Dr. Ingrid Kreissig, Univ.-Prof., Prof. honoris causa for Research, elected Honoree at ARVO Foundation for Research, received her medical Professorship at the University of Bonn, Germany. World-renowned retina specialist and pioneer in ophthalmology, she has devoted her decades-long career to improving the understanding and treatment of retinal surgical conditions, specifically management of retinal detachments and their resulting long-term visual outcomes.
Dr. Kreissig, was born into a family with no history in medicine. Her interest in medicine started as a child, when she became curious about the anatomy of animals. She worked with determination and received scholarships to support her education. After receiving a Fulbright Scholarship to study in Cleveland, Ohio, she decided to study music with George Szell and art. Returning to Germany, she continued to study medicine at the Universities of Bonn and Munich.
During her training in ophthalmology in Switzerland, she learned the use of the new three-mirror contact lens technique for diagnostics of the retina, developed by Dr. Hans Goldmann -- a powerful technique for finding the break in a retinal detachment. She then became the head of the Department of Posterior Segment of the Eye at the University of Bonn, Germany (1968-1969), which was previously led by Dr. Gerd Meyer-Schwickerath. Dr. Kreissig trained with Dr. Harvey Lincoff in New York in retinal surgery (1969-1972), which led to a 48-year long transatlantic, creative life-partnership.
She was the first woman to serve as surgical chair in Ophthalmology in Germany at the University at Tuebingen (1979-2000). In 1982, she became adjunct professor of Clinical Ophthalmology at the Weill Cornell Medical Center of New York, where she continued her clinical and research work with Dr. Lincoff, Dr. Stanley Chang, and Dr. Jackson Coleman. From 2000-2003 she was an elected member of the Selection Committee of ARVO, where she also was responsible for the annual program of the ARVO Meeting. Since 2001, she has been Professor of Ophthalmology at the University of Mannheim-Heidelberg, Germany. There she works with Dr. Jost Jonas on intravitreal triamcinolone. In 2011, she was named Professor honoris causa for Research at the Ufa Eye Research Institute, Russia (Fig. 7), and in 2022, she was elected as Honoree at the ARVO Foundation for Research.
Dr. Kreissig introduced the expanding-gas operation, an intraocular injection of SF6 gas without prior drainage under local anesthesia as treatment for retinal detachment (1979), which 6 years later was re-introduced by Dr. Alfredo Dominguez (1985), who named the procedure pneumocausis followed by Dr. George Hilton (1986), who renamed it pneumatic retinopexy.
Together with Dr. Lincoff, she confirmed the strength of the cryosurgical adhesion in a 3-year animal study (1969-1972), and refined extraocular minimal surgery as a repair for retinal detachment. From 1979 she collaborated on the Lincoff-Kreissig Balloon, a temporary buckle without fixating sutures, without drainage, and done with topical or local anesthesia. They subsequently introduced the various expanding perfluorocarbon gases as treatment for retinal detachments, and the 4 Lincoff-Kreissig Rules to find the break in an eye up for reoperation (1996).
Dr. Kreissig’s special interest was devoted to long-term anatomical and functional results of eyes with intraocular tumors having been treated by iodine-125 plaques and a 15-year follow-up of anatomical and visual (quantitative and qualitative) results after extraocular minimal segmental buckling. As Emerita, since 2001, she now works with Dr. Jost Jonas on the intravitreal injection of triamcinolone for various macular and retinal diseases at the University of Mannheim-Heidelberg, Germany. She also covers the field of medical retina with particular emphasis on diagnosis and treatment options for diabetic retinopathy and AMD.
Dr. Kreissig has trained more than 300 ophthalmologists from around the world. Many of her trainees have achieved leadership positions at Universities or Eye Hospitals in their respective countries. Over the past 30 years, together with her former co-workers -now being abroad- she had organized up to present 134 teaching courses on retinal detachment surgery, including extraocular minimal surgery, the diabetic eye, AMD, and intraocular tumors. These courses were performed together with New York Presbyterian Hospital - Cornell University; in the beginning with Dr. Jackson Coleman, then continued with Dr. Donald D’Amico.
