Scleral buckling versus combined pars plana vitrectomy and scleral buckling in primary rhegmatogenous retinal detachment: a 20-year retrospective comparative study

Scleral buckling (SB) has been progressively displaced by pars plana vitrectomy (PPV) in the management of rhegmatogenous retinal detachment (RRD); however, this transition appears to be driven more by evolving surgical training patterns than by clear differences in outcome data. Long-term comparative evidence spanning the full arc of this shift remains scarce. We retrospectively analyzed 373 eyes (367 patients) undergoing SB ( n = 172) or PPV/SB ( n = 201) for primary RRD over a 20-year period (2002–2022) at a tertiary referral center. Primary anatomical success was defined as retinal attachment maintained without additional retinal surgery during the first three postoperative months, whereas final anatomical success was defined as retinal attachment at the last follow-up. Functional success required ≥ 2-line improvement in best-corrected visual acuity. Binary logistic regression identified independent predictors of anatomical and functional success. SB utilization fell from two-thirds to one-third of procedures over the study period, including among phakic patients. Final anatomical success was comparable between groups (98.3% vs. 98.0%; p = 1.00). SB preserved the crystalline lens substantially longer, with a threefold greater interval to cataract extraction (14.9 vs. 4.2 months) and a markedly lower extraction rate (24.4% vs. 68.8%). Final functional success was higher in the PPV/SB group (72.6% vs. 61.0%; p = 0.011), and multivariable analysis similarly identified worse preoperative best-corrected visual acuity (BCVA) as independently associated with higher odds of both primary and final functional success. Both findings likely reflect the greater potential for measurable improvement in eyes with poorer baseline vision rather than a true surgical advantage. Preoperative proliferative vitreoretinopathy (PVR) grade C–D was independently associated with lower odds of primary anatomical success, whereas pseudophakia was independently associated only with final functional success. SB achieved durable anatomical reattachment with a clinically meaningful advantage in crystalline lens preservation. Although its use has declined over time, SB remains an important surgical option in appropriately selected RRD cases, highlighting the value of maintaining proficiency with this technique in contemporary vitreoretinal practice.