Scleral Buckling Surgery (Without Vitrectomy) — Cost, Top Hospitals & Success Rates | MyMedicPlus

Scleral buckling without vitrectomy is an external approach to surgical repair of rhegmatogenous retinal detachment — the most common type of retinal detachment, caused by one or more tears or breaks in the retina through which fluid from the vitreous cavity passes under the retina, causing it to separate from the underlying retinal pigment epithelium (RPE). The goal of scleral buckling is to indent (buckle) the outer wall of the eye (the sclera) from outside, bringing the choroid and RPE into apposition with the detached retina to allow the subretinal fluid to reabsorb and the retinal break to close.

The procedure involves the surgeon placing silicone sponge or solid silicone rubber elements (the buckle) on the outer surface of the sclera, sutured in precise position to create an indentation that reduces the inward traction from the vitreous on the retinal break. Cryotherapy or laser photocoagulation is applied around the retinal break to create chorioretinal adhesion that seals the break permanently once the retina reattaches. Subretinal fluid can be drained externally through a small sclerotomy (drainage of subretinal fluid — DSRF) if the detachment is bullous (high), or left to absorb spontaneously if the buckle adequately supports the break.

Scleral buckling was the historical gold-standard surgical technique for retinal detachment repair and remains the preferred approach for specific anatomical situations — particularly in young phakic (natural lens in place) patients with inferior detachments, in breaks amenable to external support, and in centres where surgeons have maintained mastery of this technically demanding procedure. It avoids the intraocular manipulation of vitrectomy and preserves the natural lens in phakic patients.

Scleral buckling without vitrectomy is used for rhegmatogenous retinal detachment — the most common form, accounting for approximately 90% of all retinal detachments. This occurs when a retinal break (tear, dialysis, or hole) allows liquefied vitreous to seep under the retina. Rhegmatogenous detachment is most common in highly myopic (short-sighted) individuals, after ocular trauma, following posterior vitreous detachment (PVD), and in aphakic or pseudophakic eyes (natural lens removed or replaced).

Scleral buckling is particularly suited for detachments with a single or few peripheral retinal breaks with well-identified tear locations accessible to external buckling support, young phakic patients where avoiding intraocular surgery reduces the risk of cataract formation compared with vitrectomy, inferior detachments where gravity facilitates subretinal fluid drainage and buckle support, and patients with atopic retinal dialyses (tears along the ora serrata — the buckle is ideally suited to support these anterior breaks). It is less suitable for complex detachments with multiple breaks in different quadrants, proliferative vitreoretinopathy (PVR), posterior breaks, or giant retinal tears.

Ideal candidates for scleral buckling alone (without vitrectomy) are patients with fresh rhegmatogenous retinal detachment, clear media (no significant vitreous haemorrhage or cataract obscuring the view of breaks), identifiable peripheral retinal breaks amenable to buckling support, no or minimal PVR (proliferative vitreoretinopathy — preretinal membrane formation that complicates repair), and particularly young phakic patients in whom lens preservation is a priority.

Contraindications or relative contraindications to scleral buckling alone include posterior breaks (not reachable by external buckling), multiple breaks in different meridians requiring large circumferential buckles, pre-existing PVR grade C or higher (requiring vitrectomy), significant vitreous haemorrhage precluding visualisation for cryotherapy/laser, and pseudophakic or aphakic patients in whom vitrectomy outcomes may be superior. In these situations, pars plana vitrectomy (PPV) alone or combined scleral buckling with PPV may be more appropriate.

The surgical technique begins with conjunctival peritomy (opening of the transparent conjunctival covering), isolation of the four extraocular muscles with slings, and careful examination of the entire fundus (internal retinal surface) with indirect ophthalmoscopy and scleral depression to identify all retinal breaks. Cryotherapy is applied transsclerally to the area surrounding each retinal break under indirect ophthalmoscopic visualisation, creating a sterile inflammatory response that produces chorioretinal adhesion as healing occurs.

The silicone buckle element is sutured to the sclera in the location corresponding to the retinal break(s). A radial sponge placed perpendicular to the break is used for single posterior tears; a circumferential band (240-band or similar) encircles the entire equator of the eye for multiple or anterior breaks. Optional drainage of subretinal fluid (DSRF) through a careful small sclerotomy allows the retina to settle immediately against the buckle rather than waiting for spontaneous absorption. An intravitreal gas bubble (SF6 or C3F8) or air injection may be added to provide additional internal tamponade, particularly for superior breaks. The conjunctiva is closed at the end of the procedure. Chandelier illumination and wide-angle viewing systems allow contemporary vitreoretinal surgeons to perform 360-degree cryotherapy and drainage with enhanced visualisation. The conjunctiva is closed at the end of the procedure with absorbable sutures, and a subconjunctival antibiotic-steroid injection administered. Patients are instructed on post-operative head positioning to maintain contact between the scleral buckle and the area of retinal break.

