Pneumatic Retinopexy for the Repair of Retinal Detachments: A

Transcription

SURVEY OF OPHTHALMOLOGY
VOLUME 53 ! NUMBER 5 ! SEPTEMBER–OCTOBER 2008
DIAGNOSTIC AND SURGICAL
TECHNIQUES
MARCO ZARBIN AND DAVID CHU, EDITORS
Pneumatic Retinopexy for the Repair of Retinal
Detachments: A Comprehensive Review (1986--2007)
Clement K. Chan, MD, FACS,1,2 Steven G. Lin, MD,3 Asha S.D. Nuthi, DO,3
and David M. Salib, MD3
1
Southern California Desert Retina Consultants,Palm Springs, California; 2Department of Ophthalmology, Loma Linda
University, Loma Linda, California; and 3Southern California Desert Retina Consultants, Palm Springs, California,
USA
Abstract. Pneumatic retinopexy has become an important surgical technique in the modern era of
retinal surgical management for retinal detachments. It is primarily indicated for uncomplicated retinal
detachments with retinal breaks involving the superior 8 clock hours of the fundus, although more
complex retinal detachments may be successfully managed with this technique on a selected basis.
Qualified candidates must be willing to maintain a specific head posture for five or more days for optimal
outcome with pneumatic retinopexy. Basic surgical steps of pneumatic retinopexy include retinopexy of
retinal breaks with cryotherapy or laser, intraocular gas injection before or after retinopexy, and
maintenance of proper head posture by the patient for the required time period after surgery. Phakic eyes
fared better than nonphakic eyes for pneumatic retinopexy, with the single-operation successes of 71--84%
for the former and 41--67% for the latter. Despite lower single-operation successes with pneumatic
retinopexy in comparison to sclera buckling, the multicenter pneumatic retinopexy trial and other
published reports have shown that the final anatomical and visual outcomes are not disadvantaged by the
initial pneumatic retinopexy. An extensive discussion of complications associated with pneumatic
retinopexy is presented. In addition, a key feature of this review is a comprehensive update in the outcome
of pneumatic retinopexy in published reports from 1986 to the present in chronological order not
available in the current literature. This comprehensive summary shows updated average surgical outcomes
for the 4,138 eyes in the 21-year period to be similar to previous reports: single-operation successes
(74.4%), final operation successes (96.1%), new retinal breaks (11.7%), and proliferative vitreoretinopathy (5.2%). (Surv Ophthalmol 53:443--478, 2008. ! 2008 Elsevier Inc. All rights reserved.)
Key words. Complications of pneumatic retinopexy ! expansile gas ! gas injection !
pneumatic detachment of vitreous ! pneumatic retinopexy ! pneumoretinopexy ! surgical
outcome of pneumatic retinopexy ! visual outcome of pneumatic retinopexy
can be managed by pneumatic retinopexy.40 Its
efficacy for repairing a retinal detachment depends
on three cardinal steps: 1) induction of retinopexy
around all retinal breaks with cryopexy or laser; 2)
Pneumatic retinopexy (PR) is an office-based procedure designed for repairing selected retinal
detachments. Brinton and Hilton estimated that at
least 40% of rhegmatogenous retinal detachments
443
! 2008 by Elsevier Inc.
All rights reserved.
0039-6257/08/$--see front matter
doi:10.1016/j.survophthal.2008.06.008
444
Surv Ophthalmol 53 (5) September--October 2008
intraocular gas injection; and 3) consistent postoperative head positioning for appropriate gas
tamponade to achieve closure of the retinal breaks.
Since its introduction in 1985,111 PR has become
a well-accepted alternative surgical technique to
scleral buckling and vitrectomy for uncomplicated
rhegmatogenous retinal detachments with superior
retinal breaks in the modern era of retinal surgical
management. Proponents of PR have underscored
the advantages of less tissue trauma, usual lack of
major complications, no hospitalization, and lower
expenses, associated with PR in comparison to
scleral buckling (SBP) and vitrectomy.40,110,111,240
The purpose of this review is to present a comprehensive updated summary of the indication, anatomical and visual outcomes, and complications
associated with PR reported in the world literature
for the past two decades. The presentation of not
only the conventional but also the controversial
applications of PR is not an unqualified endorsement of the latter by the authors, but rather
a synopsis of all aspects of PR found in the world
literature in the past two decades.
