Pneumatic retinopexy: A cost-effective alternative.

Pneumatic retinopexy, since it was first described by Hilton and Grizzard, has always been a part of a vitreoretinal surgeon's armamentarium. It was essentially described as an office-based procedure to manage fresh rhegmatogenous retinal detachment. Its use, till now, has remained restricted due to its limited indications and a lower first surgery success rate compared to scleral buckling and vitrectomy.[1] However, it remained an option for those looking for a quick, outpatient procedure with relatively no or little morbidity. Practice patterns in managing retinal detachment have changed over time. Microincision vitrectomy surgery (MIVS) has become the first procedure of choice for most vitreoretinal surgeons.[2] Rapid technological advancements in MIVS have improved detachment surgery success rates to >90% with single procedure; at the same time making it lot quicker with a comfortable postoperative period. This does raise a question about the role of pneumatic retinopexy in today's era!

Pneumatic retinopexy, classically, was indicated for fresh retinal detachments in phakic eyes involving the superior 8 clock hours of retina with break/cluster of breaks not >1 clock hour in area. Reported success rates from pneumatic retinopexy alone ranges from 60-80%,[123] cochrane database systematic review 2015 comparing pneumatic retinopexy with scleral buckling showed slightly less reattachment rate with pneumatic retinopexy (relative rate 0.89; 95% confidence interval: 0.77–1.02) and higher chances of recurrence (1.80; 95% confidence interval 1.0–3.24).[4] In spite of this, Goldman et al. have shown it to be a very useful, cost-effective method of retinal detachment repair having a potential to significantly reduce health-care burden.[5] This is of utmost importance for a developing nation like India.

Furthermore, as the experience with pneumatic retinopexy has increased over time, the indications of using it have also expanded, to include aphakic and pseudophakic eyes, early PVR changes, retinal breaks up to 3 clock hours apart, and up to 3 clock hours of lattice degeneration. A retrospective study comparing traditional and expanded indications of pneumatic retinopexy has shown similar anatomical success rate.[5]

Interestingly, till date, there is very less literature comparing pneumatic retinopexy with MIVS. Preliminary reports from ongoing “Pneumatic retinopexy versus vitrectomy for primary rhegmatogenous retinal detachment trial” were presented at American Society of Retinal Specialists 2017. Muni has shown surprising results wherein patients undergoing pneumatic retinopexy had a better final visual acuity compared to vitrectomy. Furthermore, both groups had similar final attachment rates, and cataract surgery was much less frequently needed in pneumatic retinopexy group versus vitrectomy.[6]

Another indication where pneumatic retinopexy has shown its usefulness is as a first rescue procedure in early recurrence postscleral buckling or pars plana vitrectomy. It is useful as an alternative to complete resurgery, if the cause of recurrence is an open break or a missed break in superior half of retina, with variable success rates. Petrushkin et al. in their series of 42 eyes undergoing secondary pneumatic retinopexy, achieved 100% success in failed scleral buckle and 90% success in post-vitrectomy cases.[7] Sharma et al. in their series of 36 eyes of failed scleral buckle treated with pneumatic retinopexy had a success rate of 69.4%.[8] A very similar success rate of 65.5% was also shown by the authors in their series of 29 eyes of failed primary procedure.[9] In spite of the variable success rate shown by studies, one cannot deny that, in indicated situations, one can avoid a major resurgery in two out of three cases using pneumatic retinopexy.

Even though the results of the current study show pneumatic retinopexy in a very positive light; since it is indicated in a small subset of detachments only, I do not think it will change individual practice patterns to a great extent, but for all those doing pneumatic retinopexy, they will do it with lot more confidence. The only essential that one needs to keep in mind is that the success of pneumatic retinopexy is directly correlated to surgeons’ retinal examination skills.