Primary anatomical success rate (retinal reattachment with a single surgical procedure) with scleral buckling for uncomplicated rhegmatogenous detachment in phakic eyes ranges from 80 to 90% at experienced centres. Final anatomical success (including re-operations if needed) exceeds 95% in most series. Visual acuity outcomes depend critically on whether the macula was involved in the detachment (macula-on vs macula-off) — macula-on detachments treated promptly achieve near-normal vision in most cases, while macula-off detachments have more variable visual recovery depending on the duration of macular involvement before repair.

In young phakic patients, scleral buckling avoids the cataract risk associated with vitrectomy (which causes accelerated lens opacification in phakic eyes — almost all phakic eyes develop significant cataract within two to three years of PPV). Scleral buckling also does not require the patient to maintain a face-down posturing position (often required after gas tamponade in PPV) in the post-operative period in many cases, particularly with subretinal fluid drainage. Long-term, the scleral buckle remains in place permanently and does not need removal unless causing complications.

Intraoperative complications include inadvertent perforation of the sclera during suture placement (managed by cryotherapy and closure), retinal incarceration during DSRF, and suprachoroidal haemorrhage during drainage (rare but serious). Post-operative complications include elevated intraocular pressure (particularly in eyes where no drainage was performed and the buckle height causes vitreous volume reduction), diplopia (double vision from muscle manipulation and buckle effect on muscle alignment — usually temporary, resolving within weeks to months), and anterior segment ischaemia from vascular compression by buckle elements (rare, requiring buckle revision).

The scleral buckle may cause refractive change — the indentation increases the axial length of the eye, causing a myopic shift, most significant in young patients. Buckle-related complications including extrusion (erosion of the buckle through the conjunctiva, approximately 1 to 3% over ten years) and infection (endophthalmitis from buckle, very rare) may necessitate buckle removal years to decades after surgery. Subretinal fluid drainage carries a risk of vitreous haemorrhage, retinal perforation, and incarcerating the retina in the drainage site if not performed with care.

Post-operative care includes topical antibiotic and steroid eye drops for four to six weeks. Vision is blurred immediately after surgery due to intraoperative manipulation, gas bubble (if used), and periocular swelling — vision improves progressively over days to weeks as the eye settles. Patients are reviewed at day one, one week, and one month post-operatively. If a gas bubble was used, specific positioning instructions are given to maximise bubble tamponade on the repaired break.

Visual recovery after macula-on detachment repair with successful reattachment is typically achieved within four to eight weeks as the retina reattaches and subretinal fluid reabsorbs. Macula-off detachment visual recovery takes three to twelve months and is often incomplete if the macula was detached for more than 48 hours. Refraction changes from the buckle-induced myopic shift typically stabilise by three months and are corrected with updated glasses or contact lenses. Long-term, annual ophthalmological review assessing the fellow eye (which has a 10 to 15% risk of retinal detachment) and the operated eye for PVR or late redetachment is important.

Scleral buckling surgery in the United States costs $8,000 to $20,000 including surgeon fees, anaesthesia, and operating room, covered by most health insurance plans as a medically necessary procedure for retinal detachment. In the UK, NHS covers retinal detachment surgery urgently. Delays in accessing surgery for macula-on detachment can result in macular involvement and permanent visual loss — timely access to surgery is critical.

For international patients or those without adequate insurance, scleral buckling at specialist retinal surgery centres in India costs $500 to $1,500 at government-affiliated centres and $1,000 to $3,000 at private JCI-accredited centres. In Thailand and Turkey, retinal detachment surgery costs $1,500 to $4,000. These centres have experienced vitreoretinal surgeons trained in both scleral buckling and vitrectomy and can provide the most appropriate technique based on the individual patient's retinal anatomy.

Pneumatic retinopexy is a minimally invasive office-based alternative to scleral buckling for selected superior breaks in phakic eyes, using intravitreal gas injection combined with laser or cryotherapy and prone positioning to seal the detachment without surgery. It has lower primary success rates (65 to 75%) than scleral buckling or vitrectomy but avoids general anaesthesia and operating room time, and can be performed with local anaesthesia in an outpatient setting. Multiple breaks in different locations and inferior tears are not suitable for pneumatic retinopexy.

Pars plana vitrectomy (PPV) is the alternative surgical technique, performed internally by entering the vitreous cavity and directly relieving vitreous traction, laser photocoagulation around breaks under direct visualisation, and fluid-air or gas-fluid exchange to tamponade the breaks. PPV is now more widely performed globally than scleral buckling as vitrectomy technology has advanced, and it is the preferred technique for complex detachments, posterior breaks, PVR, and pseudophakic patients. Combined scleral buckling with PPV (the 'belt and suspenders' approach) is used for complex cases where both external support and internal vitreous manipulation are advantageous.