Major Review Evolution of surgery down the ages Bikramjit P Pal1 and Kumar Saurabh2

1,2Associate consultant, “Treatment of retinal detachment associated with osmotic agents were also injected into the subcon- Consultant, retinal holes should not be urged except in only junctival space in the hope of reduction of SRF. Vitreoretinal Services, eyes as a last clutch at a straw of hope”. These These included saline, gelatin, cane sugar, glycer- Sankara Nethralaya, Kolkata, India lines by Lister from 1927 and the famous survey ine and mercury salts. by Vail a decade prior (1912),1 which found a A ray of hope appeared when Leber and success rate of retinal detachment (RD) as 1 in Nordenson2 put forward their theory of vitreous Correspondence: 1000 speaks for themselves, suggest a grave prog- traction in the genesis of RD. They postulated that Bikramjit P Pal, nosis for RD. Although the current success rate in the alterations in vitreous generated secondary KamalNayan Bajaj Sankara managing uncomplicated RDs is greater than 90%, traction on the equatorial forming retinal Nethralaya, tears with RD. This concept was of paramount NewTown, Rajarahat, the journey has been the most intriguing with the Kolkata, India. emergence of many heroes. One such hero who importance as we know today but alas it met with Email: [email protected] stands apart is Jules Gonin, whose patience and severe resistance and criticism. Treatment aiming perseverance have led to the current understand- to relieve vitreous traction was introduced by likes ing and treatment of RD as we know it. The evolu- of Deutschmann (who did the same by using Von tion of RD surgery has always been divided into Graefe knife). ‘Pre-Gonin’ and the ‘Post-Gonin’ phases. With no Various non-surgical manoeuvres were also intent to change the same, we hereby briefly employed. Samelsohn1 insisted on bilateral com- describe the evolution of RD surgery as it pression bandages with bed rest with idea of unfolded. increasing intraocular pressure. Dietary modifica- tions with salt restriction were another treatment Pre-Gonin era (before 1920) on offer. Although retinal break was known to be asso- ciated with RD, the focus was solely on RD with Jules Gonin and methods of retinopexy no attention to the causative break. Various the- Jules Gonin (1870–1935) legacy in history of RD ories were put forward and treatment was direc- dares to show how ones persistence and persever- ted towards them. The first theory talked about ance can change an idea. Taking Leber and RD as being spontaneous with the main culprit Nordenson’s idea ahead with two decades of being abnormal leakage from choroid. Breaks in experimentation and self-belief, Gonin proved the retina were thought as a result of increased pres- role of retinal break in the pathogenesis of RD. He sure from fluid generated behind the retina. This introduced a procedure called as ‘Ignipuncture’ led to treatments in the form of scleral and whereby retinal breaks were painstakingly loca- retinal puncture to relieve the pressure. Various lized pre- and intraoperatively (not an easy task treatments were directed towards draining the in those days). Under local anaesthesia, subretinal subretinal fluid (SRF) only to meet with obvious space was entered after making a radial scleral failure. A combination of SRF drainage along incision near the causative break and SRF was with the idea to induce retinopexy was probably drained. Thermocautery was then introduced to introduced for the first time by Fano in 1866.1 create a retinopexy. In 1931, Gonin published his He induced chemical retinopexy in the form of series of 221 patients who underwent ignipunc- injection of iodine solution into the subretinal ture with a success rate of 63%.3 Gonin’stheory space to achieve a chemical reaction. Apart of primarily treating the break was cemented from chemical retinopexy, other modalities when his disciples namely Amslers, Weve and employed were galvanocautery, pioneered by Arruga4 reported similar success in their Deutschmann.1 operations. The second theory prevalence in this era saw a In the coming decades, various modifications role of hypotony and associated circulatory altera- of retinopexy were developed to treat the retina tions as the cause of RD. Various treatments were surrounding the causative break. The use of chem- put forward to counter the same. Injection of ical cauterization for retinopexy in the form of materials like rabbit vitreous and gelatin to potassium hydroxide after creating holes in sclera increase the intraocular pressure were attempted. (trephining) was introduced by Guist and Lindner1 Lagrange introduced a procedure known as ‘col- in 1931. Diathermy was introduced by Larsson, matage’ whereby intraocular pressure was Weve and Safar. It was used either on the bare increased by applying three rows of scleral cautery sclera (surface diathermy) or after trephining in a circumferential manner in order to increase the sclera (penetrating diathermy). Drainage of hydrostatic pressure in the retina.1 Various SRF was performed along with diathermy. This