She has authored/co-authored 424 publications, including 15 books on retinal detachment surgery (in particular the extraocular minimal surgery for repair), available in 6 languages, as well as 33 chapters in textbooks. The Kreissig Award at the yearly EURETINA Congress was established by former co-workers in 2004. She also supports Travel Grants at the EURETINA Congress and the ARVO meeting. In 2020, the annual ARVO Kreissig Award for Excellence in Retinal Surgery was established.
Our thanks to Dr. Kreissig for offering the following retina reflections.
Please share an impactful moment that shaped your career. Was there a time in your career when you witnessed history in the making?
My training in ophthalmology began in Switzerland where I learned to use the 3-mirror-contact lens to detect retinal breaks from Hans Goldmann, MD, during a 2-year stint in Switzerland. Because I knew this new technique, I was able to finish my residency with Hans Karl Mueller, MD, at the University of Bonn in Germany. After Gerd Meyer-Schwickerath, MD, had left Bonn for a chair in Essen, I was given charge of the detachment department which he had established.
In 1969, after having become an experienced detachment surgeon, I had become concerned about the poor results of our maximal surgery for repair of retinal detachment. I decided to visit other surgeons to find out how they were obtaining better results. After consulting with Rudolf Kloeti, MD, and Rudolf Witmer, MD, previous teachers in Switzerland, I visited Harvey Lincoff, MD, in New York to learn about his different detachment surgery. A key experience was learning the favorable results of his segmental nondrainage surgery for retinal detachment. I first got his attention when I was able to show him the use of the new 3-mirror-contact lens to detect the breaks. In turn, he taught me the use of the binocular indirect ophthalmoscope, since we used them on a monocular indirect ophthalmoscope in Bonn. We both quickly realized that our approaches had much in common: To scrutinize traditional surgical facts and applied treatment modalities, to practice an analytic approach, and to enjoy challenges. Thus, in 1969, I began a collaboration with Dr. Lincoff, that became a 48-year long transatlantic life-partnership.
I was fascinated by the opportunity to get to know this new segmental buckling procedure without drainage, which became my central research project, i.e., to solve the pending problem of whether cryosurgery could provide a strong enough retinal adhesion and then to replace with it the necrotizing diathermy. With this in mind, in New York I began a 3-year series of animal experiments on 312 rabbit eyes to determine the strength of the cryosurgical adhesion with follow-up by histological examinations. In this pursuit, my experience in electron microscopy proved valuable.
Over 3 challenging years, the strength of the cryosurgical adhesion was confirmed and the exact day at which the cryosurgical adhesion was sufficiently strong for clinical application was determined. However, this modified nondrainage procedure with cryosurgery and the Lincoff-sponge, often did not succeed. Why? Lincoff concluded that the causative break had not been found and thus not treated. Therefore, Lincoff and Richard Gieser, MD, analyzed the preoperative drawings of 1,000 retinal detachments and the Lincoff Rules were defined: How to find the primary break in a retinal detachment. This extraocular minimal surgery constituted a shift in the paradigm of treating a retinal detachment: A change from treating the entire circumference of the retina by a cerclage with drainage to a surgery limited to the area of the break without drainage. Given the utility of this minimized surgery for repair of a primary retinal detachment, the logical conclusion was: Why not use it as well as a reoperation? With this in mind, 87 failures of 852 extraocular minimal segmental buckle operations were analyzed and the Lincoff-Kreissig Rules were defined: How to detect the missed break in an eye up for reoperation(Fig. 1).
