Primary Retinal Detachment

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8 Systematic Review of Efficacy and Safety of Surgery
pexy; scleral resections and implants were replaced with explants
sutured over full thickness sclera [65, 66]. Extensive circumferential
buckles and encircling operations – barrier procedures that
were intended to wall away undetected breaks in the periphery –
were replaced with segmental buckles confined to the breaks. The
undetected break was less frequent because preoperative indirect
ophthalmoscopy was augmented by binocular microscopy of the
retinal periphery through the mirrors of the Goldmann lens.
Closing the retinal breaks became the sole surgical problem;
the extent of the detachment was a lesser factor. If the breaks were
effectively buckled, the large detachment would attach without
drainage after only a few additional hours (Fig. 8.2). Not draining
subretinal fluid was increasingly adopted. At the New York Hospital,
the incidence of not draining rose from 50% to 90% in the
course of the first 1,000 cases after the senior author (HL) met with
Ernst Custodis and adopted his method [67].
Diminished morbidity was the Holy Grail. The external buckle
operation with a segmental sponge and without perforation for
drainage had no intraocular complications and only infrequent extraocular
ones. There was a buckle infection initially of 3% that
dropped to 1% with the development of the closed-cell sponge and
the use of parabulbar antibiotic [68]. Diplopia might occur if a
sponge intruded on a rectus muscle. The substitution of a temporary
balloon for breaks beneath a rectus muscle eliminated postoperative
diplopia because, within hours after the balloon was
withdrawn, the muscle functioned normally again [55]. A second
operation after the sponge procedure was required in 11% and after
the balloon procedure in 7%. Failure with either the sponge or the
balloon was due to an undiscovered break or an inaccurately placed
sponge or balloon. Final attachment for the sponge operation after
a second buckle was 97% and for the balloon was 99%. Less than
2% developed PVR postoperatively after either procedure. The low
incidence of PVR was a positive affect of diminished operative
trauma. The greater incidence of PVR as we knew it in prior years
was iatrogenic, a product of trauma inflicted by extensive barrier