Is it time to call time on the scleral buckle?

Overnight, an extensive pool of subretinal fluid (SRF) disappears following the judicious application of a small plomb over a peripheral U-tear, and one can only marvel at the underlying mechanisms at play. The scleral indentation has somehow overcome the dynamic tractional forces operating in the region of the break, allowing it to close; and the “pigment epithelial pump” has obligingly dried out the subretinal space despite our having decimated the outer retinal tissues around the break in order to induce break sealing. Once the chorioretinal adhesion is fully established, it usually ensures that the break remains closed and the retina reattached even if the indentation eventually recedes and vitreoretinal traction is reinstated.

The attractions of the “Custodis” procedure are plain to see, not least because the complications of SRF drainage (and other scleral transgressions) are potentially avoided.1,2 However, the majority of rhegmatogenous retinal detachments (RRDs) cannot be treated so simply and effectively using a segmental buckle, especially where the breaks are too many or too large to indent with any degree of subtlety, too small or too well hidden to be identified with certainty, too awkward in location to be easily reached, or subject to too much traction. Twenty years ago, these challenges could be met by one or more of a series of surgical adjuncts, including encirclement of the globe (to relieve anterior circumferential traction and to ensure the maintenance of the indentations created by segmental buckles)1–3; intravitreal injection of air or gases of low solubility (to temporarily sequester the breaks from fluid vitreous that might otherwise be recruited subretinally)4,5; or closed microsurgery combined with break tamponade (to eliminate tractional elements and opacities by vitrectomy while bringing …