Background:
There are three primary ways to repair retinal detachments- scleral buckle, vitrectomy, and pneumatic retinopexy. While the goal of surgery or procedure is the same, namely achieving an attached retina, each method has varying indications, nuances with appropriate patient selection, and success rates.
Picture of retinal detachment with large retinal tear of left eye
A scleral buckle is an external approach that involves placing an encircling band around the eye to indent and support the causative internal retinal defects. Cryotherapy, or freezing, often in conjunction with externally draining the fluid under the retina and a gas bubble, allows the retinal detachment to go away over time with gradual absorption of subretinal fluid.
Vitrectomy is an internal approach, similar to a laparoscopic surgery, with three tiny incisions smaller than the tip of a ballpoint pen. Infusion is maintained throughout the surgery, and after the vitreous gel is removed, the retina is attached in real-time intraoperatively. Laser is placed around the retinal tears, and a gas or silicone oil bubble (for more advanced detachments) is placed in the eye. The gas bubble goes away over time, acting as a “cast” or tamponade to allow the laser to strengthen.
Pneumatic Retinopexy is an office procedure that involves cryotherapy to the retinal tears and intravitreal injection of a gas bubble to temporarily allow the freezing scars to heal. With positioning, the retina can re-attach with gradual resolution of the subretinal fluid.
History:
Initially described in 1949, scleral buckling was the first routinely successful surgery for fixing retinal detachments and was the only viable option for several decades. After vitrectomy was introduced in 1971, gradual adoption of vitrectomy has led to it being the most common retinal detachment repair approach in the U.S. today.
This sustained widespread use of vitrectomy as the preferred methodology for retinal detachment surgery rapidly accelerated the last two decades due to technological advancements and the development of an understanding of the many advantages vitrectomy presents compared to other methods. Given vitrectomy’s decreased incisional size, improved operating fluidics, drastically faster cut rates, and crystal clear visualization of the retina, it is not surprising that most vitreo-retinal fellowships primarily emphasize vitrectomy-based retinal detachment repair as opposed to intensive scleral buckling.
Picture of vitrectomy demonstrating internal approach to retinal detachment repair
Pneumatic retinopexy originated in the mid-1980s and has not evolved much over the decades. It has found a niche historically in other countries or managed care organizations, healthcare systems or retinal practices where consistent and timely operating room access is difficult to obtain.
Pros and Cons:
The popularity of scleral buckling has declined over the last several decades for numerous reasons. Compared to vitrectomy alone, there is longer operative time, more postoperative morbidity such as pain and swelling, unpredictable refractive shifts, and higher risks of double vision due to strabismus, droopy eyelid, and intraocular injury during drainage. There is always the possibility of buckle extrusion years or decades later which would require another surgery to fix.
Despite the potential risks, scleral buckle still on occasion is employed for particular situations; these generally are younger patients, and in Proliferative Vitreo-Retinopathy (PVR) – associated detachments which have scar tissue growth causing traction on the retina. The buckle helps support the peripheral retina in these cases where the mechanics and root cause of the detachment are different than the majority of retinal detachments
Single surgery success rates, validated across study after study, show nearly identical ~ 90% anatomic retinal re-attachment rates with scleral buckle versus vitrectomy.
However, compared to scleral buckle, vitrectomy is a shorter procedure with less pain and swelling in the postoperative period. This is because of the micro-incisional nature of the procedure, which can be sutureless, and less manipulation of the eye intra-operatively. The aforementioned more common risks found with scleral buckle are exceedingly rare or unheard of with vitrectomy as well.
During vitrectomy, the retina is physically attached by the surgeon. Knowing the retina is attached makes postoperative positioning relatively less important for vitrectomy compared to scleral buckle and pneumatic retinopexy, which carries a much higher probability of having persistent subretinal fluid that does not drain adequately.
Unlike a scleral buckle or pneumatic retinopexy, the vitreous gel, the cause of retinal tears in most detachments, is thoroughly removed during vitrectomy, decreasing the chance that new retinal tears form in the future.
