Primary Retinal Detachment

Outlook 139
4. The operation should provide a maximum of long-term visual
function, not jeopardized by secondary complications during
the prolonged life expectancy of the patient treated
Outlook
Minimal segmental buckling by a sponge or a balloon and without
drainage of subretinal fluid is the ultimate development of scleral
buckling introduced by Schepens and Custodis and subsequently
refined by Lincoff, Kreissig, and others. Minimal segmental
buckling without drainage provides an optimum of early and late
anatomical and visual results: retinal attachment results after one
operation in 91% and after reoperation in 97%. However, to obtain
this rate of attachment requires an expertise in biomicroscopy
and binocular indirect ophthalmoscopy to find the breaks preoperatively
and at surgery to localize these breaks correctly and to
adequately position the segmental buckle beneath them without
drainage of subretinal fluid. However, this “Art of minimal segmental
buckling” [25, 26] has a learning curve.
Detachments in pseudophakic eyes today are almost routinely
assigned to vitrectomy for primary repair. This may occur even
when the break can be visualized preoperatively and would respond
to a segmental buckle without drainage. For these eyes in
which the break cannot be found because the peripheral retina is
obscured by a narrow pupil or capsule opacities, a vitrectomy to
provide better access for viewing the anterior retina may provide a
better prognosis than prospective buckling, being based on the
contour of the detachment, or a cerclage.
However, we have to keep in mind that the resources available
for ophthalmology are diminishing as life expectancy increases
and new treatments for various macular and retinal diseases become
available. This expanding spectrum includes invasive and
noninvasive, but expensive, treatment modalities. All this may
force us to reconsider how to spend the limited resources for the
increasing number of patients.