Primary Retinal Detachment

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Inadequate Training
Vitrectomy is being increasingly employed for primary retinal detachments
because the number of doctors trained to do vitrectomy
has markedly increased in the past decade, as have the indications
for vitrectomy. In addition to the original indications, traction detachment
in the diabetic eye and PVR after failed retinal surgery,
vitrectomy is done for macular holes, macular puckers, dropped
lens and particles, to clear vitreous hemorrhage, and, more recently,
to dissect subretinal proliferative lesions in the macula. The indications
keep expanding. Retinal detachment can be a relatively
infrequent indication for operation on a busy retinal service and of
secondary interest. As a result, training for the treatment of retinal
detachment may be limited. There are few opportunities outside of
the fellowship to learn about buckling. Retinal programs rarely
include papers on the subject; it has all been said. Except for
William Mieler’s short course at the Academy and Ingrid Kreissig’s
Retinal Detachment Courses at various national and international
meetings, there are no workshops on the art of scleral buckling.
As a consequence, the coming generation of retinal surgeons may
not be very skillful at performing a scleral buckle. In another
decade, it is possible that the buckling operation will have become
a lost art.
Market Forces
8 Systematic Review of Efficacy and Safety of Surgery
Preparation for a segmental buckle operation can require much
study time, frequently hours and sometimes days. A decade ago, if
the senior author (HL) could not find a break that promised a 90%
prognosis after an hour’s study, he would patch both eyes, put the
patient at rest, and re-study the eye the next day. Most detachments
change with ocular rest, and the change is informative. Today, the
insurance companies and Medicare do not allow for an extra day,
nor is there payment for study time. It is more expedient to do a