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The what, why, who and how of pneumatic retinopexy
The procedure is a good option for the management of selected retinal detachments.
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Over the past 35 years, primary retinal detachment surgery has evolved from almost exclusively being performed with a scleral buckle to the current day in which small-gauge vitrectomy is becoming the standard. So, in today’s world, what is the role of pneumatic retinopexy?
Pneumatic retinopexy was first introduced by Hilton and Grizzard as an office-based procedure for the repair of retinal detachment in 1986. Over the years, this procedure has attracted many adherents, non-practitioners and detractors. If employed judiciously, there is definitely a role for pneumatic retinopexy in our management of retinal detachment.
How does pneumatic retinopexy work?
A gas bubble, typically sulfur hexafluoride 0.45 mL, is injected into the vitreous cavity, followed by a paracentesis. Some clinicians will initially treat the retinal break with cryotherapy, while others, including myself, elect to perform laser treatment with the indirect ophthalmoscope after the retina has been reattached.
There are two mechanisms that explain the process by which the retina is reattached. By placing the patient in the appropriate position, such that the retinal break is closed by the gas bubble, the retinal pigment epithelium pump will remove the subretinal fluid. In addition, by utilizing the “steamroller” maneuver, the gas bubble rolls or compresses the subretinal fluid through the retinal break and back into the vitreous cavity. Typically, after the injection of the gas bubble, the patient is placed in a prone position for 30 minutes. This will reattach the macula, allowing for faster visual recovery and preventing formation of a retinal fold in the macula. Then the patient is slowly rolled so that the gas bubble will eventually be in apposition to the retinal break. If the procedure is successful, the retina should be reattached in approximately 24 hours.
I prefer to perform laser retinopexy with the indirect ophthalmoscope after reattachment of the retina because there is less inflammation than occurs with cryotherapy. In addition, if the procedure fails and the patient is taken to the operating room, I will have virgin retina to treat.
Sometimes it can be difficult to laser a superior retinal break with a gas bubble in the eye. One trick is to place the patient in the Trendelenburg position; the bubble will roll out of the way, and the retina can be easily visualized.
Why does pneumatic retinopexy fail?
We have long been taught that there are three principles that must be observed in order to successfully repair a retinal detachment:
1. Localize the retinal break
2. Create a chorioretinal adhesion
3. Release the vitreoretinal traction
Pneumatic retinopexy follows only two of these three principles because the gas bubble may counteract the vitreous traction but it does not release it. Therefore, during the pre-procedure examination, it is important to carefully assess the extent of vitreous traction on the retinal break. If the vitreous traction appears to be extensive, pneumatic retinopexy is not a good option. It is also important to examine the retina for all possible breaks. If the detachment extends inferiorly, missed retinal breaks will always result in failure. In addition, inferior retinal breaks and lattice degeneration within attached retina should be considered for laser treatment or perhaps may serve as a contraindication to pneumatic retinopexy.
What are the benefits?
When pneumatic retinopexy is successful, the benefits are obvious: no operating room, no eye drops, back to work quickly. Utilizing the steamroller technique, the macula is reattached soon after injection of the gas bubble on the same day that the patient presents to the office, thus allowing for a faster recovery of vision.
What is the risk of a failed procedure?
Other than the inconvenience to the patient with extra office visits, a failed pneumatic retinopexy procedure can almost always be successfully repaired with either a scleral buckle or a vitrectomy. In fact, even in failed pneumatic retinopexy cases, the macula can usually be reattached, with the gas bubble, again providing for a more rapid recovery of vision. In addition, there is often less subretinal fluid and subsequent surgery can be performed more easily. As with any intraocular injection, there is the remote risk of endophthalmitis. Also, a small percentage of patients may develop a sequential retinal break approximately 180° from the original break. Therefore, it is important to look for and treat any new breaks 1 week after the initial gas injection.
Who is a good candidate?
Patient selection is critical for pneumatic retinopexy, which best explains the wide range of reported success rates. The ideal patient is cooperative and has a one quadrant superior detachment with a small retinal tear located between 10 o’clock and 2 o’clock. In some cases, one may try to “push the envelope” and treat patients with less than ideal detachment configurations in an attempt to avoid a surgical procedure. Surprisingly, we may find success, while in others cases, surgery will ultimately be necessary. For this reason, I prefer to recommend pneumatic retinopexy for those patients living nearby because extra traveling time and office visits will be needed in event of failure.
Pneumatic retinopexy is an excellent option for the treatment of selected retinal detachments, and even in failed cases, by steamrolling the macula, it can often restore vision more rapidly and ultimately facilitate subsequent surgery.
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