The Present State of the Art and How It Came About

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Ingrid Kreissig, Harvey Lincoff

A major advance in the concept of treating a primary rhegmatoge-nous retinal detachment was the realization that the surgical problem was solely closing the leaking retinal break and that the extent of the detachment or tractional configurations remote from the break are of no consequence. Let us share with you this change in concept over time [1].

Recall, Gonin [2] postulated - for the first time - that a leaking break is the cause of a retinal detachment, and his treatment was limited to the area of this break. With his operation, the attachment rate increased from 0% to 57%. However, this localized procedure was soon modified to coagulations of the entire quadrant of the leaking break. In 1931, Guist and Lindner [3, 4] circumvented further the need for localizing the leaking break by doing multiple cauterizations posterior to the estimated position of the break; Safar [5] applied a semicircle of coagulations posterior to the break. The intent was to create a "barrier" of retinal adhesions posterior to the leaking break. As a result, the treatment was no longer limited to the break, but was expanded over the quadrant in which the break or presumed breaks were located.

In 1938, Rosengren [6] again limited - now for the second time - the coagulations to the leaking break. In addition - and for the first time - he added an intraocular tamponade of air, which was positioned in the area of the break to provide an internal support during the formation of retinal adhesion. Retinal attachment increased to about 77% with Rosengren's procedure.

However, the precise placement of coagulations around the break was difficult, and the Rosengren technique was not widely

Simbolos Cuanticos
Fig. 9.1. A three-quadrant detachment with a horseshoe tear at 1:15

adopted. Instead, the pendulum swung back to an extensive coagulation. Now, for the second time, the barrier concept was integrated into the treatment. Coagulations were placed posterior to the break, but, in addition, the barrier of coagulations was reinforced with a scleral resection. Subsequently, a polyethylene tube was embedded into the resection to create a higher wall. Thus, for the first time, a buckle was applied in detachment surgery to more effectively barricade the break (Figs. 9.1,9.2). The break was

Fig. 9.2. Scleral resection with an embedded polyethylene tube and drainage for repair of the three-quadrant detachment in Fig. 9.1. a The horseshoe tear was attached, but positioned on the anterior edge of the buckle and not sufficiently tamponaded. Diathermy coagulations were added around the tear, on the buckle, and additional lines of coagulations extended to the ora serrata. b The horseshoe tear leaked anteriorly, broke through the lines of coagulations before the adhesions were secure, and caused an anterior redetachment that progressed inferiorly and rede-tached the posterior retina

Cerklage Retina
Fig. 9.2a,b. Legend see page 178
Cerclage Retinal Detachment
Fig. 9.3a,b. Legend see page 181
Cerclage Retinal Detachment

Fig. 9.3. Encircling buckle (cerclage), extensive diathermy coagulations, and drainage for repair of the detachment in Fig. 9.1. a The horseshoe tear was attached, but positioned on the anterior edge of the buckle and not sufficiently tamponaded. b Anterior redetachment was confined by the encircling buckle. c Anterior redetachment eventually broke over the inferior buckle barrier and redetached the posterior retina

Fig. 9.3. Encircling buckle (cerclage), extensive diathermy coagulations, and drainage for repair of the detachment in Fig. 9.1. a The horseshoe tear was attached, but positioned on the anterior edge of the buckle and not sufficiently tamponaded. b Anterior redetachment was confined by the encircling buckle. c Anterior redetachment eventually broke over the inferior buckle barrier and redetached the posterior retina positioned at the anterior edge of the buckle and larger breaks were not adequately tamponaded and would leak anteriorly and cause an anterior redetachment, which descended behind the buckle, went around the buckle inferiorly, and redetached the posterior retina.

The consequence could have been a more sufficient tamponade of the leaking break. Instead, a more effective barrier was developed in 1953, the segmental buckle barrier was extended for 360° -for the first time - by Schepens [7] and in 1958 by Arruga [8]. The cerclage operation with drainage of subretinal fluid represented a maximum barrier for the leaking break. But here, as well, redetach-ments developed (Fig. 9.3). Eventually the cerclage was widened in the area of the tear with a polyethylene sleeve to buckle the anterior edge of the tear. Later, various silicone forms for buckling were designed to fit the tear combined with coagulations limited to the tear or extending over 360° (Fig. 9.4). More retinas were attached -more than 80%.

The modified cerclage with drainage represents one of the four techniques still in use for repair of a primary retinal detachment at the beginning of the twenty-first century (Fig. 9.4). Drainage, however, required by this technique, has complications.

In 1953, Custodis [9] limited the treatment - now for the third time - to the area of the leaking break, but - for the first time -omitted drainage of subretinal fluid. This exceptional technique was nearly abandoned, not because it did not work, but because of unexpected postoperative complications caused by diathermy and the polyviol plombe, which Custodis compressed over full-thickness and diathermized sclera, which sometimes caused scleral necrosis. As a result, the technique was abandoned in the United States and in Europe.

Lincoff in New York, who was convinced of the logic and simplicity of the Custodis procedure, made the operation acceptable by replacing diathermy with cryopexy [10,11] and the polyviol plombe with the tissue-inert silicone sponge [12]. In the following years, this technique was further refined by smaller segmental buckles that were positioned more precisely [13] and by replacing the sclera-fixated sponge with a temporary balloon buckle [14,15] that was not sutured onto sclera. The balloon operation was suitable for detachments with a single break. This minimal segmental buckling with sponges or a balloon represents an extraocular approach, limited, again, to the area of the leaking break.

