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 Table of Contents  
Year : 2017  |  Volume : 29  |  Issue : 3  |  Page : 213-217

Suprachoroidal buckling: A novel technique for rhegmatogenous retinal detachment and vitreoretinal interface pathologies

1 Department of Ophthalmology, Little Flower Hospital and Research Centre, Angamaly, Kerala, India
2 Department of Ophthalmology, Institute of Ophthalmology, The Retina Eye Center, Cairo, Egypt

Date of Web Publication30-Jan-2018

Correspondence Address:
Dr. Ayisha Suhana
Department of Ophthalmology, Little Flower Hospital and Research Centre, Angamaly - 683 572, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/kjo.kjo_107_17

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Suprachoroidal buckling (SCB) technique is a new approach developed by Ehab N El Rayes and Oshima for treating rhegmatogenous retinal detachment (RRD). SCB uses a specially designed catheter to inject and place a suprachoroidal filler (long-lasting hyaluronic acid solution) in the suprachoroidal space. This filler indents the choroid alone and creates a suprachoroidal buckling effect thereby closing retinal tears and supporting the overlying retina. The sclera itself is not involved in the indentation. SCB can also be used as an alternative to episcleral macular buckling for managing myopic traction maculopathy (MTM).

Keywords: Myopic traction maculopathy, rhegmatogenous retinal detachment, suprachoroidal buckling

How to cite this article:
Suhana A, Nataraj A, El-Rayes EN. Suprachoroidal buckling: A novel technique for rhegmatogenous retinal detachment and vitreoretinal interface pathologies. Kerala J Ophthalmol 2017;29:213-7

How to cite this URL:
Suhana A, Nataraj A, El-Rayes EN. Suprachoroidal buckling: A novel technique for rhegmatogenous retinal detachment and vitreoretinal interface pathologies. Kerala J Ophthalmol [serial online] 2017 [cited 2018 Sep 19];29:213-7. Available from: http://www.kjophthal.com/text.asp?2017/29/3/213/224286

  Introduction Top

Scleral buckling is a common surgical procedure for repairing uncomplicated rhegmatogenous retinal detachment (RRD). It involves the formation of a chorioretinal adhesion around the retinal break along with the release of vitreoretinal traction force by the use of the scleral buckle, thus preventing access of intravitreal fluid to the subretinal space through retinal breaks.[1],[2] Other techniques for repair include vitrectomy and a gas tamponade or repair by pneumatic retinopexy, all share in the concept of preventing fluid from reaching subretinal space through retinal holes.

Although scleral buckling can be indicated for most primary RRDs, it may result in some vision-threatening complications such as mechanical ocular motility disturbance secondary to an extraocular muscle imbalance, corneal contour changes, anterior segment ischemia, and chorioretinal circulatory disturbances due to the direct depression of the sclera with the buckle and also depending on the size and location of buckle placement.[3],[4],[5]

Because the therapeutic concept of scleral buckling is to bring retina into contact with treated choroid around retinal tears, the sclera itself may not necessarily be involved in the indentation. Based on this idea, in 2013, El Rayes and Oshima developed a new approach for treating different forms of RD by creating suprachoroidal indentation (buckling effect).[6]

Suprachoroidal buckling (SCB) technique uses a specially designed catheter to inject and place a suprachoroidal filler (long-lasting hyaluronic acid (HA) solution) in the suprachoroidal space. This filler indents the choroid alone and creates a SCB effect, thereby closing retinal tears and supporting the overlying retina. This is accomplished through a 3-mm incision, through which the catheter is guided toward the retinal tear, thus avoiding potential difficulties of placing scleral buckles.

The indentation effect achieved with SCB can also be used as an alternative to episcleral macular buckling for managing myopic traction maculopathy (MTM).[7] SCB can be used alone or in conjunction with vitrectomy.

  Surgical Procedure Top

Devices used to create suprachoroidal buckle

SCB technique uses two devices to create a suprachoroidal buckle.

EL-Rayes Flex-tip Catheter (MedOne Surgical, patent pending) [Figure 1]
Figure 1: Suprachoroidal catheter for suprachoroidal filler injection. One arm is connected to a light source and the other is connected to the filler material

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This 450-μm catheter has a dual injection/illumination capability. It can be connected to a regular bright illumination light source that illuminates a 31-gauge light fiber when placed in the suprachoroidal space for identifying the tip of the inserting cannula. The other end of the Y connector on the catheter is connected to high-pressure tubing to deliver stabilized (natural entangled) long-lasting HA solution (Healon GV or Healon V, Abbott Medical Optics Inc., or Restylane Perlane, Q-med) to the injection port of the catheter when placed in the suprachoroidal space. This works for both posterior pole retinal pathologies and peripheral breaks.

