Major Review Evolution of retinal detachment 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 retina 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 Sci J Med & Vis Res Foun July 2017 | volume XXXV | number 2 | 3 Major Review 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.