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History of Surgery for Retinal Detachment

The evolution of the retinal reattachment operation is one of the most remarkable chapters in the history of ophthalmology. Gonin’s operation for repair of the detached retina ranks with Daviel’s cataract extraction,

von Graefe’s peripheral iridectomy, and Machemer’s vitrectomy as one of history’s most important surgical treatments for blinding eye diseases.

FOUNDATIONS OF RETINAL DETACHMENT SURGERY

DISCOVERY OF RETINAL DETACHMENT

The entity of retinal detachment was recognized early in the eighteenth century by de Saint-Yves, who reported the gross pathologic examination of an eye with a detached retina. The first clinical description did not appear until almost a century later, in 1817, when Beer detected a retinal detachment without the benefit of an ophthalmoscope. Von Helmholtz’s invention of the direct ophthalmoscope in 1851 was a giant step forward in diagnostic technique, and a rapid succession of ophthalmoscopic observations of retinal detachments soon followed. In the same year, Coccius reported the ophthalmoscopic detection of breaks in the detached retina.

ESTABLISHING THE ETIOLOGY OF DETACHMENT

Von Graefe theorized in 1858 that retinal detachment was caused by a serous effusion from the choroid into the subretinal space. When he observed a retinal break, he assumed that it was secondary to the detachment and represented the eye’s attempt to cure itself. Supposing that the development of a break would

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4I: Principles

allow the subretinal fluid to pass from the subretinal space into the vitreous cavity, he attempted unsuccessfully to treat detachments with deliberate incision of the retina.

Girard-Teulon invented the reflecting binocular indirect ophthalmoscope in 1861. This potentially important contribution was generally overlooked by the profession, and more than 80 years transpired before Schepens developed the selfilluminating binocular indirect ophthalmoscope.

In 1869 Iwanoff described the entity of posterior vitreous detachment, which is now recognized as a prerequisite to the development of most retinal detachments. The following year de Wecker suggested that retinal breaks cause detachment due to the resultant passage of vitreous fluid through the break into the subretinal space. Unfortunately, his accurate interpretation was not generally accepted. In 1882 Leber reported his observation of retinal breaks in 14 of 27 retinal detachments, and he correctly inferred the role of vitreous traction in the pathogenesis of breaks. Unfortunately, he later altered this opinion. In 1889 Deutschmann treated a detachment by closing the retinal break with ignipuncture. However, the value of this procedure was not appreciated at the time, and it was discarded for several decades.

GONIN’S DETACHMENT REPAIR

Jules Gonin (1870–1935; Figure 1–1) investigated the works of Leber and became convinced of the causal role of retinal breaks in the pathogenesis of retinal detachment. Resurrecting Deutschmann’s surgical approach, Gonin treated retinal breaks

Figure 1–1. Jules Gonin, MD, 1870–1935, father of retinal detachment surgery. (Reproduced with permission from Duke-Elder S, ed: Diseases of the Retina, vol. X of System of Ophthalmology. St. Louis: CV Mosby Co; 1967.)

6I: Principles

has resulted in the laser being commonly employed in contemporary reattachment surgery.

PNEUMATIC RETINOPEXY

First performed by Ohm in 1911, the use of intravitreal air injection for retinal detachment was developed by Rosengren in 1938. Years later, Chawla, Fineberg, Vygantas, Norton, and Lincoff brought intravitreal gas into common usage, combined with or following scleral buckling or vitrectomy.

Pneumatic retinopexy is a gas injection procedure for retinal detachment, performed in the office without scleral buckling, vitrectomy, drainage of subretinal fluid, or conjunctival incision. In 1983 G. Brinton presented the first cases, and in 1985 Hilton and Grizzard published the first report using the procedure they named, “pneumatic retinopexy.” This procedure (and a similar one described concurrently by Dominguez) modified Kreissig’s and Lincoff’s technique for treating retinal tears in the posterior pole. Tornambe, Hilton, and others brought pneumatic retinopexy into the mainstream of retinal surgery.

VITRECTOMY FOR RETINAL DETACHMENT

A surgical approach to the vitreous, an important adjunct in selected cases of retinal detachment, was pioneered by Shafer in 1950 with his method of vitreous transplantation. This important branch of surgery was expanded by Cibis in 1962 with his introduction of intravitreal silicone oil injection. The development of the vitreous infusion suction cutter (VISC) by Machemer in 1971 and the use of intravitreal sulfur hexafluoride gas by Norton in 1973 further expanded the role of vitreous surgery in the management of retinal detachment. In recent years, improvements in vitrectomy instrumentation, the development of wide-angle microscopic viewing systems, the use of perfluorocarbon liquids, and the development of microincisional techniques have resulted in vitrectomy becoming a routine contemporary procedure for the treatment of primary, as well as complex, retinal detachment.

RETINAL DETACHMENT SURGERY TODAY

Three different surgical techniques are widely employed to reattach the retina: scleral buckling, pneumatic retinopexy, and vitrectomy; these are discussed in Chapters 7, 8, and 9, respectively. Although they are frequently single procedures, a combination of techniques may be required in selected cases. A discussion of preoperative factors that may favor the selection of a particular technique is presented in Chapter 10. Prevention of retinal detachment by treating selected lesions with photocoagulation or cryopexy is discussed in Chapter 6.

SELECTED REFERENCES

Custodis E: Scleral buckling without excision and with polyviol implant. In: Schepens CL, ed: Importance of Vitreous Body with Special Emphasis on Reoperations.

St Louis: CV Mosby Co; 1960:175–182.