El-Rayes curved suprachoroidal cannula

Recently, as an alternative to the illuminated tip catheter, a nonilluminated 20-gauge curved solid cannula with an olive tip for injecting the filler can be used, thus creating a SCB effect. The advantage of the olive tip is that it acts as a choroidal depressor [Figure 2]. However, this cannula can be used for peripheral pathology only; it cannot be guided into the postequatorial region.
Figure 2: The suprachoroidal cannula notices the olive tip acting as a gentle choroidal depressor

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Filler substance

Different materials are used to create the suprachoroidal buckle.

  1. Restylane Perlane (20 mg/ml) which is a high purity gel containing nonanimal HA stabilized with minimal modification resulting in a long-lasting three-dimensional gel network with excellent safety profile can be used. This filler is known to the past 8-12 months in dermal tissues and is used for restoring space and contour by its gel strength. The strength of the gel depends on the total number of cross-linkings between HA disaccharides (both chemical and natural entanglement)
  2. Shorter acting substances such as Healon5, 23 mg/ml, (Abbott Medical Optics, Santa Ana, CA, USA), which has less bonding, may also be used for treating peripheral breaks since it remains for 2-3 weeks in the suprachoroidal space which is enough to create chorioretinal adhesion after treating the break.

The issue of “how long” (duration) is no longer a problem because the stabilization, bonding technology, and higher cross-linking solve the duration issues and create a gel of superior strength. Therefore, depending on the nature of the pathology, we can choose the type that we will inject.

Animal experiment

Experimental work has been done on rabbit [Figure 3] by creating suprachoroidal buckles and has been found to be safe by gradually separating the choroid.[6],[8]
Figure 3: Suprachoroidal buckling in rabbit eyes. Suprachoroidal catheter inserted into the suprachoroidal space through a 2-mm scleral incision (a). The illuminated tip (black arrow) of the catheter can be seen underneath the retina through a magnifying contact lens (b). Histologic examination 3 months after surgery demonstrates clear separation of the choroid from the sclera (asterisk) with intact morphology in the chorioretinal layer (c). Bar = 50 μm

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  Technique for Rhegmatogenous Retinal Detachment Top

SCB may be done with or without vitrectomy. If performed along with vitrectomy, a chandelier light (25 gauge or smaller) is placed at 12 o'clock position (or any other quadrant if the tears are at 12 o'clock). Then the operating microscope and wide-angle viewing system are used to examine the fundus. The tear site is located using direct illumination from the chandelier. The tear is indented and marked applying the microscope viewing system. The conjunctiva in the quadrant of the tear is incised and a 3-mm circumferential sclerotomy, 4 mm from the limbus, is performed to expose the choroid. After this, the choroid is displaced by injecting some viscoelastic fluid to create a 1-2 mm pocket for introduction of suprachoroidal catheter or cannula. The catheter is threaded through the sclerotomy into the suprachoroidal space in the direction of the tear location, pushing against the scleral wall in the suprachoroidal space. The wide-angle system is then flipped again to see the fundus with the chandelier light and the location of the tip of the catheter in relation to the tear [Figure 4]. Once the light from the catheter is under the middle of the tear, the injection of the HA solution is initiated, causing a controlled choroidal indentation that expands in height and direction depending on the desired location and height. The indentation effect lasts for 2–3 weeks.
Figure 4: Composite intraoperative picture: (a) open break; (b) depressing the tear site with the cannula; (c) after injecting the suprachoroidal filler; (d) laser application to the break site[19]

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The procedure usually requires 0.2–0.5 ml of suprachoroidal gel, depending on the size of break and height of the buckle needed and is accompanied by anterior chamber paracentesis or subretinal fluid drainage to control intraocular pressure (IOP).

The catheter helps in targeting posteriorly located breaks irrespective of the anterior location of the sclerotomy. If two or more tears are close to each other (within 1–2 clock h), the same entry site can achieve buckling effect for all of them. The specially developed cannula may also be used with this technique and provides the advantage of gentle choroidal indentation to examine the breaks; furthermore, it can reach 2–3 clock h on either side of the entry site [Figure 4].

Once the tear is closed by the suprachoroidal buckle, the catheter is withdrawn and the sclerotomy is immediately closed by sutures. The conjunctiva is closed with sutures and the chandelier is removed from the eye. Next, the tear is treated by indirect laser ophthalmoscopy [Figure 5]. Another treatment option to create chorioretinal adhesion is cryoretinopexy, which should be performed in advance of the SCB.
Figure 5: Intraoperative view of the suprachoroidal buckle: Top image, the dome-shaped elevation created by suprachoroidal buckling; lower image, postlaser application at the same area

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IOP is rechecked and the need for another paracentesis is re-evaluated (this step is not essential if the buckling process is part of a vitrectomy procedure).

