Scleral Buckling Surgery — Cost, Top Hospitals & Success Rates | MyMedicPlus

Scleral buckling (SB) surgery is a well-established, extraocular vitreoretinal procedure for the repair of rhegmatogenous retinal detachment (RRD) — the most common type of retinal detachment, defined by the entry of liquefied vitreous through a full-thickness retinal break (tear, hole, or dialysis) into the subretinal space. RRD has an incidence of approximately 10–15 per 100,000 population per year. Key risk factors include high myopia (axial length >26 mm), posterior vitreous detachment (PVD), lattice degeneration, blunt ocular trauma, aphakia, pseudophakia, and family history of retinal detachment.

The principle of scleral buckling, pioneered by Jules Gonin in the 1920s and refined by Charles Schepens in the 1950s, is to indent the scleral wall toward the detached retina — effectively reducing the anteroposterior diameter of the eye, relieving vitreous traction on the retinal break, opposing the retinal pigment epithelium (RPE) against the neurosensory retina, and allowing the break to close. Cryotherapy or laser retinopexy creates a permanent chorioretinal adhesion (scar) around the break to seal it definitively.

The alternative primary surgical approach — pars plana vitrectomy (PPV) — has expanded significantly with the introduction of small-gauge (23G, 25G, 27G) instrumentation and has become dominant in many centres, particularly for pseudophakic RRD. However, scleral buckling retains important advantages for phakic patients (avoiding cataract), inferior breaks (silicone oil from PPV may be problematic in inferior locations), and paediatric RRD. The PIVOT trial (2016) demonstrated that PPV is non-inferior to SB for primary pseudophakic RRD, effectively validating both approaches as standard of care depending on patient and break characteristics.

Scleral buckling is indicated across a defined range of retinal pathologies:

• Primary rhegmatogenous retinal detachment (RRD): The primary indication — most commonly horseshoe tears (U-shaped tears caused by PVD-related vitreous traction) or round holes in atrophic lattice degeneration.
• Inferior retinal breaks (6 o'clock preference): SB is the preferred approach for inferior breaks because PPV with silicone oil tamponade creates downward buoyancy issues; a buckle supports inferior breaks more reliably without tamponade.
• Phakic RRD in young patients: SB preserves the crystalline lens, avoiding early cataract formation that PPV frequently accelerates (cataract develops in up to 60–80% within 2 years after PPV in phakic patients).
• Paediatric RRD: SB is preferred in children due to the formed vitreous and preference for avoiding vitreous surgery sequelae in the developing eye.
• Myopic RRD with lattice degeneration: Multiple atrophic holes in lattice; encircling band provides circumferential support for multiple breaks.
• Traumatic RRD: Dialysis (circumferential break at ora serrata) — often managed with SB; buckling the posterior lip closes the dialysis effectively.
• Retinoschisis with outer layer break: SB can seal the outer layer break; inner layer preservation.
• Recurrent RRD or adjunct to PPV: SB combined with PPV (SB + PPV) for complex cases including proliferative vitreoretinopathy (PVR) Grade C, giant retinal tears, or failure of prior PPV alone.

Appropriate patient and break selection is critical to the success of scleral buckling. Pre-operative assessment includes:

Retinal examination: Binocular indirect ophthalmoscopy (BIO) with scleral depression to map all retinal breaks meticulously — the surgeon must identify every break (missed breaks are the leading cause of surgical failure). Three-mirror slit-lamp biomicroscopy complements BIO for posterior-pole assessment. B-scan ultrasonography is mandatory when media opacity (vitreous haemorrhage, cataract) obscures fundal examination.

Ideal SB candidates:

• Phakic patients, particularly those aged <50 years, in whom lens preservation is a high priority.
• Well-localised single break or breaks within one or two clock hours in the same quadrant, amenable to segmental sponge support.
• Multiple breaks across >2 quadrants amenable to encircling band.
• Peripheral breaks (anterior to the equator) where buckling provides reliable support.
• Low PVR risk (PVR Grade A or B at most; Grade C1 possibly with SB + PPV).
• Inferior breaks where silicone oil tamponade from PPV is technically challenging.