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procedure was commonly employed for around of the same, scleral surgeries without tissue exci- two decades. Complications of diathermy in the sion were attempted. Weve’sreefing procedure by form of thinning and perforation led to search of placing lamellar suture bites, scleral outfolding other modalities for retinopexy. Electrolysis was and infolding techniques was some of these. reintroduced by Imre in 1932, but was seen to be The first ‘accidental’ temporary scleral indenda- less effective when compared with diathermy; tion during scleral buckle was done by Jess in hence never became popular. Although cryother- 19371 where a cotton swab was used for the apy was introduced by Deutschmann and Bietti, purpose to counteract hypotony secondary to SRF the credit for its current use goes to Harvey drainage. The first scleral buckling procedure Lincoff and Amoils who made its use easy by cre- using an episcleral exoplant was performed by ating a specially designed cryo-probe with use of Ernst Custodis in 1949.1 He used a material made liquid nitrogen. The use of light for retinopexy of polyviol and postulated a non-drainage surgery was also being studied with the first human use and advised reoperation if SRF failed to clear in 4 by Moran-Sales, although their results were pub- days. Charles Schepens5 gets the credit for doing lished after Meyer Schwickerath. Dr Schwickerath the first scleral buckling surgery in the USA in initially used sunlight, then carbon arc and finally 1951. He popularized segmental and encircling krypton for retinopexy. Ruby laser and then argon bands made of polyethylene tubes and used the laser became available with first report of its use same after making lamellar scleral flaps. in 1969 by L’Esperance. Complications secondary to polyethylene tubes led Schepens to introduce the silicone rubber implants Evolution of the indirect ophthalmoscope1 in 1960. It was Brockhurst in 1965 who intro- The introduction of ophthalmoscope by Helmontz duced the scleral buckle procedure done world- in 1850 was the stepping stone to the current wide for decades. His technique included lamellar indirect ophthalmoscope of the modern era. Ruete scleral dissection, diathermy to the scleral bed fol- was the first to introduce indirect viewing of lowed by implant placement. The first use of non- retina with his monocular indirect ophthalmo- absorbable sutures for scleral buckling was scope. The first binocular indirect ophthalmoscope devised by Arruga in 1958. was devised by Giraud Teulon, which was a hand- It was Harvey Lincoff in 1965 who modified held model developed in the nineteenth century. the original procedure by Custodis.1 The changes Charles Schepens devised the first clinical head included use of silicone sponge, use of improved mounted an indirect ophthalmoscope in 1947. scleral needles and use of cryotherapy instead of Four years later, a modified version was intro- diathermy for retinopexy. Silicone sponges were duced by Schepens who incorporated the light used in a radial or circumferential fashion depend- source and viewing system on the headband as we ing on the clinical scenario. know it today. He also described the use of scleral depression which historically was first described Evolution of vitrectomy and associated by Trantas in 1900, although he used his thumb- procedures nails for doing so. Ocular sustenance without vitreous was deemed Localization of retinal breaks as put forward impossible and its removal a crime. David Kashner by Gonin was tiresome and needed hours of with help of cellulose sponge and scissors per- training and patience. Various methods were formed the first vitrectomy (open sky) in a child described for localization of breaks, most of with trauma on 28 July 19616 and proved how an which relied on major anatomical landmarks and eye could survive without vitreous. Subsequently, their distances from the break. Amsler and he operated two cases with vitreous amylodosis in Dubois were first to devise a fundus chart for 1967–1968 which cemented his theory. His pupil, mapping extent of RD and its causative break in Robert Machemer, performed the first pars plana 1928. A combination of ophthalmoscopy and vitrectomy in a patient of vitreous haemorrhage perimetry was also used for the same first on 20 April 1970. He performed the same with describedbyLindner. help of VISC (vitrectomy, infusion, suction and cutter) developed by Jean Marie Parel. It was Evolution of scleral buckling Connor O’ Malley and Ralph Heinz7 who intro- Shortening of globe by scleral resection was the duced a divided 20-G vitrectomy system called first step towards scleral buckling although the Ocutome 800 working on principle of pneumatic initial idea was globe shortening and not support- cutting. Gholam Peyman introduced the electric ing the break. Creating an inward ridge for sup- solenoid-driven guillotine cutter. porting break was initially achieved either by full Steve Charles7 led the way in developing the or partial thickness scleral resection with SRF vitrectomy machines. He was instrumental in drainage and putting mattress sutures across developing the linear or proportional mode for the defect. The techniques were laborious and the first commercial vitrectomy machine: Ocutome dangerous with high complication rates. In view 800. Further on, he designed the ocular

