Before the age of the eBook, I routinely browsed the bookstore shelves for new finds and frequently picked up well-worn treasures for a quarter at the used bookstore.  It was always a thrill to discover a fresh window into the world through the eyes of a new author.  One evening when I was a resident I happened upon the Pulitzer Prize–winning novel, The Optimist’s Daughter, by the Southern author Eudora Welty.  I wasn’t familiar with the plot and it was a surprise to discover that the opening pages present a very commonly encountered retinal case history.  The book begins in a county eye doctor’s office, with a complaint of flashes from an elderly judge who is soon thereafter diagnosed as having a “slipped” retina.  Welty’s subsequent portrayal of the patient as he is wheeled out from the operating room clearly depicts the immobilization that was required after retinal detachment surgery in the late 1960s, down to the sandbags packed around his head to minimize eye movement.

Intrigued by reading the details of a retina patient’s experience from the 1960s, I queried my attendings for additional stories from the earlier days of retinal surgery.  I heard about the now almost inconceivable time when it was routine for surgeons to smoke in the operating room and toss their used cigarette butts in the corner.  One of the large operating rooms at Massachusetts Eye and Ear, where I trained as a resident and then as a fellow, housed an ancient and enormous operating table to which patients could be securely strapped before they were flipped upside down for retinal surgeries requiring manipulation under gas or oil.  I’ve always loved the precision of our current microsurgical techniques, and these were placed in sharp contrast to these and similar tools that were described to me from the 1960s and early 1970s, as the precursors to our modern vitrectomy instrumentation became available.

Since 1920—nearly 100 years ago—when Jules Gonin reported the first successful retinal detachment repair, our surgical techniques have evolved tremendously.  Today we have the benefits of small-gauge, often sutureless, surgery.  In addition to smaller, lighter, faster, and more precise instrumentation, we have improved our abilities to visualize the retina during procedures.  Noncontact widefield viewing systems give us the freedom to torque the globe during surgery to optimize the view of the far periphery of the retina. Endoscopy allows us to look past anterior segment opacities to surgically address posterior segment pathology. Intraoperative optical coherence tomography devices even provide cross-sectional imaging of retinal structures during surgery to better distinguish and manipulate delicate retinal tissue with the potential of improving outcomes.  In the future, it is possible that regenerative techniques may allow us to rebuild lost or damaged ocular structures and even further improve visual outcomes for our retinal patients.

This is a particularly opportune time to look back and appreciate the evolution of surgical techniques as the Retina Society celebrates its 50th anniversary in Boston, Massachusetts, in October 2018. In addition to the usual lively mix of cases and scientific discussions, there is an historical symposium that provides a perspective on the last 50 years of medical and surgical retinal techniques with a glimpse of what may come over the next half century.

Spoiler alert for any reader who is planning to pick up The Optimist’s Daughter: you may want to skip this last paragraph.  Unfortunately, Welty’s retina patient doesn’t fare all that well.  After more than 3 weeks lying immobile in the hospital after his surgery, he passes away abruptly.  His surgeon mourns his death, but also comments “I’d been waiting to know how well that eye would see!”  As a fledgling ophthalmologist, I was similarly disappointed.  I’d also been rooting for the patient’s hospital stay to end and for his vision to recover.  I’m thankful, however, that my subsequent experiences with real-life patients have involved surgical techniques that are so more successful than those that were available in the 1960s.  A few years after surgery, a patient once remarked “I can barely remember now which eye you operated on.”  As a surgeon, that comment delighted me.  I can’t wait to see what the next 50 years of surgical advances bring!

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