Historical Perspective
Jules Gonin, the father of retinal detachment
surgery, performed the first successful surgery to
close retinal breaks with his ignipuncture operation
in 1919. He drained subretinal fluid with a Graefe
knife after making a radial incision through the
sclera to the choroid, and cauterized the retina by
the retinal tear with a red-hot cautery.22,91 The idea
of injecting intravitreal gas for repairing a retinal
detachment was first introduced by Ohm in 1911.189
Subsequently, Rosengren described in 1938 a technique of external diathermy through the fullthickness eye wall to induce adhesion of retinal
breaks to the underlying retinal pigment epithelial
(RPE) and choroidal layers, followed by subretinal
fluid drainage and intraocular air injection for
closing the associated breaks.206,207 He reported
a success rate of 76% in his surgical series with his
technique.206 With the introduction of the Custodis
procedure in the early 1950s, scleral buckling
rapidly became the dominant surgical technique.58,59 The idea of repairing a retinal detachment with an intraocular air or gas bubble faded
from the surgical scene for the next 50 years. It was
not until 1985 that George Hilton re-introduced the
idea of intraocular gas tamponade and retinopexy
in an office setting for managing select cases of
retinal detachments.40,111 Contemporaneous with
Hilton’s discovery, Dominguez independently reported a similar technique in repairing certain
CHAN ET AL
retinal detachments.62--65 In the ensuing years,
multiple clinical studies have reported both the
benefits and complications of PR, establishing its
current important role in the repertoire of the
retinal surgeon for managing retinal detachments.1--
10,13--21,25,27,31--34,36--40,44--52,54,56,57,60,62--69,71--82,89,90,
95--100,102,104,105,107,110--112,114--117,120--124,127--129,131,132,
134--137,139,140,141,143--152,154,159,160,162--175,178--181,184--186,
190--195,197,200--203,208,209,212,214--218,220,225--228,231--235,
238--253,255--261,263--265,267,270,271,273--278
Previous surveys
of the practice patterns showed its varying popularity among retinal surgeons, partially dependent on
their prior experiences, geographic locations, and
ages. Multiple surveys have shown an increasing
trend for PR in certain regions of the United States
(i.e., California and Florida), and its lower preference in the Midwest and the Northeast of the
United States and certain parts of Europe (e.g.,
United Kingdom, Germany). Younger and more
recently trained surgeons also favor PR more than
their older colleagues trained in earlier
years.4,14,23,146,227,265
Mechanisms and Basic Requirements
All surgical techniques for successful repair of
a retinal detachment (RD) require closure of all
retinal breaks and resolution of subretinal fluid. PR
accomplishes this goal by the tamponade of retinal
breaks with an intraocular gas bubble and induction
of chorioretinal adhesion with cryopexy or laser.40,110,111,240 The property of high surface tension
associated with an intraocular gas bubble constitutes
its main mechanism for closing retinal breaks and
enhancement of subretinal fluid absorption. For
instance, a gas bubble induces an interfacial tension
of 70 dynes per cm on the retinal surface, whereas
silicone oil creates a surface tension of only 21.3
dynes per cm.84 Buoyancy of an intraocular gas
bubble plays a secondary role in re-attaching the
detached retina. For an average eye, 0.3 ml of gas
can cover 60 degrees of the retinal surface, whereas
it takes 1.2 ml of intraocular gas to cover 90 degrees
of the retinal surface.40,110,111,240 More gas is required to cover an equivalent arc of retinal surface
for a highly myopic eye with a large globe.
A lingering intraocular gas bubble with excessive
expansion may cause unwanted vitreoretinal traction, resulting in new retinal breaks.40,110,111,240
Table 1 outlines the duration and extent of
expansion of intraocular air and various gases.
Choices of the agent for intraocular tamponade
include air, sulfur hexafluoride (SF6), perfluoroethane (C2F4), and perfluoropropane (C3F8). The
law of partial pressures defines the mechanism of
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REVIEW: PNEUMATIC RETINOPEXY
TABLE 1
Intravitreal Gas Duration and Expansion
Gas
Average Duration Largest Size Average Expansion
Air 3 days
SF6 12 days
C3F8 38 days
Immediate
36 hours
3 days
No expansion
Doubles
Quadruples
gas expansion in the eye. The intraocular expansion
of an inert gas (SF6, C2F4, or C3F8) is related to its
low water solubility and the net diffusion of nitrogen
and oxygen molecules into the gas bubble (Fig. 1).
