lrena Tsui, MD, Scleral Buckle Removal: lndications and Outcomes, Survey of ophthalmology, 57-3, May-June 2012  

Deze studie brengt aan de hand van de relevante literatuur richtlijnen in kaart voor de verwijdering van SB’s (sclerale buckles/plombes). . De meest voorkomende indicaties voor verwijdering zijn extrusie, infectie en pijn.

Abstract. Primary scleral buckling has been an effective means to reattach the retina for over 50 years. After surgery, complications may arise that require scieral buckie (SB) removal. The most common indications for SB removal are extrusion, infection, and pain. 1 review the pertinent literature in an effort to develop guidelines for when to remove a SB. 

1.Introduction
Scleral buckling with exogenous material is an effective and important method to reattach the retina.36,101 Retrospective series have reported cornplications of scleral buckling, most commonly extrusion and infection, in 1.3-24.4% of eyes. 20,64,9093 Complications of a scleral buckle (SB) may present up to decades after surgery without an age predilection and their manifestation can be protean. The dreaded consequence of SB removal is redetachment of the retina. 1 review the pertinent literature in an effort to develop guidelines for their removal.

Tsui wijdt ook een paragraaf aan de commercieel niet meer verkrijgbare hydrogel buckle/plombe, ook bekend als MAI, het Refojo-implantaat of MIRAgel.

D. HYDROGEL
Hydrogel, also known as MAI, the Refojo implant, or MIRAgel, was a permanent SB material that is no longer commercially available. 39,57,87 The product was made of poly(methyl acrylate-co-2-hydroxyethyl acrylate) and was used from 1980_1995.39,57,87 Initial advantages were that hydrogel could expand in size and seemed less prone to infection and extrusion because of its lack of pores, absorption and release of antibiotics, and pliability.39,108 Complications of hyodrogel were first reported in 1992 and typically presented 5-15 years after surgery.37,67,79 One series of 82 eyes with hydrogel found complications in 7 (8.5%) eyes, most of which required SB removal. 67 Complications of hydrogel SBs are the result of an increase in size and include pain, anterior SB migration, diplopia, and orbital mass affect.49,56,76,90,91 What triggers hydrogel to swell years after surgery is unknown. Extrusion and infection, common reasons for removal of silicone elements, are less likely with hydrogel .43,56,90 Rarely, intraocular complications such as erosion and intrusion or a retinal cyst occur. 32,67,79 
Hydrogel SBs are known to cause atypical orbital lesions, and a history of SB surgery is not always reported by the patient. 6,7,37,57 Therefore, the diagnosis should be kept in mind with atypical orbital processes of unknown etiology. A B-scan ultrasound of a swollen hydrogel implant 10 years after surgery had a characteristic reflective outer contour with an acoustically silent center.113 Seven to 10 years after surgery, computed tomography (CT) of three cases of expanded hydrogel SB showed rim enhancement with dystrophic calcification,54 and magnetic resonance imaging of four cases demonstrated high water content (hypointense on T1-weighted images and hyperintenese on T2-weighted images), making the hydrogel SBs appear as fluid-filled cysts.7
Hydrogel SB removal is technically challenging and, although it has been removed in total as a single piece,57 more often the material has gellike consistency and therefore fragments.43,67,79 Postsurgical pathology and ancillary laboratory studies have confirmed chemical degradation and dystrophic calcification of hydrogel years after implantation. 13,67,125 Cryotherapy to freeze hydrogel and facilitate its successful removal is reported.55
The authors felt freezing hydrogel to be safer and faster than using traditional instruments. Another surgical technique used to facilitate removal is intraoperative injection of boric acid into the capsule to dehydrate the hydrogel.89 This was successful in two patients, hut the long-term risks of a caustic chemical like boric acid are unknown. These adjunctive methods were used because a single piece of hydrogel had swollen to a gel-like consistency; their utility may be limited where hydrogel has already fragmented, however.

Haar conclusie doet een aanbeveling tot onderricht:

VI. Conclusion
After over 50 years, the technique of scleral buckling surgery remains largely unchanged, and the safety and outcomes of the procedure with or without SB removal are excellent. Trainees should be educated on the complications of SB and how to avoid them. Newer imaging techniques may lead to a better understanding of complications of scleral buckling.