Scleral Surgeries

Scleral Surgeries: Overview - Sclera's Surgical Fixes

• Sclera: Dense, white, collagenous connective tissue; forms eye's protective outer layer.
  • Avascular; nourished by episcleral and choroidal vessels.
• Surgical Access: Typically via conjunctival peritomy.
• Primary Indications:
  • Trauma: Repair of scleral lacerations, ruptures.
  • Staphyloma: Excision or reinforcement of ectatic sclera.
  • Scleral Reinforcement: For progressive high myopia, necrotizing scleritis.
  • Glaucoma Surgery: Placement of glaucoma drainage devices (GDDs).
  • Retinal Detachment: Scleral buckling procedures.

⭐ Scleral melting can occur post-pterygium surgery with mitomycin-C use, requiring urgent repair.

Scleral Buckling - RD's Anchor

External globe compression to repair rhegmatogenous retinal detachment (RRD) by indenting sclera, supporting retinal breaks & relieving vitreoretinal traction.

• Principle:
  • Creates chorioretinal adhesion around breaks (cryopexy/laser).
  • Buckle indents sclera → apposes RPE to neurosensory retina.
  • Relieves dynamic & static vitreous traction.
• Indications:
  • Phakic RRD, esp. young patients.
  • Breaks anterior to equator.
  • Inferior breaks.
  • No or mild Proliferative Vitreoretinopathy (PVR ≤ Grade C1).
  • Retinal dialysis.
• Procedure Outline:

• Buckle Materials: Silicone sponge (segmental, radial), solid silicone bands (encircling).
• Complications:
  • Refractive: Myopic shift (↑ axial length), astigmatism.
  • Motility: Diplopia, strabismus.
  • Buckle-related: Extrusion, infection, migration.
  • Ischemia: Anterior Segment Ischemia (ASI) - esp. with 360° bands, choroidal detachment.

⭐ Scleral buckling is often preferred over vitrectomy for RRD in young, phakic patients with peripheral breaks and no significant PVR, as it avoids iatrogenic cataract progression associated with vitrectomy.

Other Scleral Procedures - Beyond the Buckle

• Scleral Reinforcement (Posterior Scleral Support):
  • Indications: Progressive high myopia, posterior staphyloma.
  • Goal: Arrest axial elongation.
  • Materials: Donor sclera, fascia lata, synthetic (Gore-Tex).
• Scleral Patch Grafts:
  • Indications: Scleral melt/thinning (e.g., necrotizing scleritis, post-surgery), perforations, GDD tube exposure.
  • Materials: Donor sclera, pericardium, amniotic membrane.
  • Goal: Tectonic support, globe integrity.

  ⭐ Scleral patch grafts are vital for globe integrity in conditions causing scleral melt, like severe autoimmune scleritis.

• Scleral Procedures in Glaucoma:
  • Trabeculectomy: Scleral flap for aqueous outflow.
  • Non-Penetrating Deep Sclerectomy (NPDS).
  • Glaucoma Drainage Devices (GDDs): Plate sutured to sclera.
• Tumor Management:
  • Plaque Brachytherapy: Radioactive plaque sutured to sclera over tumor (e.g., uveal melanoma).
  • Sclerectomy: For localized tumors.
• Other:
  • Scleral window: For vitrectomy access. oka

Scleral Surgery: Complications - Navigating Recovery

• Intraoperative Complications:
  • Choroidal/Suprachoroidal hemorrhage
  • Retinal breaks/detachment
  • Scleral perforation
  • Vitreous loss
  • Damage to vortex veins
• Postoperative Complications (Early & Late):
  • Endophthalmitis (⚠️ 0.05-0.3% after scleral buckle)
  • Uveitis, anterior or posterior
  • Glaucoma (angle closure, steroid-induced)
  • Cystoid Macular Edema (CME)
  • Buckle extrusion/migration/infection
  • Diplopia (muscle imbalance)
  • Refractive changes (myopic shift)
  • Scleral necrosis/thinning
  • Choroidal detachment

⭐ Sympathetic ophthalmia is a rare, bilateral granulomatous panuveitis that can occur after penetrating ocular trauma or surgery, including scleral procedures.

• Post-operative Care:
  • Topical antibiotics & steroids
  • Cycloplegics
  • Pain management
  • Activity restriction initially

High‑Yield Points - ⚡ Biggest Takeaways

• Scleral buckling for RRD uses silicone elements to indent sclera, aiding retinal apposition.
• Buckling complications: myopic shift, diplopia, strabismus, anterior segment ischemia, choroidal detachment.
• Scleral reinforcement grafts (donor sclera, fascia lata) manage necrotizing scleritis or posterior staphyloma.
• Scleral patch grafts repair scleral defects (melts, perforations) or cover exposed GDD tubes.
• Scleral fixated IOLs (SFIOLs) are crucial for aphakia without capsular support.
• Trabeculectomy, a key glaucoma surgery, creates a guarded fistula under a partial-thickness scleral flap.