RETINAL DETACHMENT SURGERY: MANAGEMENT 25 YEARS AGO

The history of surgery for rhegmatogenous retinal detachment is rich but short. Almost 90 years ago, Jules Gonin began disseminating his message claiming a successful procedure for a previously untreatable disorder. Gonin first provided an oral report regarding the success of his technique of “ignipuncture” to the Swiss Ophthalmologic Society in 1919,1 although his successes were not clearly substantiated by others until 1928.2 Many authorities cite 1929 as the year during which news of his achievements reached the world,3 and his first publication in English did not appear until 1930, only 76 years ago.2 Gonin’s essential steps for successful surgery have remained as follows: locate the retinal breaks and functionally close the breaks. The detection of retinal beaks was first performed with a monocular reflecting ophthalmoscope, and one of the most critical surgical advances in ophthalmology was the introduction of the binocular indirect ophthalmoscope by Schepens in the late 1940s.4 Closure of retinal breaks with Gonin’s ignipuncture technique was quickly superseded by the introduction of several diathermy techniques,3 and these in turn were replaced in most instances by the introduction of cryotherapy by Lincoff and coworkers.5 Although pneumatic retinopexy and primary vitrectomy have been employed in retinal surgery for much longer than 20 years, their use was restricted to relatively unusual cases until more recently, and the first articles on these techniques for routine retinal detachments did not appear until 206 and 237 years ago. Twenty-five years ago, the usual method of repairing rhegmatogenous detachments was with a scleral buckle. These techniques were initially introduced as temporary devices by Jess,8 but Custodis9 deserves credit as the first contemporary scleral buckler, although his initial efforts were largely unappreciated in the United States. In our country, Schepens and coworkers introduced scleral buckling.10,11 This was initially performed on only cases with a poor prognosis, and an encircling polyethylene tube was employed; hard silicone materials for buckling were introduced a few years later. Segmental nondrainage procedures introduced by Custodis were popularized in the United States by Lincoff, who also developed improved models of suturing needles.12 In summary, 22 years ago, in 1984, retinal surgeons were primarily performing scleral buckles. Vitrectomies were reserved for particularly difficult or unusual cases, and pneumatic retinopexy was employed as an intraor postoperative maneuver. Scleral buckling reduces flow through and functionally closes retinal breaks in a variety of nonexclusive ways, including the following: 1) shortening the distance between the retinal pigment epithelium and sensory retina; 2) displacing subretinal fluid; 3) reducing vitreous traction; 4) altering subretinal fluid currents; and 5) creating a functional vitreous plug. Interestingly, a permanent scleral buckle usually functionally closes retinal breaks even if a chorioretinal adhesion is not created. Fetkenhour and Hauch13 performed scleral buckling on a consecutive series of 175 cases and applied no thermal adhesive modalities. Their success rate and incidence of proliferative vitreoretinopathy (PVR) was comparable to series in which a chorioretinal adhesion had been created, and PVR remained the most common cause of failure. Contemporary scleral buckling 25 years ago included a fundamental decision about the relative value of encircling versus segmental procedures and the necessity of draining subretinal fluid, although the From the Departments of Ophthalmology, Greater Baltimore Medical Center and The Johns Hopkins University, Baltimore, Maryland. Presented at the annual meeting of the American Academy of Ophthalmology; New Orleans, Louisiana; October 26, 2004. Reprint requests: Charles P. Wilkinson, MD, 6569 N. Charles St., #505, Baltimore, MD 21204.