Retinopexy

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Many techniques were proposed for the creation of chorioretinal adhesions. Diathermy became the worldwide standard for retinopexy until the adoption of cryopexy in the 1960s. However, other methods were transiently used. In 1931, Guist cauterized the choroid around the break by touching it with a caustic potash stick in several places after it had been exposed with trephine openings through the sclera and the subretinal fluid drained [51]. This method was further modified by Lindner [52]. Passage of a galvanic electric current to produce a chorioretinal scar was proposed by Imre in 1930 followed by von Szily and Helmut Machemer in 1934 [53-55].1 The technique of diathermy was originally proposed by Larsson, Weve, and Safar and was further modified by Walker who developed a small, compact diathermy device [56-59]. Later, Weve employed both surface and puncture applications by unipolar electrodes while viewing with an indirect ophthalmoscope. Three methods of diathermy were utilized: (1) surface diathermy followed by drainage of subretinal fluid, (2) penetrating diathermy with drainage of subretinal fluid through the needle tracts, and (3) partial penetrating or surface diathermy with penetrating applications (the penetrating applications were used for drainage and were surrounded by non-penetrating applications) [10]. Dellaporta

1 Helmut Machemer was the father of Robert Machemer, the originator of vitreous surgery.

in 1954 closed retinal breaks with intraocular diathermy through the pars plana; he used a needle that was insulated except at its tip [60]. Although diathermy alone (with or without drainage of sub-retinal fluid) was the treatment of choice for retinal detachment prior to 1950, between 1955 and 1960, in most cases an indentation by a scleral buckle or scleral resection was added [61].

Light photocoagulation was first described by Czerny in 1867 who used a concave mirror and convex lens to focus sun light to induce retinal burns in animals [62]. Maggiore, in 1927, did the first experimental photocoagulation of the human retina when he focused sunlight for 10 min on the retina of a patient prior to enucleation for a malignant tumor [63]. Moran-Sales first used photocoagulation therapeutically in humans; however, Meyer-Schwickerath, in 1949, was the first to publish this technique [64, 65]. Due to his pioneering work, Meyer-Schwickerath is considered the father of photocoagulation. His work originated from his observation of chorioretinal scars secondary to eclipse burns [64]. He first tried to photocoagulate the retina with a carbon arc lamp and, then, through a series of mirrors and lenses with the sun as the source of light [66]. In cooperation with Hans Littmann,he subsequently developed a xenon-arc photocoagulation system that became available in 1958 and was used for the next 15 years. Following the development of the first laser (the ruby laser) in 1960 by Maiman, Zaret, in 1961, first published his experience with ruby laser photocoagulation of the animal iris and retina [67,68]. Campbell and coworkers, in 1963, first reported ruby laser photocoagulation of the human retina [69]. They treated a retinal tear with a combination of ruby laser and xenon-arc photocoagulation. Argon laser treatment in humans was first reported in 1969 by L'Esperance followed by Little et al. in 1970 [70,71]. At this time, point argon laser widely replaced xenon photocoagulation for treatment of retinal diseases.

Cryotherapy was introduced in 1933 by Deutschmann, who used solid carbon dioxide snow, and Bietti (1933-34), who used a mixture of this substance with acetone, to induce adhesive choroi-

ditis [72-74].Temperatures up to -8o°C could be reached using this technique. Three decades later in 1961, cryotherapy was reintroduced for intracapsular removal of cataracts by Krwawicz [75]. The cooling mechanism was a mixture of alcohol and solid carbon dioxide. In 1963, Kelman and Cooper created cryogenic chorioreti-nal scars in rabbits using a cryosurgical unit designed for treatment of neurological movement disorders that utilized liquid nitrogen to reach temperatures as low as -196°C [76]. Lincoff and coworkers, in 1964, using a similar neurosurgical Cooper-Linde cryosurgical unit, designed and built a probe for trans-scleral treatment of retinal diseases that would produce temperatures as low as -9o°C [77]. In experimental work in animals and early experience in humans, they found that -2o°C to -4o°C were the required temperatures for clinical use. Lincoff first treated humans with cryopexy in 1963, and reported the following year on his first 3o cases with retinal tears with or without retinal detachment [77]. Lincoff observed that cryotherapy did not cause scleral complications, such as those seen following diathermy application to full-thickness sclera, and led the popular transition from diathermy to cryotherapy for retinal detachment repair. Smaller, lighter, less-complicated instruments for cryopexy that are safe and easily maintained were developed that use the Joule-Thomson effect in cooling of gases such as nitrous oxide or carbon dioxide [78].

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