What factors guide your decision to perform subretinal fluid drainage during primary scleral buckle surgery for a rhegmatogenous retinal detachment?

Since external drainage of subretinal fluid is the step in scleral buckle surgery associated with the greatest risk of serious complications (i.e. subretinal hemorrhage, retinal perforation, retinal incarceration), I only drain if the subretinal fluid so bullous that drainage is necessary to insure good apposition of the retinal break(s) with the buckle. I also consider intraocular gas injection as an option if the break(s) is (are) located superiorly, especially if the patient already has a posterior vitreous detachment.

Over the years, I have been both a maximalist and a minimalist in this subject. Over the last 10 years, at least I've trended towards drainage in most cases. The risk of complications is very small compared to the risk of failure without it, or prolonged recovery with possible chronic SRF and ensuing pigment and photoreceptor damage. In some ways, this is becoming an academic debate, as surveys and my personal discussions with colleagues show that fewer and fewer buckles are done. In fact, very often if a younger colleague says buckle, they mean vit-buckle. I suspect the decreasing frequency will lead to decreased skill and increased chance of complications with drainage, contributing to the many reasons for the decline of this procedure.

The primary consideration is whether I can make the breaks flat on the buckle. If I can’t, I tend to drain. Also, if the pressure goes up to the point that the nerve isn’t perfused, I would rather drain than do an AC tap because I want the subretinal fluid to go away anyway. Chronic fluid can take up to a year to be absorbed by the RPE, and that is bad for photoreceptors.

Do if interference with buckle or impacting vision.