Alternative to the illuminated flextip catheter, a nonilluminated 20-gauge curved cannula with olive tip can be used for injecting filler and creating a SCB effect. It is used for peripheral retinal pathology only. The main advantage of this cannula is that it can access tears up to the 3 o'clock position on either side of the sclerotomy. This can create a circumferential buckling effect up to 180° from one single sclerotomy incision. This is helpful when doing inferior buckles or subsilicon retinal detachment when inferior circumferential retinal support is needed or in supporting a giant retinal break.

  Technique for Myopic Traction Maculopathy Top

MTM is schisis-like thickening in the outer layers of highly myopic eyes with posterior staphyloma, also known as myopic foveoschisis. Other findings may include inner retinal fluid, foveal detachment, and lamellar or even full-thickness macular holes with progressive retinal detachments.[9],[10],[11] Management of MTM is based on eliminating epiretinal traction forces by means of vitrectomy with or without internal limiting membrane peeling.[12],[13],[14],[15],[16] Episcleral macular buckling is a well-established technique that supports the posterior scleral wall, releasing the traction forces on the vitreoretinal interface (VMI) in the area of the staphyloma. There is a long learning curve, and it is very challenging to master the technique of locating and fixing the macular buckle in extremely thin sclera and deformed staphyloma.

The SCB technique can bypass the difficulties of conventional scleral buckling in the macular area by direct controlled delivery of a buckle-like effect (indentation) from the suprachoroidal space in the area of staphyloma. The choroidal indenting effect at the macula relieves all forms of traction at the VMI.

In macular buckling, the surgical procedure for all patients is a standard three-port, 25-gauge pars plana vitrectomy and dissection of the posterior hyaloid. Then, the same technique of SCB as for RRD is adopted. Care is taken while attempting to cross the edges of the posterior staphyloma as the choroid is extremely thin, especially at the superior edge of the staphyloma. Before crossing this site, a small amount of filler is injected to dissect and lift the choroid at the edge, before pushing the catheter into the area of the posterior staphyloma. Once the catheter is placed in the suprachoroidal space underneath the target tissue (foveoschisis or macular hole), the filler is injected to dissect the thin choroid toward the retina, creating an indentation effect bypassing the staphyloma. This effect restores the normal contour of the choroid or even indents it to a convex configuration supporting the retina. The illuminated tip of the catheter is seen with ease in patients with foveoschisis and in patients with macular holes associated with shallow posterior pole detachment [Figure 6]. Fluid/air exchange is used before filler injection if the subretinal fluid is extensive enough to obscure the catheter tip light.
Figure 6: Intraoperative view of suprachoroidal macular buckling in a case with myopic foveoschisis. The illuminated tip (white arrow) of the suprachoroidal catheter inserted into the suprachoroidal space around the macula (a). A dome-shaped choroidal buckle (white arrowheads) is clearly created at macula with an injection of the long-acting hyaluronic acid filler into the suprachoroidal space (b)

Click here to view

  Discussion Top

The treatment options for RD have evolved over the years. Most of them are based on the closure of the retinal tears and eliminating the traction forces on the retina or indenting chorioscleral wall to close the retina. The use scleral buckles reduce the vitreous traction and minimize the flux of vitreous fluid through retinal tears, thus causing reposition of the retina to the Retinal pigment epithelium (RPE). However, there are some difficulties associated with episcleral buckles which can be eliminated using suprachoroidal buckles.

The concept of SCB was first reported by Poole and Sudarsky in 1986 as suprachoroidal implantation for the treatment of peripheral retinal breaks in RD.[17] A direct injection of 1% sodium hyaluronate with a 27-gauge cannula was successful in 14 patients with RRDs with peripheral breaks. However, the concept of SCB failed to be widely accepted, possibly because of the technical difficulties and instability of the initially reported procedures. In contrast to this study, Ehab N El-Rayes and Oshima, in 2013, have succeeded in establishing a secure technique for SCB by injecting long-lasting HA solution into the suprachoroidal space with a suprachoroidal catheter, which was originally developed to inject drugs into the suprachoroidal space to treat macular edema.[18] and exudative age-related macular degeneration.

The advantages of this technique over established scleral buckling procedures include faster surgery, less invasive, temporal indentation, no risk of strabismus/diplopia, no postoperative pain, and a quieter eye at immediate postoperative follow-up. No ischemic choroidal changes occurred, may be due to cushion-like effect created by the indentation causing less mechanical pressure or deformation to the choroidal circulation as compared to silicone implants.

The complications observed were minimal which included penetration of the catheter directly through the pars plana into the vitreous cavity, penetration of the choroid, and the retina in the meridian of the primary tear. These did not result in hemorrhage or redetachment due to thin structure of the catheter, and the penetration site can be easily treated with laser retinopexy. Hyperpigmentation at the edge of indentation due to RPE heaping at the edge of the dome can occur, which usually decreases with time. Another potential complication is choroidal hemorrhage, which is also a risk of the standard buckling procedure.