Being convinced of the value of extraocular minimal segmental buckling, in 1979 I started, after having become chairperson of the Ophthalmological Department at the University in Tuebingen in Germany , a 15-yearlong study of 107 consecutive retinal detachments treated with this extraocular minimal surgery. The question was: Does the lack of a cerclage cause a re-detachment during long-term follow-up? After less than 1% of reoperations, the retina was attached in 97% after this minimal buckling. During the first postoperative 6 months, re-detachment occurred in 1% per month, mostly due to PVR. However, after 6 months up to 15 years postoperatively, the retina re-detached in only 0.5% per year. Thus, after this extraocular minimal segmental buckling without the presence of a cerclage, during the period from after 6 months to 15 years postoperatively, the retina practically remained attached, i.e., re-detachment after this long-term follow-up was minimal, almost negligible (Fig.2).
The next thing I wanted to find out was: Does the buckle in place jeopardize recovered visual function during follow-up? The postoperative increase in visual function lasted up to 1 year. However, after 1 to 15 years there was a slight decrease in visual function. But when comparing this decrease with the function in the not operated fellow eye, there was no statistically significant difference, thus, the slight decrease was due to aging.
Thus, it could be confirmed that this extraocular minimal segmental buckling provides optimal postoperative long-term anatomical and functional results. In addition, the surgery can be performed with local anesthesia and on a low budget. This is important, since at the time AMD can be treated with expensive intravitreal drugs, which often have to be repeated.
A further move towards minimal extraocular surgery for repair of a retinal detachment evolved with the development of a temporary balloon-buckle without drainage and without fixating sutures. The intention was to eliminate the last remaining extraocular and reversible complications after segmental nondrainage buckling. After 7 years of experiments, in 1979 the idea came about of a temporary buckle without a fixating intrascleral suture. The big problem was finding a company to provide a reliable device, which was ultimately developed by the Ruesch Company at Stuttgart, half an hour drive away from Tuebingen-University/Germany. The developed Lincoff-Kreissig Balloon provides the ultimate minimum of surgical trauma to an eye with retinal detachment, combined with optimal long-term visual outcome. This procedure was one of our most important accomplishments for repair of a retinal detachment (Fig.3). Click to watch related video courtesy Ingrid Kreissig, MD.
The next question was: How to teach this extraocular minimal surgery for retinal detachment to the younger generation? I had trained over 300 foreign retinal fellows who had returned to their home countries, where they had become heads of departments or chairpersons at their respective universities. A snowball effect developed. They started to send their seniors for training to us at Tuebingen. Many of them wanted to stay with us, though all of them were sent back to their home clinics, yet I had promised to provide for them several teaching courses per year at various countries on this minimal surgery. Subsequently they started to organize these teaching courses at their institutions and as a result they were integrated into the teaching faculty. The participation in these courses ranged between 100 to 500. Eventually, this snowball effect continued and created an interacting international detachment family whose members started to discuss their problem cases by email. By 2022 we had 134 international teaching courses on retinal detachment surgery (Fig.4).
In 2001, having become an Emerita, I joined the team of Jost Jonas, MD, in Mannheim, University of Heidelberg/Germany. Thus, I participated in another shift in the treatment paradigm, the change from subconjunctival or parabulbar cortisone injection to an intravitreal injection of Triamcinolone for edematous, proliferative and neovascular diseases of the retina and macula and even for endophthalmitis. This collaboration with Jonas is currently highly satisfactory, creative, and productive and with total loyalty to each other.
What career accomplishment provides you with the greatest sense of satisfaction?
To have had the chance to have worked with Harvey Lincoff and Jost Jonas, two outstanding, inventive scientists, researchers and clinicians. In addition, with Harvey Lincoff, I could experience besides our hard and creative work, the full spectrum of joy in life, of being together with interesting and challenging friends and sharing a mutual admiration, respect and deep love during our 48-year transatlantic life-partnership.
In 1979, I was gratified, as the first woman in Germany, to be named a surgical chair in Ophthalmology at the University of Tuebingen. In 1982, I became adjunct professor of Clinical Ophthalmology at New York Hospital-Cornell Medical Center. In 2002, I obtained the Lincoff Award (Fig.5).