Pneumatic retinopexy is most often considered for uncomplicated retinal detachments with superior retinal tear(s). Even with “appropriate” case selection single procedure re-attachment rates are inferior to both scleral buckle and vitrectomy, with most studies showing a ~ 70-80% success rate. That is, for every 10 vitrectomies or scleral buckles performed, 1 re-detachment occurs compared to 2 to 3 for pneumatic retinopexy.
This is consequential for three main reasons as re-detachments:
- May involve the macula and permanently cause vision loss,
- Increase the likelihood of scar tissue formation making re-detachments harder to fix,
- And require another procedure typically ending up being a vitrectomy or scleral buckle.
Why are success rates so low for pneumatics?
- Most retinal detachments have more than one retinal tear that may be missed during the exam and procedure.
- Retinal reattachment is more dependent on patient positioning for pneumatics
- Cryotherapy, compared to laser, increases the risk of PVR scar tissue forming and causing a redetachment.
- The “sticky” vitreous gel, the primary cause of retinal detachment, is never removed during a pneumatic procedure. Afterwards, its presence can cause new retinal tears at any point in the future.
“Getting it right the first time,” in my opinion, should take precedence in retinal detachment repair due to these downside risks.
While it is true that vitrectomy will more rapidly expedite cataract formation causing more blurred vision in the postoperative interim period until cataract surgery is performed, cataract formation still occurs after scleral buckles and whenever a gas bubble is injected in the eye during a pneumatic retinopexy, albeit more slowly.
For this reason, we work closely with your referring doctor or cataract surgeons to ensure no delay in cataract surgery after vitrectomy-based retinal detachment repair to mitigate this reality. Oftentimes, patients with retinal detachments are near sighted and having cataract surgery becomes a welcome refractive procedure that is ultimately advantageous for the patient in the first place.
Proponents of pneumatic retinopexy often do not have immediate or adequate OR accessibility. At Retina and Vitreous Consultants of Wisconsin, we maintain a two decades long relationship with Aurora St. Luke’s Medical Center and have the ability to add urgent cases any day or evening of the year.
With specially trained retinal OR staff, we feel comfortable offering patients the procedures with the highest success rates such as vitrectomy no matter what the time.
Finally, there has been recent debatable suggestion that pneumatic retinopexy may result in less vertical distortion than vitrectomy. Vitrectomy, when performed by a skilled surgeon, for uncomplicated retinal detachments ultimately allows the retina to reattach in a natural configuration thus alleviating this potential risk. There is a huge variance in surgical technique and experience in the retina field, and these come into play on some of these more nuanced discussions.
Summary:
Vitrectomy has equivalent outcomes compared to scleral buckle, with a ~90% surgical success rate, but without the comorbidities and significant risks. It has superior outcomes compared to pneumatic retinopexy of ~70-80% success. Pneumatic retinopexy’s inherently lower success rate should be taken seriously when it comes to retinal detachment repair.
Combined with recent and continuing technological advances, vitrectomy has not surprisingly become the most popular surgical method for retinal detachment repair in the U.S. Currently, most uncomplicated retinal detachment vitrectomies will take only 20-30 minutes under “twilight” or MAC anesthesia with minimal sedation, not much longer than most cataract surgeries. In fact, for patients who have had cataract surgery, I tell them that, other than the gas bubble, they already know what to expect with regards to the main risks and their point of view of the surgery experience.
By contrast, scleral buckle and pneumatic retinopexy have not changed fundamentally since the 1980s. There are no new scleral buckle techniques or technology coming out, and concentrated gas and cryotherapy, the 2 pillars of these procedures, are the same. Nonetheless, there are some situations where a scleral buckle may be preferred over a vitrectomy most commonly in younger patients or PVR-related retinal detachments, and some situations where a pneumatic retinopexy might be appropriate.
Retina and Vitreous Consultants of Wisconsin’s approach to retinal detachment repair is based on one singular goal- “to help patients maximize their vision.” Our collective experience helps us rigorously evaluate all options and increase your chance of success while minimizing issues with retinal detachment surgery. Commitment to helping patients navigate cataract surgery after vitrectomy expedites visual recovery. Finally, our ability to add urgent surgical cases at Aurora St Luke’s Medical Center allows us to maximize your chance of success with vitrectomy 365 days a year.
Nicholas Tosi, MD
2/1/2024