Chapter 9

Pneumatic Retinopexy

Initially described in the mid-1980s, pneumatic retinopexy (PR) has provided clinicians with another option for primary as well as rescue treatment in the management of rhegmatogenous retinal detachments (RRDs).[1-5] It remains a useful office based procedure, providing a relatively simple, minimally invasive approach with superior cost-effectiveness.[6-8] With proper case selection, PR provides a lower morbidity (e.g. less cataract progression), yet still maintains high anatomic reattachment rates with single procedure reattachment rates typically ranging from 65-80%.[6,7,9] Despite the lower reattachment rates compared to other surgical techniques, the prognosis for final anatomic reattachment (>98%) remains comparable to other primary surgical procedures for RRD. Most importantly there is evidence to suggest that patients undergoing PR achieve superior functional outcomes compared to pars plana vitrectomy and scleral buckle.[3,7] The randomized prospective PIVOT trial demonstrated that patients undergoing PR achieved superior ETDRS visual acuity outcomes at every time point including the one-year endpoint (10 letters at 3 and 6 months and 5 letters at 1 year). Furthermore, patients in the PR group had less vertical metamorphopsia compared to vitrectomy at 12 months.[7] Evidence from the Pneumatic Retinopexy Trial and the PIVOT trial demonstrate that even if the initial PR procedure fails and an additional procedure such as scleral buckle, vitrectomy or combination surgery are required, that the patient will still achieve anatomic reattachment and functional outcomes similar to patients undergoing primary PPV or SB.[3,6,7,10]

More recent evidence has suggested that there are also certain anatomic advantages of PR compared to PPV. Specifically PR is associated with a lower risk of retinal displacement compared to patients undergoing PPV.[11] Furthermore, PR is associated with a lower rate of ellipsoid zone and external limiting membrane discontinuity compared to PPV.[12] These studies suggest that a high integrity retinal attachment is more likely with successful PR vs PPV.[11-12] From the patients perspective, patients undergoing PR first line have superior vision-related quality of life in the first 6 months compared to PPV.[13] Appropriate patient selection remains paramount especially with the expansion of traditional indications over time.

Dominguez A. Cirugia precoz y ambulatoria del desprendimiento de retina. Arch Soc Esp Oftalmol. 1985;48(1):47-54.

Hilton GF, Grizzard WS. Pneumatic retinopexy. A two-step outpatient operation without conjunctival incision. Ophthalmology. 1986;93(5):626-641.

Tornambe PE, Hilton GF. Pneumatic retinopexy. A multicenter randomized controlled clinical trial comparing pneumatic retinopexy with scleral buckling. The Retinal Detachment Study Group. Ophthalmology. 1989;96(6):772-783; discussion 784.

Zhou C, Lin Q, Wang Y, Qiu Q. Pneumatic retinopexy combined with scleral buckling in the management of relatively complicated cases of rhegmatogenous retinal detachment: A multicenter, retrospective, observational consecutive case series. J Int Med Res. 2018;46(1):316-325.

Vidne-Hay O, Abumanhal M, Elkader AA, Fogel M, Moisseiev J, Moisseiev E. Outcomes of Rhegmatogenous Retinal Detachment Repair after Failed Pneumatic Retinopexy. Retina. 2020 May;40(5):805-810.

Brosh K, Francisconi CLM, Qian J, et al. Retinal Displacement Following Pneumatic Retinopexy vs Pars Plana Vitrectomy for Rhegmatogenous Retinal Detachment. JAMA Ophthalmol. 2020 Jun 1;138(6):652-659.

