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Primary Retinal Detachment

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182<br />

9 Repair of <strong>Primary</strong> <strong>Retinal</strong> <strong>Detachment</strong><br />

designed to fit the tear combined with coagulations limited to the<br />

tear or extending over 360° (Fig. 9.4). More retinas were attached –<br />

more than 80%.<br />

The modified cerclage with drainage represents one of the four<br />

techniques still in use for repair of a primary retinal detachment at<br />

the beginning of the twenty-first century (Fig. 9.4). Drainage, however,<br />

required by this technique, has complications.<br />

In 1953, Custodis [9] limited the treatment – now for the third<br />

time – to the area of the leaking break, but – for the first time –<br />

omitted drainage of subretinal fluid. This exceptional technique<br />

was nearly abandoned, not because it did not work, but because of<br />

unexpected postoperative complications caused by diathermy and<br />

the polyviol plombe, which Custodis compressed over full-thickness<br />

and diathermized sclera, which sometimes caused scleral<br />

necrosis. As a result, the technique was abandoned in the United<br />

States and in Europe.<br />

Lincoff in New York, who was convinced of the logic and simplicity<br />

of the Custodis procedure, made the operation acceptable by<br />

replacing diathermy with cryopexy [10, 11] and the polyviol plombe<br />

with the tissue-inert silicone sponge [12]. In the following years, this<br />

technique was further refined by smaller segmental buckles that<br />

were positioned more precisely [13] and by replacing the sclerafixated<br />

sponge with a temporary balloon buckle [14, 15] that was not<br />

sutured onto sclera. The balloon operation was suitable for detachments<br />

with a single break. This minimal segmental buckling with<br />

sponges or a balloon represents an extraocular approach, limited,<br />

again, to the area of the leaking break.<br />

However, the “conditio sine qua non” for a spontaneous attachment<br />

without drainage was that all of the leaking breaks had to be<br />

found and tamponaded adequately. Otherwise, the disappearance<br />

of subretinal fluid would not occur. Finding all the breaks was<br />

helped by the development of binocular indirect ophthalmoscopy,<br />

biomicroscopy with contact lenses, the 4 Rules to find the break in<br />

a primary detachment [16, 17], and the 4 Rules to find the break in<br />

an eye up for reoperation [18, 19].

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