To determine the various factors affecting the duration of scleral buckle surgery, the percentage of profitable scleral buckle cases, and the operational break-even point. This single-center retrospective consecutive series comprised patients diagnosed with primary rhegmatogenous retinal detachment (RD) repaired with scleral buckling between 2019 and 2021. The primary outcome was operative time. Factors associated with longer surgery time were identified using regression analysis. A time-driven activity-based cost analysis was performed. Following are the mean values: duration of 108 primary RD scleral buckle repairs, 106 ± 35 minutes (range, 52-231; median, 98); number of breaks, 2.15 ± 1.5 (range, 0-10); extent of the RD, 4.3 ± 2.0 clock hours (range, 0-9); duration of follow-up with a retina physician, 489 ± 355 days (range, 0-1316). Twenty eyes (19%) required subsequent RD repair. A regression analysis showed the following main risk factors for prolonged duration of RD repair via scleral buckling: number of breaks (β = 5.98;  = .005), use of radial elements (β = 52.09;  = .001), and gas injection (β = 31.27;  < .001). The median cost per case was $7674.64, which was $2713.64 (55%) more than the maximum Medicare reimbursement of $4961.00. The break-even time was 54.43 minutes. Independent risk factors for a prolonged duration of primary scleral buckle surgery include multiple breaks, use of radial elements, and gas injection. These additive steps could justify a separate complex Current Procedural Terminology code. The large majority of cases were not profitable, with losses proportional to operative time. This study demonstrates the clear need for greater reimbursements and economic incentives for scleral buckle surgery.