4 Sci J Med & Vis Res Foun July 2017 | volume XXXV | number 2 | Major Review connection machine (OCM), the forerunner for RD surgery in India various vitrectomy machines like Accurus and Looking into the evolution of RD surgery in India Constellation. Dr Charles is also credited for devel- has proved to be more laborious than operating a oping fluid air exchange, flute needle, internal complex RD. The following paragraph was formu- drainage of SRF and endophotocoagulation tech- lated based on the inputs from eminent indivi- niques. He was also instrumental in developing duals in the field of vitreoretinal surgery in India various scissor segmentation and delamination as well as with help of old issues of Indian techniques. As success for treating simple rhegma- Journal of . togenous RDs evolved, so did various instruments Probably, the first person to start vitreoretinal for complex RDs. Machemer with his bent needle services was Dr JM Pahwa from AIl India Institute technique and O’Malley with his pic forceps of Medical Sciences (AIIMS), New Delhi (personal made peeling of membranes easier. End-grasping communication). However, literature search has forceps by Steve Charles and diamond dusted not provided any concrete evidence of same. The membrane scrapper by Yasuo Tano were other same search showed Dr Bijayananda Patnaik from innovative instruments which are still widely used Maulana Azad Medical College publishing his today. results of scleral buckling in 100 cases in the year It was Ohm who gets credit for the first use of 1974.11 Dr PK Khosla from AIIMS published their tamponade: although air in conjunction with RD results of scleral buckling in 1977 followed by surgery in 1911. This was then routinely adopted another one in 1981.12 Another legend Dr DN by Arruga8 and then Rosengren who was a Gangwar from Postgraduate Institute of Medical leading figure in propagating the pneumoretino- Education and Research, Chandigarh, published pexy. The use of sulphur hexafluoride (SF6) as a their results of scleral buckle in 1983.13 tamponade agent was devised by Edward W.D The first vitrectomy in India was done by Norton.1,4 Perfluorocarbon gas and its use in RD Dr Gholam Peyman in a case of vitreous were introduced by Vygantas and Lincoff. Giant haemorrhage during a workshop in Madurai retinal tears and its complex treatment with Medical College in 1974 (personal communica- nothing short of gymnastics being performed by tion). Those attending this workshop were the surgeon were eliminated with the introduction Dr. SS Badrinath of Sankara Nethralaya and of perfluorocarbon liquids (PFCL). It was Haidt Dr. P Namperumalsamy of Arvind Eye Care who first introduced PFCL in 1982 although System; who later became the doyens in develop- Stanley Chang gets credit for making its use ing vitreoretinal surgery and trained many more popular in treating complex RDs. Paul Cibis9 who themselves became authorities. trained by Schepens himself was first to use sili- It is ironic to say the least that we know so cone oil in RD surgery. However, he did not use it little of our past. We hope this rich history of ours as a tamponade but as a tool to dissect preretinal gets unfolded too. RD surgery is still evolving and membranes in cases with proliferative vitreoreti- its history is a candid example of how persistence nopathy. Interestingly, Paul Cibis was part of and perseverance of human endeavours can shape operation ‘paper clip’, a secret program offered by an idea. We conclude with following lines by Dr the government of USA to employ scientist and Charles Schepens. doctors from Germany after the World War II. It “Never stop dreaming; what seemed impossible was Zivojnovic who pioneered the use of silicone yesterday can become a reality tomorrow” oil and its use as a tamponade. Early 21st century saw the introduction of the Acknowledgements We thank Dr Lingam Gopal 25 gauge by Eugene Dejuan and then the and Dr Muna Bhende: Sankara Nethralaya, 23-gauge system by Klaus Eckardt, making RD Chennai, Dr P Namperumalsamy: Aravind Eye surgery less cumbersome and much faster with Care System and Dr Pradeep Venkatesh: AIIMS for excellent results. The introduction of 27-gauge providing inputs in preparing the manuscript. We vitrectomy by Oshima has further made patient also thank Dr Abhinav Dhami: Senior Resident, rehabilitation faster.7,10 Department of Vitreoretina, Sankara Nethralaya in Viewing systems used during vitrectomy have providing materials for the above review. also seen their share of evolution. From the initial days of Goldmann planoconcave lens and Landers lens system where peripheral vitreous was mostly untouched, various contact and References non-contact wide-angled viewing systems have 1. Wilkinson CP, Rice TA. (1997) Michels retinal detachment, 2nd revolutionized the way we see and operate retina. edn. Mosby, St Louis, MO, pp. 241–333. 2. Gloor BP, Marmor MF. Controversy over the etiology and The introduction of binocular indirect ophthal- therapy of retinal detachment: the struggles of Jules Gonin. momicroscope (BIOM) by Manfred Spitznas and Surv Ophthalmol. 2013;58(2):184–95. its variants have greatly eased performing an RD 3. Wolfensberger TJ, Gonin Jules. Pioneer of retinal detachment surgery. surgery. Indian J Ophthalmol. 2003;51(4):303–8.

