Prevalence of Failure After Scleral Buckling and Cryotherapy for Primary Retinal Detachment
The overall failure rate after primary scleral buckling with cryotherapy for rhegmatogenous retinal detachment ranges from 10-18%, with approximately 5% due to proliferative vitreoretinopathy (PVR) and 8% from non-PVR causes. 1
Primary Failure Rates
The most comprehensive recent data demonstrates that among 530 consecutive scleral buckling procedures for primary retinal detachment, 69 cases (13%) experienced surgical failure 1. This aligns closely with historical data showing an 18% initial failure rate in unselected consecutive cases 2.
Breakdown of Failure Mechanisms
- PVR-related failures: 5% of all primary scleral buckling cases 1
- Non-PVR failures: 8% of all primary scleral buckling cases 1
- Common non-PVR causes include: buckle malposition, new or missed retinal breaks, and inability to close giant tears 2
Risk Factors for Failure
Patients with preoperative vitreous hemorrhage have 8.2 times higher odds of PVR-associated failure, while those with preoperative PVR have 22.7 times higher odds. 1
Additional significant risk factors include:
- Smoking history: Previous smokers have 28.8 times higher odds of PVR-associated failure 1
- Delayed presentation: Longer time between symptom onset and surgery increases PVR risk 1
- Inadequate treatment of horseshoe tears: The most common cause of failure is inadequate treatment at the anterior border where visualization is difficult 3
Reoperation Requirements
Among surgical failures, 46% require one additional intervention, while 53% require two or more procedures to achieve final reattachment. 1
The final anatomic success rate after accounting for reoperations reaches approximately 90% 2. This represents a substantial improvement over the initial 82-87% single-operation success rate 2, 4.
Special Populations
Pseudophakic Retinal Detachment
In pseudophakic eyes with undetected breaks, scleral buckling with cryotherapy achieves:
These cases represent particular challenges due to difficulties in peripheral retinal visualization and break identification 5.
Retinal Detachment Without Identified Breaks
When no break is detected preoperatively or intraoperatively:
- Single-operation success with scleral buckling alone: 61.5% 4
- Final anatomic success: 84.6% after additional procedures 4
Critical Technical Considerations
The chorioretinal adhesion from cryotherapy or laser is not firm or complete for up to 1 month following treatment, during which time continued vitreous traction can pull tears beyond the treated area. 3
Common Pitfalls Leading to Failure
- Insufficient anterior extension: Treatment must extend to the ora serrata if tears cannot be completely surrounded 3
- Incomplete treatment of horseshoe tears: Particularly at the anterior border where visualization is most challenging 3
- New break development: 10-16% of patients develop additional breaks during long-term follow-up, with pseudophakic patients at higher risk 3
Long-Term Outcomes
The American Academy of Ophthalmology guidelines note that a Cochrane systematic review found low to very low certainty evidence indicating little or no difference between pars plana vitrectomy and scleral buckling in anatomical and visual acuity outcomes 3. This suggests that while failure rates exist, the overall effectiveness of properly performed scleral buckling with cryotherapy remains comparable to alternative surgical approaches.
Retinal detachments may occur despite appropriate therapy, as vitreous traction can overcome even properly placed treatment adhesions, especially with larger breaks or bridging retinal blood vessels. 3