Pneumatic retinopexy is the only clinic-based method of repair of rhegmatogenous retinal detachment. Introduced by Hilton in 1986 [1], pneumatic retinopexy has several potential advantages including quick restoration of visual acuity, the avoidance of systemic anesthesia, lower cost, and less cataract progression. The procedure has been traditionally best employed in phakic eyes with single retinal breaks or a cluster of retinal breaks in a single anatomic location in the superior clock hours.
There has been new excitement around the procedure following data released from the PIVOT [2] trial. This Canadian-based randomized controlled trial compared the clinical outcomes associated with pneumatic retinopexy versus pars plana vitrectomy for management of non-complex rhegmatogenous detachment in both phakic and pseudophakic eyes. The trial required the detachment to include a single retinal break or a group of breaks in detached retina within one clock hour above the 8 to 4-o’clock meridian with any number, location, and size of retinal breaks or lattice degeneration in the attached retina. In total, 176 patients were enrolled. PIVOT disclosed that primary anatomic success was achieved in 81% of patients undergoing pneumatic versus 93% of patients undergoing vitrectomy. In addition, those patients treated with pneumatic retinopexy appeared to have better subjective visual acuity, less metamorphopsia, and a faster restoration of vision.
We presented new data on the “real-world” experience with pneumatic retinopexy at AAO 2020. The purpose of this population-based study was to determine the clinical efficacy and safety of pneumatic retinopexy for non-complex retinal detachment using data from the IRIS® Registry (Intelligent Research in Sight). The inclusion criteria were initial treatment with pneumatic retinopexy and three months or more of follow-up. Key exclusion criteria were giant retinal tear, tractional retinal detachment, traumatic retinal detachment, and a number of other types of complex retinal detachments.
The main outcome measure was single operation success defined as anatomical retinal reattachment in a single procedure without a subsequent vitreoretinal surgery aimed at retinal reattachment. There were also secondary outcome measures including logMAR best corrected visual acuity, time to maximal visual recovery, metamorphopsia, vitreous hemorrhage, epiretinal membrane, proliferative vitreoretinopathy, and endophthalmitis.
We included a group of 9,659 eyes, the largest cohort of eyes treated with pneumatic retinopexy to date. Single operation success was achieved in 6,613 (68%) eyes. LogMAR best-corrected visual acuity differed (p<0.001) at 9–12 months postoperatively between the single operation success group (mean=0.24) and the single operation failure group (mean=0.43) as expected. Endophthalmitis and other key adverse events were uncommon. Of note, single operation success was associated with female gender (OR 1.51), while current smoking status (OR 0.78) was associated with failure. The single operation success rate in this IRIS cohort was similar to a report on the experience on U.S. vitreoretinal fellows (67%) [3].
Data from this study comes on the heels of another important report from the IRIS Registry on reoperation rates in patients treated with pars plana vitrectomy and scleral buckling [4]. In their study of 24,068 patients, Rao et al. found that the single operation success with scleral buckling was 88% while those receiving a pars plana vitrectomy with or without scleral buckle had a single operation success of 88%.
We believe these studies indicate that the real world experience with scleral buckling or pars plana vitrectomy with or without scleral buckling may achieve a significantly higher rate of single anatomic success than pneumatic retinopexy. Nevertheless, for its multiple advantages as a clinic based procedure with the potential for faster visual recovery, pneumatic retinopexy remains a reasonable option, especially in phakic eyes with single superior breaks.
Dr. Yannuzzi is a consultant for Novartis, Genentech, and Allimera Sciences.
References
1. Hilton GF, Grizzard WS. Pneumatic retinopexy. A two-step outpatient operation without conjunctival incision. Ophthalmology. 1986;93(5):626-641.
2. Hillier RJ, Felfeli T, Berger AR, et al. The Pneumatic Retinopexy versus Vitrectomy for the Management of Primary Rhegmatogenous Retinal Detachment Outcomes Randomized Trial (PIVOT). Ophthalmology. 2019;126(4):531-539.
3. Emami-Naeini P, Deaner J, Ali F, et al. Pneumatic Retinopexy Experience and Outcomes of Vitreoretinal Fellows in the United States: A Multicenter Study. Ophthalmol Retina. 2019;3(2):140-145.
4. Rao P, Kaiser R, Lum F, et al. Reoperation rates of patients undergoing primary noncomplex retinal detachment surgery in a cohort of the IRIS Registry. Am J Ophthalmol. 2020.
