the retina separates from the underlying retinal pigment epithelium (RPE) and choroid. This can lead to vision loss.

Retinal detachment is typically caused by retinal tears. The retinal tears are due to trauma, age, myopia, etc. Once a retinal break occurs, fluid from the vitreous cavity can leak through the tear and build up between the retina and the RPE, creating a subretinal space. The accumulation of fluid further separates the retina from the others layers, further disrupting the oxygen supply to the retina.

Scleral buckling is performed to restore the link between the detached neurosensory retina and the RPE layer. During the procedure, a silicone band is placed on the sclera and sutured in place. The silicone pushes the sclera inward, leading to a buckle under the retinal tear.

This allows the RPE layer and the neurosensory retina to come into contact again. It also helps to reduce the flow of subretinal fluid, facilitating the reattachment of the detached retina. The buckle creates external support for the weak area of the retina, which reduces future tears.

The surgeon makes a small incision on the sclera near the affected area.

The surgeon exposes the outer layers of the eye and a silicone or plastic band is placed around the affected area of the sclera. This buckles the wall of the eye inward. This helps the retina reattach.

If there is a significant amount of fluid in the eye, the surgeon may drain it to improve the reattachment of the retina.

The incision is closed with sutures or clips.