Outlook

Minimal segmental buckling by a sponge or a balloon and without drainage of subretinal fluid is the ultimate development of scleral buckling introduced by Schepens and Custodis and subsequently refined by Lincoff, Kreissig, and others. Minimal segmental buckling without drainage provides an optimum of early and late anatomical and visual results: retinal attachment results after one operation in 91% and after reoperation in 97%. However, to obtain this rate of attachment requires an expertise in biomicroscopy and binocular indirect ophthalmoscopy to find the breaks pre-operatively and at surgery to localize these breaks correctly and to adequately position the segmental buckle beneath them without drainage of subretinal fluid. However, this "Art of minimal segmental buckling" [25,26] has a learning curve.

Detachments in pseudophakic eyes today are almost routinely assigned to vitrectomy for primary repair. This may occur even when the break can be visualized preoperatively and would respond to a segmental buckle without drainage. For these eyes in which the break cannot be found because the peripheral retina is obscured by a narrow pupil or capsule opacities, a vitrectomy to provide better access for viewing the anterior retina may provide a better prognosis than prospective buckling, being based on the contour of the detachment, or a cerclage.

However, we have to keep in mind that the resources available for ophthalmology are diminishing as life expectancy increases and new treatments for various macular and retinal diseases become available. This expanding spectrum includes invasive and noninvasive, but expensive, treatment modalities. All this may force us to reconsider how to spend the limited resources for the increasing number of patients.

Probably, the future question no longer will be: which method is better for attaching a primary detachment:

1. A limited or a prospective buckle?

2. An intraocular or extraocular surgery?

Rather, it will be:

3. Which method is applied at its optimum with a minimum of strain on our financial resources?

And this could mean treating a break in a primary detachment by an extraocular surgery, limited to the break, i.e., a surgery, performed under local anesthesia and on a small budget, with a low rate of morbidity and reoperations, and with optimal long-term visual results. Perhaps in the future a less morbid procedure to attach the retina will be developed, or the pendulum of detachment surgery, as witnessed already during the past 75 years, might swing back to an extraocular minimal surgery. And in this case, we again might have to train surgeons skilled in preoperative diagnostics to find the break(s) and in the art of applying a minimum of segmental buckling without drainage to attach a retina.

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