In pediatric RRDs associated with high myopia or Stickler syndrome, how do you decide between scleral buckle alone versus combined vitrectomy and buckle?

Most of the time, a buckle works great. If there is posterior PVR that will not relax with a buckle or there is a GRT, then a vitrectomy will be necessary.

I'm pretty much a scleral buckle first surgeon if it looks doable. There shouldn't be any post-equatorial breaks, as I think the time of radial sponges has passed. The sclera can't be too thin. You have to have a lot of experience with scleral buckles.

Obvious indications for vitrectomy also include anything that significantly obscures the view, giant retinal tears, macular holes (which are really just another post-equatorial break), and any significant preretinal fibrosis.