Advantages

  1. Superior visual acuity outcomes
  2. Faster recovery of visual acuity (VA)
  3. Less metamorphopsia
  4. Greater chance of achieving a high integrity retinal attachment
  5. Simple ambulatory procedure that can be completed in minutes
  6. Less morbidity (reduced pain, no diplopia, scleral buckle implant complications, cataract development)
  7. Highly cost effective
  8. No compromise to final VA or retinal reattachment with PR failure

Indications

  1. Recent clinical trial criteria (PIVOT) include patients with a single break or multiple breaks within one clock hour in detached retina in the superior 8 clock hours (above 8 and 4 o’clock) with any number, location and size of retinal breaks or lattice degeneration in attached retina.7
  2. Patients with a small single tear < 2 clock hours (30°- 60°) or multiple small tears within 2 clock hours are also good candidates
  3. Patients outside these criteria are considered “extended criteria” and can still do very well with PR

Contraindications

  1. Significant media opacity limiting 360 degrees of peripheral examination: corneal scarring, cataract, vitreous hemorrhage
  2. Inferior breaks in area of detached retina
  3. Proliferative vitreoretinopathy (PVR) grade B or worse
  4. Inability to posture
  5. Mental incapacity or uncooperative patient
  6. Unreliable or unable to maintain close follow up appointments
  7. Requirement for air travel before gas has fully resorbed

Relative Contraindications

  1. Posterior breaks
  2. Absence of an identifiable break
  3. Mild vitreous hemorrhage or other media opacity obscuring clear visualization

Table 1. Inclusion and Exclusion Criteria for Pneumatic Retinopexy Based on the PIVOT Trial

Inclusion

  • A single retinal break or group of breaks, no larger than one clock hour, in detached retina
  • All breaks in detached retina to lie above the 8 and 4 o’clock meridian
  • Breaks or lattice degeneration in attached retina at any location

Exclusion

  • Breaks inferiorly in detached retina
  • Significant media opacity
  • PVR grade B or worse
  • Previous retinal detachment in index eye
  • Previous PPV in index eye
  • Mental incapacity or physical inability to posture post-operatively

Complications

  1. Traumatic cataract (capsule penetration with needle in phakic patients) or gas cataract if positioning not maintained
  2. Vitreous hemorrhage
  3. Raised intraocular pressure
  4. Endophthalmitis (rare)
  5. Migration of gas into the anterior chamber
  6. Displacement of subretinal fluid through the macula (in patients with a macula-on presentation)
  7. Development of new retinal breaks
  8. “Fish egg” gas bubbles
  9. Migration of gas into the subretinal space or injection of gas into the suprachoroidal space or canal of Petit

Equipment List

  1. Universal precautions: sharps container, sterile gloves (optional), mask (optional)
  2. Topical amethocaine (tetracaine)
  3. Subconjunctival anesthesia (e.g. 1% lidocaine in 3.0 cc syringe with 30-gauge needle)
  4. Cryotherapy (1-step procedure) or laser (2-step procedure)
  5. Eyelid speculum
  6. Povidone-iodine or chlorhexidine antiseptic
  7. 2 x 30 gauge ½" needle on 1.0 cc syringe for anterior chamber paracentesis
  8. Millipore filter (for filtering gas)
  9. Sterile gas (e.g. SF6, C2F6, or C3F8 at 100% concentration) in a 1.0 cc syringe with 30 gauge ½“ needle
  10. Sterile cotton-tipped applicator
  11. Indirect ophthalmoscope and condensing lens
  12. Tonometer
  13. Indirect laser (2-step procedure)

Procedure

The authors recommend setting up all materials prior to administration of anesthesia. Ensure all equipment, including cryotherapy, millipore filter, gas and indirect laser are available and functional. Label syringes to avoid confusion.

There are two options for retinopexy: cryotherapy (1-step procedure) or laser (two-step procedure). Cryotherapy is applied prior to injection of the gas bubble. Laser is applied following injection of the gas bubble, once the retina has reattached. Laser retinopexy to lattice or breaks in attached retina is applied prior to the gas bubble injection. Cryotherapy has the advantages of being better able to localize the break(s) than post-gas indirect retinal laser and an ability to be applied even when subretinal fluid is present. It can also aid in identifying small breaks missed during clinical examination and be beneficial in aphakic patients or patients with a suboptimal view of the posterior segment.

The theoretical disadvantage is a higher risk of proliferative vitreoretinopathy (PVR) with heavy cryotherapy when retinal pigment epithelial (RPE) cells are liberated into the vitreous cavity and a delay in achieving chorioretinal adhesion. In general, the authors prefer laser. If cryotherapy is used laser can be used to augment the retinopexy.

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