The influence of scleral buckle on choroidal architecture: An unexplored link with the spectrum of acquired overload choroidopathy?

Scleral buckling (SB) has been a cornerstone in the surgical management of rhegmatogenous retinal detachment for decades, achieving success rates above 85 %; however, its impact on choroidal architecture and hemodynamics has been less thoroughly explored until recent advancements in ocular imaging techniques. We synthesize current evidence on the effects of SB surgery on choroidal structure and circulation, examining its implications for postoperative complications and exploring a potential link with the newly described spectrum of acquired venous overload choroidopathy (AVOC). Various imaging modalities including indocyanine green angiography, optical coherence tomography (OCT), and OCT angiography have demonstrated that SB induces both transient and sometimes persistent alterations in choroidal thickness, blood flow patterns, and vascular morphology, with encircling buckles showing more pronounced and enduring effects than segmental approaches. Notably, persistent subretinal fluid (PSF), a known complication following SB surgery, appears associated with alterations in choroidal architecture, particularly in eyes with preexisting pachychoroid features, suggesting potential overlap with the AVOC spectrum characterized by impaired venous outflow from the choroid. The mechanical indentation of the sclera by the buckle may compress vortex veins, disrupt the Starling resistor mechanism regulating choroidal fluid dynamics, and contribute to venous congestion, with implications for long-term visual outcomes. While vascular adaptations often mitigate these effects through the development of collateral circulation, in some cases, particularly with encircling bands, persistent choroidal alterations may contribute to complications like PSF. Further research is needed to establish a definitive link between SB-induced choroidal changes and the AVOC spectrum, which could significantly influence patient selection, surgical technique, and postoperative management strategies for RRD.