SF6 doubles in size by 24 to 36 hours, and lasts from
6--12 days.40,110,111,240 Previous studies have shown
that it takes 7--14 days for the formation of
a retinopexy scar with optimal tensile strength
following cryopexy or laser.197 Thus, the optimal
intraocular gas is one that expands sufficiently to
cover all retinal breaks, and lasts long enough for
the retinopexy scar to develop optimal tensile
strength before its rapid disappearance subsequently. Perfluoroethane has the characteristics that
match these criteria the best, but it has not been
approved by the FDA for clinical use. In contrast,
both SF6 and C3F8 have been approved by the FDA
for clinical use. The long duration of C3F8 is
advantageous for selected cases that require prolonged gas tamponade. Because of its greater
expansion, only a small volume of C3F8 is required.
However, many surgeons consider the long duration
of C3F8 to be excessive, causing unnecessary delay in
the resumption of normal activities and traveling for
the patient. By default, SF6 has become the gas of
choice used most frequently by most surgeons for
PR.
The basic criteria required for PR include the
following:40,110 1) presence of a single or multiple
retinal breaks occupying one clock hour of the
retinal arc; 2) location of all retinal breaks in the
superior 8 clock hours of the globe; and 3) ability of
the patient to maintain the proper head position for
at least 16 hours a day for five days or more. Patients
with a retinal detachment not satisfying these
criteria are expected to have much poorer responses
to PR than those that do.
Patient Selection
The following conditions associated with a retinal
detachment constitute the ideal case scenarios for
performing pneumatic retinopexy (class I or II
evidence-based support [A to C]):40,110
LIMITED SUPERIOR RETINAL BREAKS
The limitation of one or more small retinal breaks
within one clock hour of the retinal arc in one or
two superior quadrants without other retinal breaks
is associated with a favorable prognosis for PR.
SUPERIOR RETINAL DETACHMENT
The limitation of the RD primarily to a superior
quadrant is another highly favorable clinical situation for PR.
PHAKIA
Most clinical series on PR have shown substantially higher success rates for managing phakic RDs
in comparison to pseudophakic and aphakic
RDs.3,6,8,15,32,34,37--40,44,46,47,51,52,71,77,78,89,98,104,105,110-112,129,134,140,152,164,166--169,178,180,181,185,190,192--194,200,
201,214,216,217,220,225,234,235,240--243,248,249,251,252,257,259,
260,269,271,273,275--277
Fig. 1. Intraocular expansion of inert gas is related to its
low water solubility and net diffusion of nitrogen and
oxygen molecules into the gas bubble.
The lower success rates associated with the latter two conditions are thought to
be related to the presence of multiple small missed
or new peripheral retinal breaks, frequently in
conjunction with peripheral vitreoretinal traction.
However, Hilton and others have reported favorable responses to PR for many nonphakic eyes.
Thus nonphakia per se is not a contraindication
for PR.40,110
Certain eyes with features of RD not consistent
with the best case scenarios outlined above may
still respond appropriately to PR, if they satisfy
the basic criteria described in the preceding section.
In addition to the basic criteria, the following
446
considerations are crucial for proper patient selection for successful PR:40,110 1) Can the patient follow
directions, 2) Does the patient have physical
problems that may prevent compliance with positioning requirements, 3) Does the patient’s home
situation allow consistent postoperative positioning,
4) Are there potential obstacles to vital postoperative visits and close monitoring, 5) Does the patient
plan on air or mountain traveling shortly after
surgery, 6) Is there risk of wound dehiscence related
to recent eye surgery, and 7) Is there history of
severe or endstage glaucoma.
OTHER FAVORABLE CONDITIONS
Brinton and Hilton have advocated pneumatic
retinopexy to be particularly appropriate for the
following clinical situations:40,110
LOCATION OF RETINAL BREAKS UNDER THE
SUPERIOR RECTUS MUSCLE
Placement of a segmental scleral buckle under
the rectus muscle for vertical action may induce
diplopia, a risk avoided by PR.
