Primary Retinal Detachment

Optimal Orientation of a Segmental Buckle 101
retinal break. The retinal break represented the only issue of the
new surgery.
In subsequent years, the preconditions for this specific break
surgery were further improved by better fundus examination
techniques: binocular indirect ophthalmoscopy, as developed by
Schepens, biomicroscopy, as introduced by Goldmann, development
of various direct and indirect contact lenses, the 4 Rules for
finding the primary break [19, 20], and the subsequent 4 Rules for
finding a missed break in an eye requiring reoperation [21, 22].
Today, these 8 Rules represent essential guidelines for the detection
of the leaking break in a detachment, which is the precondition for
surgery limited to the area of the break. By performing this kind
of a minimal extraocular surgery, the time required for a retinal
detachment operation became dramatically reduced; however, the
time needed for preoperative study increased.
If retinal attachment did not result within days following
surgery, the logical questions had to be: (1) Has a break been overlooked?
(2) Is the break that was buckled still leaking due to an
inadequate tamponade? Both causes of failure are iatrogenic. Thus,
one can understand why an operation that would provide retinal
attachment on the table and additional prophylaxis for overlooked
breaks by encircling might be preferred by some surgeons.
Optimal Orientation of a Segmental Buckle
Because the retina is fixed at the ora serrata and at the disk, when
detaching, it tends to form radial folds. A circumferentially oriented
buckle will augment, or at least preserve, the radial folds because
it shortens the circumference of the globe, causing redundant
retina circumferentially. The resulting radial folds tend to aggravate
and align with a retinal break, producing what is termed
“fishmouthing” of the retinal break (Fig. 6.2). The fishmouthing, in
turn, provides a path for vitreous fluid to enter the subretinal
space, causing failure. The logical approach to filling the potential