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We read with interest the recent article by Arroyo and associates.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 placement during posterior segment open globe repair with matched control patients who did not undergo primary scleral buckle 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 benefits of primary scleral buckle placement are that it is technically easy and there is no scarring between the wound and overlying Tenon’s capsule and conjunctiva. However, there are some important considerations against primary scleral buckle such as the 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 2 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 (especially in the hands of an inexperienced doctor who 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 scleral buckle, 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 10–14 days after the injury (when inflammation is under control, and the intraocular anatomical status has been assessed adequately).4
We believe that the results of the study by Arroyo and associates contribute to the understanding of the role of prophylactic primary scleral buckle in the treatment of posterior segment open globe injuries. Their impressive results suggest that the benefits of placing a prophylactic primary scleral buckle may outweigh the risks involved. A multicentre randomised clinical trial is desirable to confirm their results.
We read with interest the comments made by Fernandez and colleagues regarding our article.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 minimise the risks of very early (potential bleeding, inflammation, and poor visualisation) and very late (cellular proliferation) complications.
We agree that a prospective randomised clinical trial is needed to better delineate the role of primary encircling scleral buckle placement at the time of open globe injury repair.
The authors have no proprietary or financial interest in any products or techniques described in this article.