GLAUCOMA FILTERING BLEB AND DRAINAGE
DEVICE
PR is associated with the theoretical advantage of
averting the disturbance of conjunctival integrity
critical for a functional bleb and any underlying
drainage device for an eye that has undergone
a glaucoma filtering procedure,24,40 although the
peritomy may circumvent the filtering bleb and
disturbance of the fibrous capsule surrounding
a drainage device may be avoided in the case of
SBP. There is also a lack of reports in the literature
showing higher bleb failure rates after scleral
buckling in comparison to PR.
RECURRENT RETINAL DETACHMENT
FOLLOWING SCLERAL BUCKLING
A limited superior RD associated with new or
recurrent superior retinal breaks after scleral
buckling is often more easily managed with PR than
buckle revision. Friberg and Eller reported successful repair of 36 of 40 eyes (90%) with a recurrent RD
after SBP with laser pneumatic retinopexy, whereby
laser is applied around new or missed retinal breaks
with a binocular indirect ophthalmoscopic device
after flattening of the detached retina with additional intraocular gas injection.80,82
OTHER MISCELLANEOUS CONDITIONS
Besides the previous conditions, Hilton has
pointed out the advantageous of PR over scleral
CHAN ET AL
buckling for treating an RD in the presence of the
following clinical conditions:40,110 1) large irregular
retinal breaks that are difficult to close with scleral
buckling; 2) globe with thin sclera at risk for
perforation during scleral buckling; 3) need for
maintaining emmetropia and avoidance of anisometropia often associated with scleral buckling; 4)
avoidance of strabismus that may be induced by
SBP; 5) minimizing cosmetic defects (i.e. lid ptosis
and enophthalmos); 6) need to cancel scleral
buckling due to mishap from a retrobulbar or
peribulbar anesthetic injection; 7) extensive conjunctival scarring that hinders the performance of
a peritomy required for SBP; 8) patient with an
illness or physical condition at increased risk for
complications with a surgical procedure in the
operating room; 9) patients undergoing anticoagulant therapy at risk for ocular bleeding during SBP
or vitrectomy; 10) patients with a physical condition
at risk for intravenous or general anesthesia
associated with SBP or vitrectomy;11) delay in
availability of the operating room; and 12) lack of
equipment or limited financial resources for SBP or
vitrectomy.
Advantages, Benefits, and Disadvantages
The major advantages and benefits of PR over
SBP and vitrectomy consist of the performance of
a relatively non-invasive and brief procedure in the
office setting, bypassing numerous requirements
and their associated expenses for surgery in the
operating room.40,110,111,240 The disadvantage is
greater attention to retinal break detection necessary for PR.40,110,111,240 A scleral buckle procedure is
potentially ‘‘more forgiving’’ for missed retinal
breaks and postoperative peripheral vitreoretinal
traction that may be supported by an encircling
buckle. Consistent and precise postoperative positioning is also more critical for PR to enhance
adequate retinal break closure and subretinal fluid
absorption.
Contraindications
The following clinical situations contraindicate
PR for repairing a retinal detachment. 40,110,111,240
PRESENCE OF RETINAL BREAKS WITHIN THE
LOWEST 4 CLOCK HOURS OF THE INFERIOR
QUADRANTS
Although a recent report showed the successful
repair of certain retinal detachments with breaks
along the inferior 4 clock hours (4 to 8 o’clock) for
selected patients,49 PR usually fails to repair such
447
RDs. Most patients cannot tolerate the unnatural
position required for proper gas tamponade of the
retinal breaks found in the lowest 4 clock hours.
retinal detachment, that is, substantial PVR, and
diabetic retinopathy.
HAZY MEDIA
PRESENCE OF PROLIFERATIVE
VITREORETINOPATHY GRADE C OR D
An RD with substantial proliferative vitreoretinopathy (PVR) including considerable retinal traction is not a good candidate for PR. For optimal
outcome, the basic criteria for PR require the
absence of PVR grade C or D. However, successful
outcome with PR has been reported for RD with
limited grade C PVR (see following section on
Expanded Use of Pneumatic Retinopexy for Special
Clinical Conditions).