Contraindications to SB alone (PPV preferred): PVR Grade C2 or higher (fibrous membrane traction requires vitreous surgery); posterior pole break (inaccessible to external buckle); unlocalisable or very posterior break; giant retinal tear (>90°); highly bullous RRD with long-standing detachment; previous glaucoma filtering surgery (risk of scleral thinning at suture sites); complex or media-opaque cases requiring direct visualisation of the retina intraoperatively.

Axial length and refraction: Pre-operative axial length is measured and documented for post-operative myopic shift prediction and IOL planning if concurrent cataract surgery is anticipated.

Encircling Band (Element 240): A 2 mm-wide silicone band (element 240) is placed circumferentially around the entire equator of the globe and sutured to the sclera using non-absorbable mattress sutures (5-0 Mersilene or nylon). An encircling sleeve holds band tension at the desired buckle height. This creates a 360° scleral indent — the "encircling buckle" — that supports all breaks regardless of position and reduces overall vitreous volume. Best suited for multiple breaks, extensive lattice degeneration, or cases where break localisation is uncertain. Encircling bands carry higher myopic shift risk (−1 to −3 D) than segmental approaches.

Segmental Sponge or Explant: A silicone sponge (element 506: 5 × 7 mm oval; element 519: 5 × 10 mm) or a solid silicone tyre is placed directly beneath the retinal break as a radial or circumferential segmental buckle, secured with mattress sutures. Suitable for a single break or small group of breaks within the same clock-hour segment. Produces less myopia induction than an encircling band and is preferred for localised superior breaks.

Cryotherapy: Applied to seal the retinal break edges under indirect ophthalmoscopic visualisation. A cryoprobe is applied to the external scleral surface directly over the break; the freeze-thaw-freeze cycle (−60°C) creates a chorioretinal scar (white frost response visible through the sclera). Cryotherapy produces a permanent, reliable chorioretinal adhesion that closes the break. Overfreezing is avoided to minimise inflammatory reaction and PVR risk.

Subretinal Fluid (SRF) Drainage: External drainage via a radial sclerotomy over the choroid allows SRF to escape, facilitating immediate retinal reattachment and easier placement of the buckle beneath the break. The BSSR (British Superior Segmental Rhegmatogenous detachment) trial assessed drainage vs non-drainage strategies: non-drainage is preferred when the retina is mobile, the break can be covered by the buckle height, and the detachment is not bullous. Drainage is reserved for bullous, long-standing, inferior, or macula-off detachments where immediate retinal flattening is required.

SB + PPV Combination: For PVR Grade C or greater, posterior pole breaks, or complex RRD, SB is combined with pars plana vitrectomy, membrane peeling, and gas or silicone oil tamponade. The buckle component provides peripheral support while vitrectomy addresses central traction and tamponade facilitates reattachment.

Anaesthesia: SB is performed under general anaesthesia (most centres) or regional (peribulbar or retrobulbar) block. Operating time: 60–120 minutes. Hospitalisation: typically 1–2 nights.

Scleral buckling offers a unique combination of advantages that make it the preferred approach in well-defined clinical scenarios:

• High primary reattachment rate: 85–92% primary retinal reattachment in appropriately selected phakic RRD cases. Overall anatomical success after one or two procedures exceeds 95%.
• Lens preservation: SB avoids intraocular surgery, preventing the accelerated cataract development that affects 60–80% of phakic patients within 2 years of PPV. This is a decisive advantage in young, phakic patients where binocular vision and lens integrity are paramount.
• No intraocular tamponade requirement: Most SB cases do not require intraocular gas or silicone oil, eliminating post-operative positioning restrictions, tamponade-related complications, and the need for oil removal surgery.
• No vitreous entry: Avoids vitreous surgery sequelae — epiretinal membrane formation, vitreous haemorrhage, iatrogenic breaks — that are risks of PPV.
• PIVOT trial validation: The PIVOT trial (2016) demonstrated non-inferiority of PPV versus SB for primary pseudophakic RRD, confirming SB as the accepted standard for phakic RRD in centres with vitreoretinal expertise. SB showed superior preservation of contrast sensitivity and colour vision in some secondary analyses.
• Permanent structural support: The buckle remains in situ permanently, providing lasting structural reinforcement to the vitreous base and equatorial retina — relevant for myopic patients at ongoing risk of new breaks.
• Paediatric preference: In children, SB is particularly valued as it avoids the fibrous proliferation and vitreous surgery complications associated with PPV in the developing vitreous.

