Sir,

Raman et al1 advocate the use of the operating microscope for scleral buckling surgery. Iatrogenic scleral perforation is a recognized complication of scleral buckling surgery, and the authors elucidate manoeuvres that may decrease the likelihood of this intraoperative complication.

Time is of the essence when surgery is required to repair a macula-attached retinal detachment, as progression of the detachment to the macula will influence visual outcome significantly.2 When non-elective scleral buckling surgery is undertaken for these patients, ideal surgical facilities may not be available to the surgeon—for example, the eye operating room might be unavailable, while the general operating facility is more accessible. In the absence of the operating microscope under such circumstances, the surgeon will have to rely on loupes or the naked eye to pass partial thickness scleral sutures.

The authors suggest the use of the non-dominant hand for passing scleral sutures in certain positions to access parts of the scleral quadrants. In our view, the use of the non-dominant hand leads to considerable loss of control and proprioception, increasing the possibility of an iatrogenic perforation. Also, the frequency of scleral buckling surgery has decreased somewhat, following the universal adoption of extracapsular cataract extraction techniques.3, 4 This has diminished the opportunity for trainee surgeons to develop ambidexterity for scleral suturing manoeuvres.

The authors assert that using the operating microscope promotes comfort and good posture, since the surgeon remains seated ‘all the time’ during the operation. We believe that scleral buckling surgery is necessarily a dynamic operation in which the surgeon can remain seated only some of the time, because indirect ophthalmoscopy must still be performed at various points during the surgery when the surgeon will stand and the microscope will be removed from the field.