Primary Retinal Detachment

182
9 Repair of Primary Retinal Detachment
designed to fit the tear combined with coagulations limited to the
tear or extending over 360° (Fig. 9.4). More retinas were attached –
more than 80%.
The modified cerclage with drainage represents one of the four
techniques still in use for repair of a primary retinal detachment at
the beginning of the twenty-first century (Fig. 9.4). Drainage, however,
required by this technique, has complications.
In 1953, Custodis [9] limited the treatment – now for the third
time – to the area of the leaking break, but – for the first time –
omitted drainage of subretinal fluid. This exceptional technique
was nearly abandoned, not because it did not work, but because of
unexpected postoperative complications caused by diathermy and
the polyviol plombe, which Custodis compressed over full-thickness
and diathermized sclera, which sometimes caused scleral
necrosis. As a result, the technique was abandoned in the United
States and in Europe.
Lincoff in New York, who was convinced of the logic and simplicity
of the Custodis procedure, made the operation acceptable by
replacing diathermy with cryopexy [10, 11] and the polyviol plombe
with the tissue-inert silicone sponge [12]. In the following years, this
technique was further refined by smaller segmental buckles that
were positioned more precisely [13] and by replacing the sclerafixated
sponge with a temporary balloon buckle [14, 15] that was not
sutured onto sclera. The balloon operation was suitable for detachments
with a single break. This minimal segmental buckling with
sponges or a balloon represents an extraocular approach, limited,
again, to the area of the leaking break.
However, the “conditio sine qua non” for a spontaneous attachment
without drainage was that all of the leaking breaks had to be
found and tamponaded adequately. Otherwise, the disappearance
of subretinal fluid would not occur. Finding all the breaks was
helped by the development of binocular indirect ophthalmoscopy,
biomicroscopy with contact lenses, the 4 Rules to find the break in
a primary detachment [16, 17], and the 4 Rules to find the break in
an eye up for reoperation [18, 19].