NONCOMPLIANCE WITH REQUIRED HEAD
POSITIONING
The presence of retinal breaks outside of the 11 to
1 clock hours in the superior quadrants requires
more extreme head tilt positioning following PR
that may be difficult for patients with certain
physical disabilities, neck and back problems, or
mental incompetence.
Ocular opacities that impede the identification of
all retinal breaks may lower the success rate of
pneumatic retinopexy. Certain aphakic and pseudophakic eyes with multiple small peripheral retinal
breaks in the presence of a cloudy peripheral lens
capsule are poor candidates for PR. However,
obscuration of a portion of the retina does not
necessarily prevent success with PR, as long as the
retinal breaks are appropriately located and treated.
Expanded Use Of Pneumatic Retinopexy
For Special Clinical Conditions
The following sections describe the unconventional application of PR for various special clinical
conditions (class II or frequently only class III
evidence-based support). Considerable controversy
and differing opinions exist among retina surgeons
regarding the appropriateness of PR for these
conditions. Many surgeons continue to advocate
scleral buckling and vitrectomy instead of PR for
these conditions.
SEVERE GLAUCOMA
With the exception of advanced glaucoma, most
eyes with concomitant RD and glaucoma can be
safely managed with PR, as long as the intraocular
pressure is closely monitored, and corrective measures are taken if necessary.
EXTENSIVE LATTICE DEGENERATION AND
VITREORETINAL TRACTION
The proponents of PR advocate PR for treating
RD associated with limited lattice degeneration.
They point out that most eyes with mild or moderate
lattice degeneration associated with an RD respond
well to PR.40,241 Tornambe showed successful repair
of RD with 3 or fewer clock hours of lattice
degeneration with PR in his retrospective series of
302 eyes.241 In that series, the presence of limited
lattice degeneration (less than 3 clock hours) did
not lower the single operation success rate. However, there is a lack of published controlled prospective studies contrasting the efficacy and safety of
PR for cases with and without lattice degeneration.
In addition, most agree that extensive lattice degeneration may indicate increased risk for vitreoretinal traction and new retinal breaks that are best
treated with scleral buckling or a vitrectomy. PR is
also unable to relieve significant vitreoretinal and
fibrous traction associated with a rhegmatogenous
RETINAL BREAKS MORE THAN 1 CLOCK HOUR
APART AND LIMITED PVR
Although the basic criteria for pneumatic retinopexy require one or more retinal breaks to be within
one clock hour in extent, some surgeons have
reported the successful management of an RD with
multiple retinal breaks spanning up to 3 clock hours
with PR.249 The technique of alternate head tilt may
be employed for proper tamponade of the multiple
breaks in this situation (Fig. 2). An RD with limited
and localized PVR (grade C or less) at a substantial
distance from the retinal breaks may respond well to
PR.
Tornambe et al reported an overall 75% success
rate of retinal reattachment in a series of 40 eyes
with retinal lesions that exceeded the basic criteria
for PR (i.e., multiple breaks in multiple quadrants,
large retinal breaks up to 2.5 to 6 clock hours in size,
presence of moderate PVR of not more than grade
C2).249 For eyes with limited PVR, PR was most
effective when the star folds were not in the area of
the retinal breaks.249 New breaks developed in
12.5% of eyes.
GIANT RETINAL TEARS OR DIALYSES
In 1993, Irvine and Lahey reported the successful
management with PR for four of five selected RDs
448
CHAN ET AL
tilt followed by cryopexy led to complete retinal
reattachment of both eyes one day later. Additional
cryopexy successfully treated a new break on inferior
attached retina of left eye 6 months later.239
PNEUMATIC RETINOPEXY FOR RETINAL
DETACHMENT ASSOCIATED WITH PROGRESSIVE
RETINOSCHISIS
Fig. 2. Alternate head tilt allows proper gas tamponade
of multiple breaks more than 1 clock hour apart for
expanded indication of pneumatic retinopexy.
In 2000, Vrabec reported successful repair of
a case of RD associated with a progressive retinoschisis.258 Three superior pinpoint inner-walled
holes were first closed with PR after cryotherapy.
After flattening of both RD and retinoschisis by the
next day, laser was applied around two large
temporal posterior outer-walled holes. Complete
retinal attachment was maintained with a visual
acuity recovery to 20/30, ten months later. She
advocated consideration of PR for selected cases
with combined retinoschisis and RD, instead of
automatically choosing vitrectomy and scleral buckling for such cases.
