Origins of Minimal Segmental Buckling Without Drainage

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Minimal segmental buckling without drainage for repair of a primary rhegmatogenous retinal detachment is an extraocular technique in which the buckle and the coagulations are limited to the area of the break. The two components of this procedure can be traced back over several decades. The present minimal surgery developed in small steps over the years. Eliminating drainage of subretinal fluid and applying the surgery only in the area of the break was a change from treating the entire extent of the detachment to a surgery of the retinal break (Fig. 6.1).

For the first time since Gonin (1929), the coagulations were limited to the break [1]. However, the advantage of this limited and focused treatment was given up over the years, and coagulation of the entire periphery of the detached retina again was recommended to create a secure barrier against redetachment [2,3]. Coagulating limited to the leaking break was taken up again - for the second time - by Rosengren in 1938 [4]. However, with this procedure, redetachments occurred because the intraocular duration of the air bubble was sometimes too short for a sufficient adhesion to develop around the break. Consequently, the barrier concept was integrated again into the treatment of retinal detachment. This resulted in coagulations over the entire retinal periphery, and, subsequently, a circumferential buckle was added by Schepens in 1957 [5] and Arruga in 1958 [6]. Thus, the cerclage operation with drainage of subretinal fluid evolved.

Yet, drainage, which was applied with this procedure, represented a dangerous and vision-threatening complication. The procedure

Drawing Ophthalmology

Fig. 6.1. Minimal segmental buckling without drainage, so-called extraocular minimal surgery. The treatment is limited to the area of the break and not determined by the extent of the detachment. The small (top left) and the more extensive detachment (top right) are caused by the same horseshoe tear at 1:00. The treatment of both is the same, consisting of buckling the tear either by a segmental sponge (as depicted) or a temporary balloon without drainage of subretinal fluid was accompanied by serious complications, such as intraocular hemorrhages, which occurred in 15.6% of patients in our series, as reported in 1971 [7], in 16% as published by Blagojevic in 1975 [8], and in 6.9% as reported by Huebner and Boeke [9]. Additional complications consisted of choroidals in 8.6%, as reported by Toernquist and Toernquist in 1988 [10] and intraocular infection and incarceration of vitreous and retina, as described by Lincoff and Kreissig [11].

A procedure without drainage to attach the retina would eliminate two major hazards of drainage: (1) perforation of choroid with its serious complications and (2) the subsequent intravitreal injection to restore lost volume, which adds the risk of an intraocular infection.

The needed change was already "ante portas" in 1953 when Custodis [12] introduced a different approach to attach a retina. The procedure (1) eliminated drainage of subretinal fluid and the accompanying complications and (2) limited the coagulations and the buckle to the area of the break. The operation was in complete contrast to cerclage with drainage. Nondrainage of the Custodis technique was made feasible by the use of an elastic explant, the polyviol plombe, which was compressed by an intrascleral mattress suture over the detached retinal break. However, the sclera was treated by full-thickness diathermy, which subsequently proved detrimental to this exceptional technique. Due to the subsequent expansion of the compressed elastic plombe, the retinal break would be closed, and subretinal fluid would be absorbed. Thus, drainage was eliminated, and the intraoperative complications were reduced to a minimum. The simplicity of this Custodis principle was a concept of genius: "After the leaking break is closed, the pigment epithelium will pump out subretinal fluid and attach the retina." But despite all, this exceptional technique was nearly abandoned, not because it did not work, but because of unexpected serious postoperative complications caused by the polyviol plombe compressed over full-thickness and diathermized sclera. The diathermized sclera became necrotic, and, if bacteria were present under the compressed explant (polyviol), a scleral abscess and perforation could result. In 1960, the Boston group [13] reported serious postoperative complications after the Custodis procedure, i.e., scleral abscess and endophthalmitis requiring even enucleation. As a result, this exceptional procedure was abandoned in the United States and in Europe.

Actually, this was not true for everybody in the United States -not for Lincoff in New York. He had observed complications as well, but, on the contrary, did not give up the Custodis method. Instead, he was convinced of the logical approach and simplicity of the new Custodis procedure. Therefore, in the subsequent years, he with his group replaced diathermy with cryopexy [14,15] and the polyviol plombe with a tissue-inert silicone plombe - the Lincoff sponge [16]. The operation was called the modified Custodis procedure and was subsequently named the cryosurgical detachment operation. The technique represents an extraocular approach, since drainage was eliminated, and the cryosurgery and the buckle were limited to the area of the break. The procedure is the basis for today's extraocular minimal surgery for a retinal detachment.

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