Conclusion

Whereas modern examination techniques facilitate localization of breaks and allow for precise treatment of the holes, drainage and encircling continue to be popular and are used by a majority of surgeons. Careful preoperative examination including a detailed fundus drawing was advocated by Schepens and should still be done, irrespective of the surgical method. Examination is time consuming in the age of managed care and even the best effort cannot always identify all breaks. For the buckling procedure to be successful, all breaks have to be identified and closed, encircled or not.

Encircling and drainage were successful in 78-96% and have become synonymous with scleral buckling [15,37]. Since the 1950s, at least two generations of surgeons have been well trained in this procedure. It is "dependable" and incorporates the barrier concept [2]. Intraoperative localization as to latitude is critical, but meridional localization may be less precise compared with minimal radial buckling. The vitreous base is ring-like; supporting it treats the hidden break and the anticipated traction. Broad buckles support anterior PVR and circumferential retinotomies [42]. This "ring" concept is behind prophylactic buckling and laser circling for 360 degrees, as they are meant to barrage and reduce the incidence of secondary breaks in alternate techniques [14,16]. Most encircling is reversible: a band can be cut in a timely fashion without re-detachment or permanent damage from ischemia.

Can the surgeon sleep better after the retina has been drained flat? It depends: a non-drainage procedure increases the chance of primary failure, but the eye will survive the attempt almost intact. By draining, the retina may be attached on the table, yet morbidity (blood under the macula etc.) may forever preclude visual recovery. Who could sleep well after the latter? From a pathologist's viewpoint, drainage will always be a penetrating injury to a vascular tissue in an inflammatory and hypotonous setting. The data reporting intraocular hemorrhage attest to this simple fact that cannot be changed by even the most sophisticated technique. The fear of anatomic failure (first operation success or lack thereof) apparent to both physician and patient has helped the propagation of techniques that flatten the retina under the surgeon's eye, like external drainage or internal drainage during vitrectomy. Both procedures share the complications of penetrating ocular injury.

After careful examination, a skillfully executed encircling and drainage operation has a high rate of success. However, morbidity leads to a gradual change in the author's practice. Encircling and drainage are not necessary conditions for a high rate of first operation success after scleral buckling; in fact, one can be equally successful employing less-morbid procedures. An editorial concluded that "accurate localization of all retinal holes and precise placing of the buckle are of course essential, and confidence in the success of the procedure is necessary to outweigh a fear of failure induced in the surgeon by the presence of fluid under the retina at the end of the operation. The temptation to drain and 'make sure' must be resisted.Yielding may well court complications" [43].

■ Acknowledgements. Illustrations by Daniel Casper, MD, PhD. This chapter was supported by an unrestricted grant generously provided by Mr. Walter Klein.

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