INFERIOR RETINAL BREAKS
with a giant retinal tear within 180 degrees in extent
and a mobile retinal flap.121 Melgren and Michels
also published successful repair of RD with a giant
retinal dialysis (3 or more clock hours in size) in the
superior 8 clock hours of the fundus in four selected
eyes with PR.173
RETINAL BREAKS ON BOTH ATTACHED AND
DETACHED RETINA
Some surgeons have also successfully employed
PR for repairing retinal breaks present on both
attached and detached retina,40,110,111,240 when
proper steps are taken. First, laser or cryopexy
should be applied on breaks and lattice degeneration on attached retina before injection of an
intraocular gas bubble and treatment of the retinal
breaks on detached retina. To prevent the migration
of subretinal fluid under attached retinal breaks and
lattice degeneration, the steamroller maneuver
should be performed immediately after intraocular
gas injection (see following discussion for details).
BILATERAL RETINAL DETACHMENT
In 1987, Tornambe reported the successful repair
of bilateral retinal detachment with bilateral PR in
a case report.239 Multiple superior large and small
breaks and lattice degeneration were separated by
more than 30 degrees in one eye with an RD that
also had a macular hole. There were two large
breaks separated by 30 degrees in the other eye.
Sequential PR for the two eyes and alternate head
Tornambe et al showed that RDs with retinal
breaks in the inferior one-third of the fundus do not
respond well to PR. Despite prior reports of poor
responses with PR for RDs with inferior breaks,
Chang et al presented successful outcome with
‘‘inverted’’ PR for RD with retinal breaks involving
the inferior 4 clock hours (including 6 o’clock) in
selected patients in 2003.49,79,165,212 In their series,
highly motivated patients with inferior retinal breaks
associated with an RD were required to assume an
inverted head posture for successful closure of those
breaks. They found closure of the inferior breaks
after as little as 8 hours of appropriate gas
tamponade. They achieved a single-operation success of 81.8%, and a final success of 100% of their
cases. Through their experience with inverted PR,
they showed the proof of concept that shorter
duration than routine practice for gas tamponade is
needed even for superior retinal breaks associated
with PR. Further literature search also showed that
the idea of utilizing PR to treat RD with inferior
retinal breaks was first described by Friberg and
Eller in their report of pneumatic repair of primary
and secondary RD with a binocular indirect ophthalmoscopic laser device in 1988.81,82 On a practical
basis, most patients are unable to tolerate and
maintain the unnatural inverted head posture
required for using PR to repair an RD with inferior
retinal breaks between 4 and 8 o’clock. The use of
PR for such cases remains to be a highly unorthodox
and controversial practice. In 1989, Bagolini et al
reported an unorthodox technique of temporary
449
surgical rotation of the extraocular muscles in order
to shift retinal breaks located on the inferior fundus
to the upper quadrants for superior gas tamponade
during pneumatic retinopexy.17
RETINAL DETACHMENT ASSOCIATED WITH
POSTERIOR RETINAL BREAKS, INCLUDING
MACULAR HOLES, AND OPTIC NERVE PIT
It is difficult for scleral buckling to repair an RD
associated with posterior retinal breaks, including
macular holes, and macular detachment associated
with an optic nerve pit. Pars plana vitrectomy with or
without membrane stripping and long-acting gas or
silicone oil tamponade is the current standard
therapy for repairing these conditions. Alternative
unconventional techniques for their repair include
macular buckling, exchange of liquefied vitreous
fluid with intravitreal gas, and drainage of subretinal
fluid followed by intraocular gas injection.29,30,130,159,203,237 Some surgeons have found
PR to be an effective alternative for treating such
cases under certain circumstances. For instance,
Lincoff et al and Blodi et al proposed injecting
intravitreal expansile gas followed by postoperative
prone positioning for repairing selected cases of
myopic RD associated with a macular hole.30,159
Kusuki and coworkers treated 12 eyes in 12 patients
with macular-hole RD by injecting SF6 gas followed
by head-prone positioning.141 Seven eyes (58.3%)
were successful after one injection and three eyes
after two injections, with a final success of 83.3%.
