JEK Galbraith -History of retinal surgery

JEK Galbraith descibes the history of retinal surgery

The Retina Unit was set up by the late Professor Gerard Crock in 1963. When I joined him a year later as his First Assistant, my first job was to review the results of retina surgery at the Royal Victorian Eye and Ear Hospital for the two years before the establishment of the Retina Unit.

I spent several hours in the Records Department to establish that the rate of successful re-attachment of detached retinae was less than 40% - a not surprising figure for the techniques employed at the time. We did not dare to release the figures because the general feeling in the hospital was that a Retina Unit was an unnecessary luxury, and these appalling figures would have exacerbated an uncomfortable situation. And besides, everyone seemed to have a shot at retina surgery using the standard operation: ‘diathermy and drain’. We told the staff that the resident’s histories were either illegible or of such poor quality that we could not establish an accurate figure. An explanation that was accepted without question.

The technique of the ‘diathermy and drain’ operation was simple. An incision was fashioned through the sclera down to the choroid overlying the deepest part of the detachment and the choroid was perforated with a large needle. The surgeon pressed on the eye to express the subretinal fluid and then applied suction, achieved by using a glass tube with a diameter of about 6mm to one end of which was attached a rubber bulb. The tube was pressed against the sclera, centred on the drainage hole, after first squeezing the bulb. Suction was applied when the bulb was released and this was thought to ensure that the last of the sub-retinal fluid was extracted, often accompanied by a piece of retina and some vitreous.

At this time a few adventurous souls were performing the new scleral buckling procedure - an ellipse of sclera was excised down to the choroid, a needle puncture then allowed the sub-retinal fluid to escape. Next, potassium hydroxide was applied to the exposed choroid with a cotton bud and the edges of the excised sclera were sutured together. This produced an internal buckle in the chemically irritated choroid to which the retina hopefully became adherent.

This was marginally better than diathermy and drain and was later improved by burying the excised sclera to increase the size of the buckle. The results were still poor and for the first year of its the life, the Retina Unit’s workload was re-operating on such patients. The surgery was extremely difficult because the choroid was invariably necrotic and the slightest touch resulted in vitreous prolapse. It was not unusual for such an operation to last four hours.

In an attempt to overcome this difficulty, we excised the plantaris tendon from a leg of such patients and used this as an implant – it had the advantage that we were still using the patient’s own tissue. Even though the Schepens technique with implanted silastic shapes was becoming established, we were reluctant to use it as the implant would inevitably migrate through the necrotic choroid into the vitreous cavity.

Eventually this technique died out and the Unit celebrated when finally a retinal detachment was referred for surgery – one in which no attempt at repair had been made prior to referral. Both Prof Crock and I had spent time with Dr Schepens in Boston and Dr Harrell Pierce at Johns Hopkins Hospital in Baltimore and were well versed in this technique. We had begun to wonder if we would ever be able to apply the Schepens technique. I was also fortunate, during my tenure of a Harkness Foundation Scholarship, to have visited Dr Charles Kelmann in New York who was perfecting the first cryotherapy unit. We met at the end of an operating session at the Manhattan Eye and Ear Hospital. Dr Kelmann immediately invited me to his laboratory to see what he described ‘a fascinating new approach’ to retinal surgery – and apologised that we would have to go there by car because his helicopter was being serviced.

At the lab, he instructed a technician to anaesthetise a cat and dilate one pupil. Then he gave me the handpiece of his first cryo unit, demonstrated the foot switch and told me to apply it to the conjunctiva over the posterior infero-temporal segment of the cat’s eye while watching the indentation with an indirect ophthalmoscope. Suddenly an ice ball formed at the apex of the indentation and rapidly grew into a snowball several millimeters in the overlying vitreous. It was probably the most exciting spectacle I have ever seen in my career. This technique opened a new era in retina surgery, and subsequently the Retina Unit purchased a Linde cryo-machine which used liquid nitrogen to freeze, and hence inflame the choroid to 'glue' the retina in position without damaging the choroid. This enabled flat retinal holes to be treated by freezing through intact conjunctiva - a real advance in a Unit that was constantly short of beds.

Because of the need for familiarity with the indirect ophthalmoscope and the importance of accurate positioning of the buckle, most ophthalmologists did not persist with the older techniques…. until the Arruga String was publicised as an easy and quick treatment of retinal detachment.

In this procedure, a suture encircled the globe, passing around beneath the rectus muscles, taking a bite of sclera in each quadrant. Subretinal fluid was then drained thorough a scleral needle puncture anterior to the string which was then tightened and knotted.

A steep, sharp buckle resulted with encouraging short term results. Unfortunately the buckle was associated with serious complications. Either the long ciliary arteries were kinked as they crossed the buckle and this caused anterior segment ischaemia, or the suture cut through sclera, choroid and retina and presented n the vitreous cavity! That was the end of that unsuccessful procedure.

At about this time the Schepens group developed a new approach to the treatment of giant tears of the retina. They designed and then built on operating table to which the patient was securely strapped in a supine position. The table was then elevated on a single leg to a height just above the surgeons head, and was rotated like a giant propeller so that the patient was now facing down. The surgeon then stood and performed surgery with his hands higher than his head. The theory was that gravity would assist in replacing the edge of the giant tear.

Schepens presented a video of this development at a meeting in Europe. The following night at the final dinner of the conference, Professor Meyer-Schwickerath of Essen made a speech and apologised that he would have to show a slide during his talk. He projected a picture of himself standing operating on an anaesthetised patient. He then explained that in Essen they could not afford the very expensive Schepens table but suggested that other units in the same situation could take his advice.

“If you can’t have the patient hanging from the table, why not hang the surgeon from the ceiling?”

His slide then reappeared on the screen, this time upside down. The Boston group did not participate in the general hilarity that followed. One of Schepens’ staff told me later that the first time the table was used; a giant tear was successfully reattached.

“That was the worst result he could have had,” he said, “because he now believed that the table really worked. It was not until several failures later that he decided not to persevere with the technique.”

The (non-rotating) Schepens operation was the platform from which were launched the methods employed today, albeit modified by the use of gas infusion into the vitreous cavity, the employment of vitreous suction-cutters, and retinal membrane-peeling techniques. Furthermore, retinal surgery is now the province of well-trained retinal surgeons, thanks to the increasing sub-specialisation in ophthalmology.