In conclusion, based on favorable results obtained from animal experiments and preliminary clinical trials, SCB procedure with the suprachoroidal catheter is technically safe and feasible. Since the physiologic adhesion between the choroid and sclera is loosened, no serious complications related to the insertion of the catheter and injection of HA solution into the suprachoroidal space was encountered. This technique represents a great addition to surgical inbox for repair of selected cases of retinal detachment. Further study is recommended to evaluate the choice of fillers for SCB according to the pathology and desired length of indentation.[19]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

The repair of rhegmatogenous retinal detachments. American academy of ophthalmology. Ophthalmology 1990;97:1562-72.  Back to cited text no. 1
Wilkinson CP, Rice TA. Michel's Retinal Detachment. 2nd ed. St. Louis, MO: Mosby; 1997.  Back to cited text no. 2
Sewell JJ, Knobloch WH, Eifrig DE. Extraocular muscle imbalance after surgical treatment for retinal detachment. Am J Ophthalmol 1974;78:321-3.  Back to cited text no. 3
Smiddy WE, Loupe DN, Michels RG, Enger C, Glaser BM, deBustros S, et al. Refractive changes after scleral buckling surgery. Arch Ophthalmol 1989;107:1469-71.  Back to cited text no. 4
Yoshida A, Feke GT, Green GJ, Goger DG, Matsuhashi M, Jalkh AE, et al. Retinal circulatory changes after scleral buckling procedures. Am J Ophthalmol 1983;95:182-8.  Back to cited text no. 5
El Rayes EN, Oshima Y. Suprachoroidal buckling for retinal detachment. Retina 2013;33:1073-5.  Back to cited text no. 6
El Rayes EN. Supra choroidal buckling in managing myopic vitreoretinal interface disorders: 1-year data. Retina 2014;34:129-35.  Back to cited text no. 7
Mittl RN, Tiwari R. Suprachoroidal injection of sodium hyaluronate as an 'internal' buckling procedure. Ophthalmic Res 1987;19:255-60.  Back to cited text no. 8
Baba T, Ohno-Matsui K, Futagami S, Yoshida T, Yasuzumi K, Kojima A, et al. Prevalence and characteristics of foveal retinal detachment without macular hole in high myopia. Am J Ophthalmol 2003;135:338-42.  Back to cited text no. 9
Gaucher D, Haouchine B, Tadayoni R, Massin P, Erginay A, Benhamou N, et al. Long-term follow-up of high myopic foveoschisis: Natural course and surgical outcome. Am J Ophthalmol 2007;143:455-62.  Back to cited text no. 10
Shimada N, Ohno-Matsui K, Yoshida T, Sugamoto Y, Tokoro T, Mochizuki M, et al. Progression from macular retinoschisis to retinal detachment in highly myopic eyes is associated with outer lamellar hole formation. Br J Ophthalmol 2008;92:762-4.  Back to cited text no. 11
Kanda S, Uemura A, Sakamoto Y, Kita H. Vitrectomy with internal limiting membrane peeling for macular retinoschisis and retinal detachment without macular hole in highly myopic eyes. Am J Ophthalmol 2003;136:177-80.  Back to cited text no. 12
Kwok AK, Lai TY, Yip WW. Vitrectomy and gas tamponade without internal limiting membrane peeling for myopic foveoschisis. Br J Ophthalmol 2005;89:1180-3.  Back to cited text no. 13
Spaide RF, Fisher Y. Removal of adherent cortical vitreous plaques without removing the internal limiting membrane in the repair of macular detachments in highly myopic eyes. Retina 2005;25:290-5.  Back to cited text no. 14
Kuhn F. Internal limiting membrane removal for macular detachment in highly myopic eyes. Am J Ophthalmol 2003;135:547-9.  Back to cited text no. 15
Shimada N, Sugamoto Y, Ogawa M, Takase H, Ohno-Matsui K. Fovea-sparing internal limiting membrane peeling for myopic traction maculopathy. Am J Ophthalmol 2012;154:693-701.  Back to cited text no. 16
Poole TA, Sudarsky RD. Suprachoroidal implantation for the treatment of retinal detachment. Ophthalmology 1986;93:1408-12.  Back to cited text no. 17
Tetz M, Rizzo S, Augustin AJ. Safety of submacular suprachoroidal drug administration via a microcatheter: Retrospective analysis of European treatment results. Ophthalmologica 2012;227:183-9.  Back to cited text no. 18
El Rayes EN, Elborgy E. Suprachoroidal buckling: Technique and indications. J Ophthalmic Vis Res 2013;8:393-9.  Back to cited text no. 19


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]


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