In a case of primary retinal detachment, do you perform pneumatic retinopexy as first-line management?

Perspective

Michael A. Singer

Yes, I perform pneumatic retinopexy as primary therapy. My goal in patients with retinal detachment is to preserve macular function. Given our busy clinic schedule, by doing pneumatic retinopexy I am able to do that either as a primary procedure or as a secondary procedure. Although the studies do show that by waiting to repair macula-off retinal detachment for up to a week, we still end up with the same amount of vision, I feel that for both the patient’s satisfaction and my own peace of mind, the sooner I get the macula flat, the better. Even if I am unable to fix the retina totally, I can usually get the macula flat and then can always bring them to the operating room to do a planned operation where I can perform a primary vitrectomy and/or a scleral buckle if indicated.

Michael A. Singer, MD
Disclosure: Singer has no relevant financial disclosures.

Perspective

Timothy W. Olsen

Yes, I use pneumatic retinopexy as first-line treatment for repair of primary, superior retinal detachments, especially when the operating room is less readily available (weekends). The ideal candidate would be phakic with a superior (upper 6 clock-hours), single and smaller retinal break(s) in a motivated patient who fully understands the risks and estimates for success. When successful, there are many benefits: less expensive, quick, little pain, no OR time, low risk of refractive change and less risk of cataract progression. When pneumatic procedures fail, and they do (30% to 40% of cases), the properly consented patients will be mentally prepared for surgery. My strategy is to be certain that patients understand the risks and positioning requirements.

Timothy W. Olsen, MD
Disclosure: Olsen’s financial disclosures include RO-1AG025392, NIH/NEI:R44 EY016229, RPB unrestricted grant, Emtech Biotechnology grant, Georgia Research Alliance, Dobbs Foundation and Johnson & Johnson.

Perspective

Jennifer I. Lim

Yes, if the retina detachment is primarily superior with the tears within the top 4 to 5 clock-hours, pneumatic retinopexy is an option. It is important to exclude patients in whom obvious vitreous traction or fibrosis already is present that would limit the chance of success. If there are opacities that limit a good view of the peripheral retina, such that other tears cannot be excluded, then that patient is not a good candidate. It is important to make sure the patient limits exertion post-PR, as there is a gas bubble in a non-vitrectomized eye that could contribute to vitreous traction. The patient must be informed of the risks of additional tears, usually inferiorly, or at points 180° from the original tear. Of course, I inform patients also of the risk of flying, general anesthesia and high altitudes while there is gas intraocularly.

Jennifer I. Lim, MD
Disclosure: Lim has no relevant financial disclosures.

Perspective

Howard F. Fine

No, in phakic patients, a scleral buckle is my preferred operation for the vast majority of patients to avoid cataract acceleration. In pseudophakes, I will consider scleral buckle vs. pars plana vitrectomy vs. a combination of the two, depending on the configuration of the pathology. I would only consider pneumatic retinopexy for “perfect” candidates with a single superior tear and no additional peripheral pathology. While pneumatic retinopexy is certainly less invasive, many studies suggest the success rate is at least a few percentage points lower than for other methods of surgical repair, and failures following pneumatic retinopexy are more likely to develop proliferative vitreoretinopathy and other complications. Since I work in a retina group setting, if I am unable to schedule the procedure for myself, one of my retina surgical partners is always available in the OR to manage an additional case.

Howard F. Fine, MD, MHSc
Disclosure: Fine is a consultant/speaker for Genentech, Regeneron and Allergan and is a consultant for and has equity and patent interests in Auris Surgical Robotics Inc.