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• Author's Reply
  Jorge G Arroyo
  Published on: 4 June 2003
• Primary scleral buckle placement during repair of posterior segment open globe injuries
  J. Fernando Arevalo
  Published on: 21 May 2003

• Published on: 4 June 2003

  Author's Reply

  • Jorge G Arroyo, Retina Surgeon
  • Other Contributors:
    • Eric A. Postel

  Dear Editor

  The authors read with interest the comments made by Dr Arevalo and colleagues.[1] We certainly agree that new breaks may develop in the vitreous base region within 2 clock hours of the scleral wound. Because of this, we advocate the use of encircling scleral buckles (3.5-5 mm wide) as opposed to segmental scleral buckles in patients undergoing primary open-globe injury repair.

  We agree that...

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  Dear Editor

  The authors read with interest the comments made by Dr Arevalo and colleagues.[1] We certainly agree that new breaks may develop in the vitreous base region within 2 clock hours of the scleral wound. Because of this, we advocate the use of encircling scleral buckles (3.5-5 mm wide) as opposed to segmental scleral buckles in patients undergoing primary open-globe injury repair.

  We agree that placing an encircling scleral buckle to support the posterior edge of the vitreous base does require more skill than simply closing an open-globe wound. However, we have found that with adequate training, encircling scleral buckles can usually be placed after open- globe injury repair in 15-30 minutes.

  The timing of vitrectomy in cases of ocular trauma is controversial. We also try to wait at least 1-2 weeks before performing a vitrectomy, if necessary, in order to minimize the risks of very early (potential bleeding, inflammation and poor visualization) and very late (cellular proliferation) vitrectomy.

  We agree that a prospective randomized clinical trial is needed to better delineate the role of primary encircling scleral buckle placement at the time of open-globe injury repair.

  Reference

  (1) Arevalo JF, Fernandez CF, Mendoza AJ. Primary scleral buckle placement during repair of posterior segment open globe injuries [electronic response to JG Arroyo et al. A matched study of primary scleral buckle placement during repair of posterior segment open globe injuries] bjophthalmol.com 2003 http://bjo.bmjjournals.com/cgi/eletters/87/1/75#147

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  Conflict of Interest:
  None declared.

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• Published on: 21 May 2003

  Primary scleral buckle placement during repair of posterior segment open globe injuries

  • J. Fernando Arevalo, MD
  • Other Contributors:
    • Carlos F. Fernandez MD, and Aristides J. Mendoza MD

  Dear Editor

  We read with interest the recent article by Dr Arroyo et al.[1] They are to be commended on a very interesting study to compare the visual and anatomical outcomes of patients who underwent primary scleral buckle (SB) placement during posterior segment open globe repair with matched control patients who did not undergo primary SB placement.

  Prophylactic scleral buckle of posterior se...

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  Dear Editor

  We read with interest the recent article by Dr Arroyo et al.[1] They are to be commended on a very interesting study to compare the visual and anatomical outcomes of patients who underwent primary scleral buckle (SB) placement during posterior segment open globe repair with matched control patients who did not undergo primary SB placement.

  Prophylactic scleral buckle of posterior segment open globe injuries has been a controversial topic in ophthalmology. The value of scleral buckling to support peripheral and especially inferior breaks is rarely disputed. However, the utility of using an encircling buckle in the absence of retinal breaks remains controversial.

  The beneficial facts of primary SB include that it is technically easy and there is no scarring present between the wound and overlying Tenon’s capsule and conjunctiva. However, there are some considerations against primary SB important to remember such as that in the case of eyes with perforating injury subsequent rhegmatogenous retinal detachment (RD) is often not directly related to the site of the posterior exit wound but develops secondary to a new retinal break in the vitreous base region within two clock hours of the wound.[2] In addition, it is usually difficult to place a buckle over the exit wound and involves potentially high morbidity (specially on the hands of an inexperienced resident that usually receives the patient in the emergency room [at least in Venezuela]).

  To counter subsequent traction at the vitreous base, a vitrectomy may be just as effective as a prophylactic SB, avoiding the associated morbidity.[3] If retinal incarceration occurs through the wound, secondary reconstruction must almost always be performed anyway, typically involving a scleral buckle and vitrectomy 10 to 14 days after the injury (when inflammation is under control, and the intraocular anatomic status has been assessed adequately).[4]

  We believe that the results of the study by Dr Arroyo and associates contribute with the understanding of the role of prophylactic primary SB in the treatment of posterior segment open globe injuries. Their impressive results suggest that the benefits of placing a prophylactic primary SB may out weight the risks involved. A multicenter randomized clinical trial is desirable to confirm their results.

  References

  (1) J G Arroyo, E A Postel, T Stone, B W McCuen, and K M Egan. A matched study of primary scleral buckle placement during repair of posterior segment open globe injuries. Br J Ophthalmol 2003;87:75-78.

  (2) Cooling RJ. Immediate management of posterior perforating trauma. Trans Ophthalmol Soc UK 1982;102:223-4.

  (3) Kuhn F, Pieramici DJ. Ocular Trauma: Principles and Practice. New York: Thieme Medical Publishers, 2002: 277.

  (4) Han DP, Mieler WF, Abrams GW, et al. Vitrectomy for traumatic retinal incarceration. Arch Ophthalmol 1988; 106: 640-645.

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  Conflict of Interest:
  None declared.

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