Bradley S. Gundlach, MD and Cindy Zhao, MD
Wills Eye Hospital
Philadelphia, PA
1986 – the first year of the Rock and Roll Hall of Fame, the year of Diego Maradona’s infamous “Hand of God” goal, and the last year Halley’s comet passed through our inner solar system. Many things have changed in the last 40 years, but some have stayed the same. Dr. Ronald G. Michels, in his comprehensive article in RETINA, outlining the techniques of scleral buckling (and likely precursor to his infamous textbook first published in 1990), demonstrates a profound expertise in vitreoretinal surgery that has stood the test of time: https://pubmed.ncbi.nlm.nih.gov/3517998.
Over the course of nearly 50 pages, Dr. Michels illustrates the principles and techniques of retinal re-attachment surgery, providing expert guidance for every step of scleral buckling surgery, from peritomy to closure, as well as peri-operative considerations and tips for reoperations. He advocates for local anesthesia with retrobulbar block for straightforward adult cases, but general anesthesia for children or reoperations. Each surgery begins with a peritomy, often 2mm from the limbus, which may spare the need for radial incisions with a limbal peritomy. Rectus muscles are identified and hooked, and the sclera is examined for areas of thinning.
Dr. Michels favors the use of circumferential bands placed equidistant from the limbus in all quadrants, with mattress sutures used to secure the band. Some of the techniques he describes would be considered more unusual for today’s standards, including intrascleral implants and large scleral pockets for scleral buckle placement. However, much like today, the workhorse of his surgical approach relies on the circumferential band, with modification of radial elements as needed. Beyond the selection of scleral buckling elements, he also highlights many other surgical pearls, including X-sutures to allow for stronger buckle imbrication particularly for radial elements, case selection for drainage of subretinal fluid, adjustment of scleral buckle height, and management of intraocular pressure using softening techniques and intraocular injections.
More than any specific technique, Dr. Michels places emphasis on the principles of retinal detachment surgery that have remained unchanged: identify the breaks, treat the breaks, and relieve vitreoretinal traction. He emphasizes that the imbrication of encircling bands is often enough to relieve traction, even in low and medium height scleral buckles. He prefers cryotherapy treatment whenever possible, and offers insight to ensuring appropriate placement of the treatment, which can be made more challenging in bullous detachments due to the parallax effect. Dr. Michels advocated that subretinal fluid drainage is not needed in many cases, and that retinal pigment epithelium pumping is almost always adequate when the break is well supported. But, he does acknowledge that vitreous surgery may be necessary in cases with more severe vitreoretinal pathology.
Despite being older than the world wide web itself, Dr. Michels’ article is a valuable read for all vitreoretinal surgeons and trainees. He skillfully details the approach to scleral buckle surgery, the rationale and tips for each step in this mainstay of retinal detachment repair in a thorough and timeless tutorial for those looking to further their understanding of a technique that should be in every vitreoretinal surgeon’s toolbox.
MICHELS, R. SCLERAL BUCKLING METHODS FOR RHEGMATOGENOUS RETINAL DETACHMENT. Retina. 1986;6(1):1-49.
