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The authors read with interest the comments made by Dr Arevalo and
colleagues. 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...
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
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.
(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
We read with interest the recent article by Dr Arroyo et al. 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...
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. 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
To counter subsequent traction at the vitreous base, a vitrectomy may
be just as effective as a prophylactic SB, avoiding the associated
morbidity. 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).
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.
(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.