OBJECTIVE To the report 20-year follow-up data for patients receiving a scleral buckle for treatment of a primary rhegmatogenous retinal detachment (RRD). METHODS Nonconsecutive, retrospective case series. We identified 227 eyes with primary RRD who were treated with a scleral buckle, and for whom at least 20 years of follow-up data were available. Results were classified into 3 subgroups: retina reattached with 1 procedure; retina reattached with 1 or more additional vitreoretinal procedures; or retina detached at 20 years. RESULTS One hundred eighty-six eyes (82%) achieved retinal reattachment with 1 scleral buckling procedure and with a median final visual acuity of 20/40 at 20 years of follow-up. An additional 30 eyes (13%) achieved retinal reattachment after 1 or more additional vitreoretinal procedures, with a median final visual acuity of 20/50. Eleven eyes (5%) were detached at the 20-year follow-up examination, with a final visual acuity in all eyes of no light perception. CONCLUSIONS Scleral buckling for primary RRD achieves anatomical efficacy and preservation of central vision in the majority of eyes at 20 years' follow-up. The 1-operation success rate was 82%, overall success rate was 95%, and median final visual acuity was 20/40. This study may serve as a basis for comparison with the long-term results of other surgical techniques used in the treatment of primary RRDs.