In 2003, former coworkers at the University of Tuebingen established the Kreissig Foundation to provide annual travel grants and awards for experts in the field of retina (Fig.6). In 2011, I became a professor honoris causa for Research, and in 2022, I was elected as Honoree Member of the ARVO Foundation for Research (Fig. 7).
What do you feel is the most significant development or change in the practice of retina?
I consider extraocular minimal segmental buckling introduced by Lincoff, further developed with me, and the Lincoff-Kreissig Balloon Procedure as significant changes in retina. However, the premise for success with these 2 minimal procedures was first established by the Lincoff Rules on how to find the primary beak in a detachment and the Lincoff-Kreissig Rules on how to detect the missed break in an eye up for reoperation.
Another change was entering the vitreous by an intraocular injection by Jonas and his group, including me, with triamcinolone, followed by other drugs and the introduction of vitrectomy by Robert Machemer, MD, with its large spectrum of applications. Another change came in 1979 when I introduced the expanding-gas operation as treatment of retinal detachments with an intraocular injection of the expanding gas SF6 without prior drainage.
In 1982, the clinical use of an intraocular gas injection without drainage was increased when Lincoff and his group, including me, introduced the various expanding perfluorocarbon gases. In 1985, Alfredo Dominguez, MD, re-introduced the expanding gas operation without drainage (introduced by me in 1979), but instead, he re-named the procedure pneumocausis, being applied for uncomplicated detachments. In 1986 George Hilton, MD, re-introducing this procedure as pneumatic retinopexy.
Can you share any advice to future generations of retina specialists?
First of all, listen to a patient before and after surgery. I recall a patient whose retina was attached after surgery and visiting colleagues told him, “Your retina is looking fine.” However, the patient said to me, “Everybody is saying my retina is looking fine, but, I do not see well, I cannot read.” From that moment on, I asked every patient postoperatively for the amount and quality of regained visual acuity, which led to my studies on postoperative quantity and quality of visual acuity, color vision, light sensitivity threshold, and metamorphopsia, which could be drastically changed.
Second, always remain open to suggestions from colleagues and residents. Once a resident asked me during surgery, “Why do you use in this detachment with a posteriorly located hole so difficult to be sutured on a circumferential buckle and not a radial one?” After that remark I preferred, whenever possible, a radial segmental buckle as tamponade for a break.
Third, sometimes it is appropriate to suggest that a patient gets a second opinion; it will benefit both of you.
Fourth, question your knowledge and expertise when teaching experts and residents. You might get unexpected questions and when you cannot answer with simple words, then you have to re-think what you are saying.
Fifth, try to publish your research and clinical results or write them up in a book, because then you will have to analyze, organize, standardize, and scrutinize your knowledge.
Sixth: Whenever you are teaching, always be aware of recent publications in your field.
How do you imagine the practice of retina will change by 2040?
It is hard to predict what might be developed by 2040. First of all, I think, you still have to listen to a patient prior and after your treatment or surgery. As a surgeon you may find that less is more (i.e., 2 small surgeries are better than 1 surgery being too large). In addition, telemedicine might increase to monitor chronic diseases. But minimal extraocular segmental buckling might remain a gold standard as repair of a retinal detachment: providing long-term favorable outcome and being performed on a low budget. Hopefully the parabulbar balloon procedure, representing the ultimate extraocular minimum of surgical intervention, will become available again, with its optimal long-term visual results. However, an essential premise for success with these 2 extraocular surgeries is that, while time-consuming, preoperative break identification is needed, the Lincoff and Lincoff-Kreissig Rules will help to find the breaks, to assure that the breaks are documented precisely by a drawing to be found during surgery and then to be localized precisely though this has to be done without prior drainage. Why is this so important? Because, otherwise, these extraocular minimal techniques will not succeed. The use of pneumatic retinopexy might get a limited application. Hopefully, gene therapy for hereditary ocular diseases will become a better treatment option. With further developments in technology, vitrectomy might develop further to an even more minimal approach and then with additional indications.
(Retina Reflection published 2022)