Scleral buckling carries both procedure-specific and general ophthalmic surgical risks that require careful pre-operative counselling:

Myopic shift: The most common and predictable optical complication. The encircling band increases axial length, inducing a myopic shift typically of −1 to −3 D — clinically significant in already highly myopic patients. A segmental sponge induces less shift. Accurate axial length measurement before any planned cataract surgery is essential to adjust IOL power calculation. Anisometropia and spectacle correction adjustment are required post-operatively.

Diplopia and strabismus: Extraocular muscle imbalance from scleral suture placement, muscle disinsertion during access, or buckle-induced restrictive strabismus occurs in 5–10% of cases; the majority resolve within 3–6 months. Persistent diplopia may require strabismus surgery.

Scleral perforation: During suture needle passes, risk of inadvertent globe perforation causing choroidal haemorrhage or vitreous prolapse; prevented by controlled needle placement under direct visualisation.

Choroidal detachment: Develops in 10–15% post-operatively as fluid accumulates in the suprachoroidal space following SRF drainage or scleral depression; usually resolves spontaneously within 1–2 weeks; rarely requires surgical drainage.

Buckle infection and extrusion: Late buckle exposure through the conjunctiva or infection of the silicone element occurs in 1–3% of cases; requires explant removal (the retina typically remains reattached by the time the scar has formed).

Anterior segment ischaemia: Rare (<1%) complication from interruption of anterior ciliary artery circulation during rectus muscle disinsertion; presents as corneal oedema and anterior chamber reaction.

Elevated intraocular pressure (IOP): Transient IOP rise from reduced vitreous volume (buckle indentation) immediately post-operatively; managed with acetazolamide; rarely persistent.

Proliferative vitreoretinopathy (PVR): Fibrous membrane proliferation on the retinal surface and subretinally — occurs in 5–10% of RRD cases and is the leading cause of surgical failure after SB and PPV alike. Managed with PPV, membrane peeling, relaxing retinotomies, and silicone oil tamponade. Overfreezing with cryotherapy increases PVR risk and should be avoided.

Post-operative monitoring after scleral buckling follows a structured protocol to assess retinal reattachment, detect complications early, and monitor for refraction changes:

Day 1 review: Intraocular pressure measurement; anterior segment examination for choroidal detachment signs; dilated fundal examination to assess retinal reattachment status, subretinal fluid resolution, buckle position and height, and cryotherapy reaction. Most cases show partial or full retinal reattachment at 24 hours if the break is supported.

Week 1–2: Repeat dilated fundal examination; assessment of SRF resolution; break closure confirmation; IOP monitoring. If the retina is not fully flat, consideration of additional laser retinopexy or whether further intervention is required.

Month 1–3: Dilated fundal examination monthly; refraction to document and quantify myopic shift (typically stabilises by 3 months); IOP check; buckle integrity assessment; signs of early PVR (grey wrinkled retina, star folds, retinal shortening).

3–6 months: OCT of the macula to assess macular architecture, epiretinal membrane formation, and sub-foveal fluid resolution (impacts visual prognosis). Best-corrected visual acuity (BCVA) assessment. Refraction for spectacle prescription update.

6–12 months: Formal BCVA and refraction; dilated fundal examination for PVR, buckle migration, residual SRF, and new break formation at the buckle margin. Fellow eye prophylactic examination — asymptomatic breaks or lattice degeneration treated with laser retinopexy to reduce fellow-eye RRD risk (30-year cumulative fellow-eye RRD risk is approximately 10–15%).

