History of Retinal Detachment Surgery1

While progress was being made in the examination techniques, several theories were postulated for pathogenesis of retinal detachment. Theory of distention stated that retinal detachment is due to relative inelasticity of the retina as compared to choroid and sclera. So, when the globe enlarges in myopia, retina does not enlarge as much as the choroid and sclera, resulting in detachment.¹¹ Several authors believed that hypotony is the cause of retinal detachment (Theory of hypotony).^12,13 In their opinion it was the vitreous gel that was keeping the retina attached against the hydrostatic pressure exerted by the choroids. Authors who supported Theory of vitreous 2traction, thought that the primary event is some inflammation in the vitreous cavity.¹⁴ This leads to vitreous traction that subsequently pulls retina causing a detachment.

Those who believed in the Theory of exudation suggested that exudation of fluid from choroid induced detachment.

Several procedures were devised to treat retinal detachment based on the above theories. But the results were uniformly poor as the theories per se were incorrect. Procedures in those days included bed rest with immobilization of the head,¹⁵ subretinal fluid drainage with incision of the retina by von Graefe,¹⁶ scleral resection by Muller,¹⁷ subretinal fluid drainage with chorioretinal adhesion using galvanocautery¹⁸ among others.

His motto was “Look for the hole, find it and close it.” What von Graefe did for glaucoma, Gonin did same for retinal detachment.

His concept that “every retinal detachment has a retinal hole and every hole has a retinal detachment” is valid today but now there are exceptions (Figs 1.2 and 1.3). In 1919, Gonin described his surgical success to the Swiss Ophthalmological Society.¹⁹ His concepts had worldwide acceptance when he presented his findings to the International Congress of Ophthalmology in 1929 in Amsterdam.^6,19 In his Ignipuncture operation, Gonin made a radial incision on the sclera down to the choroid with a Graefe knife after localizing the retinal break. With the same knife he drained the subretinal fluid and then cauterized the break with a red-hot cautery (thermo-cautery).

Later many surgeons tried to improve upon his Ignipuncture operation. Guist introduced multiple trephination.²⁰ Penetrating diathermy²¹ or Larsson surface diathermy²² were other modifications.3

Modern examination techniques have contributed significantly in reaching the current high level of surgical success. Besides Charles Schepens electrically illuminated binocular indirect ophthalmoscope, Goldmann three-mirror lens,³⁶ indirect wide-field contact lenses and non-contact lenses like +78D made the localization of breaks easier and more accurate.

Harvey Lincoff's introduction of cryotherapy achieved adequate chorioretinal adhesion without causing scleral damage.^28,37 Unlike diathermy, it was effective through the full thickness of sclera avoiding scleral dissection and could be used on wet sclera, staphylomatous sclera and avoided damage to ciliary arteries if applied over them. Photocoagulation introduced by Meyer-Schwickerath was an alternative means to achieve chorioretinal adhesion.³⁸ Now Xenon-arc photocoagulators have been replaced by laser photocoagulation systems. Indirect ophthalmoscope laser delivery system is used in some cases after retinal reattachment,³⁹ slit-lamp delivery system in postoperative period and endolaser photocoagulation during pars plana vitrectomy.^40,41

Ernst Custodis (1953) introduced polyviol explant for scleral ‘buckling’.^26,42 The purpose of this pioneering concept was to approximate retinal break(s) with the underlying retinal pigment epithelium and choroid by reducing vitreoretinal traction, as well as closure of retinal break and formation of a chorioretinal adhesion. Schepens advocated the use of scleral implants made of polyethylene tube and later solid silicone material in the scleral bed.^24,25 Scleral dissection allowed proper diathermy as well as accurate positioning of the buckle element. However, this procedure was causing weakening of the sclera leading to intrusion of the buckle and higher infection rate. Lincoff introduced a soft silicone sponge explant.²⁹ Now majority of the retinal surgeons are using solid silicone tire explants.5

Drainage of subretinal fluid was done universally in Gonin's period. Later many surgeons suggested non-drainage procedures to avoid complications.^43,44 However majority of the surgeons drain in most of their cases.^45,46 Sclerotomy method of drainage comprising diathermy of sclera, radial sclerotomy, cautery and puncture of the choroid is gradually being replaced by safer modified needle drainage method.⁴⁷

Newer methods have been introduced to manage uncomplicated rhegmatogenous retinal detachment like pneumatic retinopexy,⁴⁸ Lincoff's balloon⁴⁹ and primary pars plana vitrectomy (Fig. 1.4).⁵⁰ Pneumatic retinopexy is being performed for primary rhegmatogenous retinal detachment having superior retinal breaks without proliferative vitreoretinopathy. In this procedure a long acting gas usually SF₆ is injected after cryopexy of the retinal break. After this the patient is positioned for tamponade of the break. Lincoff balloon is used for single superior break in uncomplicated rhegmatogenous retinal detachment. In this procedure the balloon is introduced in the parabulbar space after transconjunctival cryopexy. Primary vitrectomy is done in selected cases with posterior breaks.

Complex retinal detachments like those with proliferative vitreoretinopathy, giant retinal tear, and vitreous hemorrhage are managed by vitreous surgery. This comprises pars plana vitrectomy, membrane dissection, posterior hyaloid detachment, fluid air exchange, endolaser photocoagulation and internal tamponade by long acting gas or silicone oil. Robert Machemer introduced pars plana vitrectomy³¹ shortly after the initial description of the first planned open sky vitrectomy by Kasner.⁵¹ Robert Machemer is considered the father of modern vitreous surgery because he introduced modern pars plana method of vitreous surgery, instrumentations as well as basic surgical principles. Machemer's original instrument was called VISC (vitreous-infusion-suction-cutter). Later O'Malley and Heintz introduced the concept of ‘divided-system instrumentation’.^52,53 This consists of separate infusion, endo-illumination and vitrectomy cutter probe. Modern vitreous surgery is done under an 6operating microscope described by Littman⁵⁴ and later modified by Parel and coworkers.⁵⁵ Initially Goldmann planoconcave fundus contact lens and its various modifications were used for visualization during surgery.^56,57 Now non-contact lenses like BIOM with SDI are more frequently used to prevent corneal damage and for wide field view.^58,59 These are fitted on the operating microscope. Membrane dissection comprises peeling, delamination and segmentation, primarily described by Steve Charles.⁶⁰ Fluid-gas exchange was done with a hypodermic syringe mechanically but now automated devices are used.^61,62 Internal tamponade is provided intraoperatively or long-term postoperatively using air, gases like SF₆ or C₃F₈, silicone oil, and heavy perfluorocarbon liquids.^32–35

Surgical innovations are evolving as is understanding of the pathology of retinal detachment.