However, the "conditio sine qua non" for a spontaneous attachment without drainage was that all of the leaking breaks had to be found and tamponaded adequately. Otherwise, the disappearance of subretinal fluid would not occur. Finding all the breaks was helped by the development of binocular indirect ophthalmoscopy, biomicroscopy with contact lenses, the 4 Rules to find the break in a primary detachment [16,17], and the 4 Rules to find the break in an eye up for reoperation [18,19].

Fig. 9.4. Modified cerclage: Encircling silicone band with a local buckle beneath the tear and drainage for repair of the detachment in Fig. 9.1. With coagulations limited to the area of the tear (a) or with coagulations extended for 360° (b)

As a result, minimal segmental buckling with sponge(s) or a balloon without drainage represents a second option for repair of a primary retinal detachment in use at the beginning of the twenty-first century (Fig. 9.5).

Apart from these two options for closing the leaking break with a circular barrier (cerclage) or a segmental buckle (sponge or balloon) limited to the break, both of which are extraocular, two options for an intraocular approach developed. An intraocular gas bubble to tamponade a leaking break was introduced - now for the second time. Instead of air, SF6 was injected by Norton and Lincoff [20,21]. This technique required drainage of subretinal fluid with its complications.

In 1979, Kreissig [22] applied - for the first time - intraocular SF6, an expanding gas, without prior drainage in selected detachments. The procedure was named the expanding-gas operation without drainage. However, an increased rate of postoperative proliferative vitreoretinopathy (PVR) caused Kreissig to reserve intraocular gas for problematic breaks not suitable for buckling. Subsequently to reduce the morbidity of intraocular gas, Kreissig developed the balloon-gas procedure which enables to inject primarily a larger bubble of a gas with a shorter intraocular duration [23]. To close a leaking break with a gas bubble and without prior drainage was introduced again - for the second time - by Hilton [24] and simultaneously by Dominguez [25] in 1986.

Hilton called the procedure pneumatic retinopexy which represents a third option for repair of a primary retinal detachment in use at the beginning of the twenty-first century (Fig. 9.6a). When supplemented by 360° barrier coagulations, it is no longer a procedure limited to the break (Fig. 9.6b) [26].

Pneumatic retinopexy has become a popular procedure, despite the fact that it has a greater morbidity for closing the leaking break than minimal segmental buckling without drainage. Its popularity is due to its relative simplicity.

To reduce the postoperative complications of intraocular gas, a vitrectomy was added [27]. The rationale was that a vitrectomy

Fig. 9.5. Minimal segmental buckling without drainage and coagulations limited to the tear for repair of the detachment in Fig. 9.1. The buckle is obtained by a radial sponge (a) or by a temporary balloon beneath the tear (b). After withdrawal of the unsutured parabulbar balloon (after 1 week), the tear will be only secured by coagulations

Fig. 9.5. Minimal segmental buckling without drainage and coagulations limited to the tear for repair of the detachment in Fig. 9.1. The buckle is obtained by a radial sponge (a) or by a temporary balloon beneath the tear (b). After withdrawal of the unsutured parabulbar balloon (after 1 week), the tear will be only secured by coagulations

Fig. 9.6. Pneumatic retinopexy without drainage for repair of the detachment in Fig. 9.1. With coagulations limited to the tear (a) or with coagulations extended for 360° (b) [25]. An expanding gas was injected into the vitreous, and the patient's head was positioned so that the gas bubble tamponaded the tear. Air travel will be restricted until the volume of the gas bubble is less than 10% of the ocular volume

Fig. 9.6. Pneumatic retinopexy without drainage for repair of the detachment in Fig. 9.1. With coagulations limited to the tear (a) or with coagulations extended for 360° (b) [25]. An expanding gas was injected into the vitreous, and the patient's head was positioned so that the gas bubble tamponaded the tear. Air travel will be restricted until the volume of the gas bubble is less than 10% of the ocular volume

Fig. 9.7. Primary vitrectomy with resection of the vitreous and internal drainage for repair of the detachment in Fig. 9.1.With coagulations around the tear (a) or with coagulations extended for 360°, a local buckle beneath the tear and an encircling band (b). Gas was injected to replace the vitreous and the patient asked to avoid face up during sleep. Air travel will be restricted until the volume of the gas bubble is less than 10% of the ocular volume

Fig. 9.7. Primary vitrectomy with resection of the vitreous and internal drainage for repair of the detachment in Fig. 9.1.With coagulations around the tear (a) or with coagulations extended for 360°, a local buckle beneath the tear and an encircling band (b). Gas was injected to replace the vitreous and the patient asked to avoid face up during sleep. Air travel will be restricted until the volume of the gas bubble is less than 10% of the ocular volume might eliminate traction on the break and reduce postoperative anterior and posterior vitreous proliferation. The analysis in Chap. 8 indicates that this aim has not been achieved; nevertheless, the procedure is increasingly applied.

Primary vitrectomy has become a fourth option for repair of a primary retinal detachment at the beginning of the twenty-first century (Fig. 9.7). When supplemented by extensive barrier coagulations and a cerclage, it is no longer a procedure limited to the break.

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