Patient education: Warning signs requiring urgent assessment — new flashes of light, shower of floaters, advancing visual field shadow, or curtain of vision loss — are reviewed carefully and should prompt emergency presentation within 24 hours.

Scleral buckling is generally more cost-effective than pars plana vitrectomy for primary RRD in appropriate cases. The following cost considerations apply:

• USA: Total episode cost for scleral buckling (surgeon + facility + anaesthesia + implant materials + post-operative visits) ranges from USD 8,000–18,000 as an inpatient 1–2 night procedure. PPV for the same indication typically costs USD 12,000–25,000. The cost advantage of SB is meaningful in healthcare systems and insurance plans that compare surgical options.
• UK NHS: SB and PPV are fully funded for eligible patients; no direct cost. Private UK cost: GBP 4,000–8,000 for SB; GBP 6,000–12,000 for PPV including anaesthesia and inpatient stay.
• Medical tourism: India (USD 1,500–4,000), Singapore (USD 4,000–9,000), Thailand (USD 2,500–6,000), Turkey (USD 2,000–5,000) for scleral buckling including surgeon, anaesthesia, hospital stay, and implants. Internationally accredited vitreoretinal units in these countries have excellent outcomes data for RRD repair.
• Implant materials: Silicone band (element 240), sponges (506/519), and sutures (Mersilene 5-0) add approximately USD 200–500 to material costs — significantly less than intraocular instrumentation for PPV.
• If general anaesthesia is required: Anaesthesiologist fee (USD 800–2,000 in the USA) adds to the total episode. Regional block (peribulbar/retrobulbar) by a trained ophthalmologist is less expensive.
• Additional procedures: If PVR develops and PPV is subsequently required for failure, a second episode of care adds substantially to the total cost — emphasising the importance of optimal patient selection to maximise first-surgery success rates.

Several alternative surgical and non-surgical approaches are available for rhegmatogenous retinal detachment, with the choice depending on break characteristics, PVR grade, lens status, and surgeon expertise:

Pneumatic Retinopexy (PR): An office- or clinic-based procedure suitable for superior breaks (8 o'clock to 4 o'clock positions) in phakic or pseudophakic patients with no PVR and a mobile retina. An intravitreal gas bubble (SF6 20% or C3F8 12–14%) is injected under aseptic conditions, combined with cryotherapy or indirect laser retinopexy. The patient positions with the break uppermost for 5–10 days while the bubble seals the break. Primary success rate 70–80% (lower than SB/PPV); if failure, PPV or SB is required. Advantages: office procedure, no incision, local anaesthesia, lowest cost. Disadvantages: strict positioning requirement, limited to superior breaks, higher re-operation rate, not suitable for multiple or inferior breaks.

Pars Plana Vitrectomy (PPV): The primary alternative and, in many centres, the dominant approach. 23G or 25G minimally invasive PPV with excellent wide-angle visualisation, removal of vitreous traction, endolaser retinopexy, and gas (SF6, C3F8) or silicone oil tamponade. Preferred for: pseudophakic RRD (PIVOT trial); posterior pole or posterior breaks; PVR Grade C or higher; giant retinal tears; complex media opacity; multiple quadrant breaks. Requires post-operative positioning (face-down or lateral depending on gas type and break location). Associated with earlier cataract development in phakic patients.

Combined SB + PPV: For complex detachments with PVR, multiple breaks in both superior and inferior positions, or failed prior procedures; combines the peripheral support of SB with the intraocular versatility of PPV.

Laser retinopexy or cryotherapy alone: Only appropriate for very shallow detachments with subretinal fluid limited to the break margin, or for retinoschisis with a small outer layer break. Not appropriate for established full retinal detachment with significant SRF.

Observation: Rarely appropriate; considered only for long-standing inferior RRDs with a demarcation line and no documented progression or macular threat, after careful discussion with the patient.