In the latter half of the twentieth century, the buckle operations invented by Charles Schepens in 1951 [63] and Ernst Custodis in 1953 [64] were modified and refined. Diathermy was replaced with cryo-

pexy; scleral resections and implants were replaced with explants sutured over full thickness sclera [65, 66]. Extensive circumferential buckles and encircling operations - barrier procedures that were intended to wall away undetected breaks in the periphery -were replaced with segmental buckles confined to the breaks. The undetected break was less frequent because preoperative indirect ophthalmoscopy was augmented by binocular microscopy of the retinal periphery through the mirrors of the Goldmann lens.

Closing the retinal breaks became the sole surgical problem; the extent of the detachment was a lesser factor. If the breaks were effectively buckled, the large detachment would attach without drainage after only a few additional hours (Fig. 8.2). Not draining subretinal fluid was increasingly adopted. At the New York Hospital, the incidence of not draining rose from 50% to 90% in the course of the first 1,000 cases after the senior author (HL) met with Ernst Custodis and adopted his method [67].

Diminished morbidity was the Holy Grail. The external buckle operation with a segmental sponge and without perforation for drainage had no intraocular complications and only infrequent ex-traocular ones. There was a buckle infection initially of 3% that dropped to 1% with the development of the closed-cell sponge and the use of parabulbar antibiotic [68]. Diplopia might occur if a sponge intruded on a rectus muscle. The substitution of a temporary balloon for breaks beneath a rectus muscle eliminated postoperative diplopia because, within hours after the balloon was withdrawn, the muscle functioned normally again [55]. A second operation after the sponge procedure was required in 11% and after the balloon procedure in 7%. Failure with either the sponge or the balloon was due to an undiscovered break or an inaccurately placed sponge or balloon. Final attachment for the sponge operation after a second buckle was 97% and for the balloon was 99%. Less than 2% developed PVR postoperatively after either procedure. The low incidence of PVR was a positive affect of diminished operative trauma. The greater incidence of PVR as we knew it in prior years was iatrogenic, a product of trauma inflicted by extensive barrier

Fig. 8.2. The small detachment (upper left) and the more extensive one (upper right) both responded to a radial sponge buckle (lower center).The larger detachment attached after only a few additional hours

coagulation, constriction by the encircling band, and the draining of subretinal fluid - all of which contribute to a breakdown of the blood-aqueous barrier and the infusion of cells and protein that provoke PVR. Of the 2% that failed to attach because PVR prevented closure of the break with a buckle, vitrectomy could attach half of them. Thus, blindness from a retinal detachment, which was inevitable before 1929, was a rare event at the end of the twentieth century. Why the current swing to an intraocular procedure, which our analysis indicates has a greater morbidity in terms of requiring 2nd surgeries and causing PVR? - We suggest that the reasons are external and not related to results.

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