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4. Rezaei KA, Abrams GW. (2005) Chapter 1: the history of retinal 9. Feibel RM, Blodi CF, Cibis Paul A., MD: a pioneer of modern detachment surgery: primary retinal detachment: options for vitreoretinal surgery. JAMA Ophthalmol. 2013;131(8):1077–82. repair., 1st edn. Springer, pp. 1–25. 10. Nagpal M, Verma A, Goswami S. Micro-incision vitrectomy 5. McPherson A. Charles Schepens 1912–2006. Retina. 2006;26(6): surgery past, present and future. Eur Ophthal Rev. 2015;9 597–98. (1):64–8. 6. Blodi CF, Kasner David, MD, and the road to pars plana 11. Patnaik B, Kalsi R. Retinal detachment (operative experience in vitrectomy. Ophthalmol Eye Dis. 2016;8(Suppl 1):1–4. hundred consecutive cases). Indian J Ophthalmol. 1974;22 7. Charles S. The history of vitrectomy: innovation and evolution. (1):25–9. Retina Today. 2008:27–29. 12. Khosla PK, Tewari HK, Garg SP. Aphakic retinal detachment. 8. Ascaso FJ, Grzybowski A. Hermenegildo Arruga (1886–1972): a Indian J Ophthalmol. 1981;29(4):369–76. versatile ophthalmologist who simplified cerclage to retinal 13. Gangwar DN, Grewal SP, Jain IS. Retinal detachment surgery surgery. Acta Ophthalmol. 2014;92(8):814–7. sine retinopexy. Indian J Ophthalmol. 1983;31(3):197–8.

How to cite this article Pal B.P. and Saurabh K. Evolution of retinal detachment surgery down the ages, Sci J Med & Vis Res Foun 2017;XXXV:3–6.

Evolution of retinal detachment surgery: L’Esperance: first to use argon laser as retino- The ‘Firsts’ pexy in 1969 Albrecht von Grafe: first to notice and docu- David Kashner: first to perform ‘open sky ment a retinal tear vitrectomy’ Herman von Helmontz: first to introduce Robert Machemer: first to perform pars plana ophthalmoscope vitrectomy on 20 April 1970 in a patient with James Ware: first attempt in treating retinal vitreous haemorrhage detachment in 1805 Anton Banko: first to develop vitrectomy probe Jules Gonin: first to give retinal tear its due having infusion and aspiration, although never importance and attempts to treat the same commercialized it Giraud Teulon: first to introduce binocular indir- Jean Marie Parel (along with Machemer): first to ect ophthalmoscope (hand-held) in nineteenth commercialize vitrectomy probe called as VISC centaury (vitrectomy, infusion, suction and cutter), first to Charles Schepens: first to introduce head introduce operating microscope with X–Y mounted indirect ophthalmoscope in 1947, first movement to introduce encircling silicone bands Jean Haut: first to use silicone oil in combin- Larsson, Weve and Safar: first to introduce ation with pars plana vitrectomy in 1978 diathermy Conor O’ Malley: first to introduce three-port Ernst Custodis: first to use exoplant for scleral 20-g pars plana vitrectomy buckle in 1949 Gholam Peyman: first to introduce a separate Deutschmann: first to introduce cryotherapy in endoillumination probe 1933 Steve Charles: first to start internal drainage of Harvey Lincoff: first to introduce the modern subretinal fluid, fluid gas exchange, air-silicone cryounit for trans-scleral use oil exchange Moran Sales: first to use photocoagulation as a OHM: first use of intravitreal gas (air) in 1911 therapeutic modality in humans Edward Norton: first to use iso-expansile gas Gerd Meyer Schwickerath: first to publish tech- (SF6) with retinal detachment surgery nique in use of therapeutic photocoagulation in Haidt: first to introduce perfluorocarbon liquids 1949 as vitreous substitute in 1982

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