Menchini et al reported a success rate of 77.8% for
treating myopic retinal detachment with a macular
hole with PR.175 They applied limited laser around
the macular hole besides gas injection, followed by
head-prone positioning for a number of days.
Rashed and Sheta treated 50 eyes with retinal
detachment associated with a macular hole.202 Ten
eyes underwent PR with plain room air (group 1),
30 eyes underwent vitrectomy and fluid air exchange (group 2), and 10 underwent a vitrectomy
followed by silicone oil tamponade due to PVR
(group 3). Eight of 10 eyes in group 1, 21 of 30 eyes
in group 2, and 8 of 10 eyes in group 3 achieved
successful closure of the macular hole. The visual
outcome was the best for eyes undergoing PR
(group 1). In 1990, Focosi et al performed PR to
treat the macular hole after repairing concomitant
peripheral retinal breaks with cryopexy and scleral
buckling in six eyes.74 They achieved successful
retinal reattachment and macular hole closure in
all six eyes. Lazzaroni achieved 50% and Santillo
58.6% success, whereas La Torre achieved 73.9%
success for macular hole detachment in their
series.143,147,209 In 1993, Zhai et al advocated
intraocular gas injection followed by head prone
posture for selected cases of posterior retinal
perforation associated with trauma.278 Despite these
reports, many surgeons consider the treatment of
these conditions with PR or its variations a controversial practice.
PNEUMATIC RETINOPEXY FOR RETINAL
DETACHMENT ASSOCIATED WITH OTHER
SPECIAL CLINICAL ENTITIES
In 1993, Glacet-Bernard and Coscas described the
successful employment of PR for repairing an RD
complicating Vitelliform macular dystrophy.88 Mild
grid laser was applied around the macular hole
responsible for the RD after flattening of the RD
with gas tamponade. In 1996, Haimovici et al
reported a successful repair of a nasal RD associated
with two small nasal flap tears as well as a supranasal
choroidal melanoma with PR.102 Iodine-125 plaque
radiation therapy was performed 3 months after PR.
Six months later, the retina was completely attached
and the visual acuity was improved to 20/70. There
was absence of tumor regrowth, extension, and
metastasis 11 months later. However, the patient’s
survival status and the condition of the melanoma
are not known at 5 years or beyond, the minimal
time interval usually required for judging the
efficacy and safety of a therapy involving a choroidal
melanoma. In 1998, McAuliffe and Heinemann
used PR to reattach a superior bullous RD associated
with a single superior flap tear in an eye that has
received a ganciclovir intraocular device for CMV
retinitis with a visual recovery of 20/30.170 However,
recurrent inferior retinal detachment associated
with multiple inferior necrotic breaks developed
2 months later, requiring a vitrectomy and silicone
oil tamponade. The visual outcome was 20/70 seven
months later. In 1993, Greco and Ambrosino
reported successful repair of recurrent RD associated with Marfan syndrome after failed SBP.92
Surgical Techniques
IDENTIFYING BREAKS
Prior to any surgical maneuvers, the surgeon must
spend sufficient time to re-identify and confirm all
retinal breaks associated with the retinal detachment, and devise his or her strategy for treating
those breaks.40,110,111,240 Inadequate endeavors on
this aspect of the surgery frequently lead to surgical
failure. If any previously missed retinal breaks are
now detected to be 2 or more clock hours from the
originally identified superior breaks, alternate head
tilt to allow appropriate gas tamponade for both sets
of tears may be performed after retinopexy is
450
applied (see previous section on Expanded Use of
Pneumatic Retinopexy for Special Conditions), or
PR may be abandoned for another procedure. For
retinal tears located in the inferior quadrants, the
surgeon must be prepared to treat the RD with
another procedure, such as scleral buckling. The
surgeon must also be prepared to treat all retinal
breaks and lattice degeneration located on attached
retina with laser or cryopexy first, prior to gas
injection.40,110,111,240
ANESTHESIA
For most patients, subconjunctival anesthesia
supplemented by topical anesthesia is sufficient for
the performance of PR. However, some patients
need retrobulbar or peribulbar anesthesia for
achieving adequate analgesia, particularly in cases
requiring substantial cryotherapy and laser treatment for retinal breaks during PR.40,110,111,240
General anesthesia is almost never performed with
PR, since it forfeits the major advantage of PR as an
office-based procedure. In the rare instance of
general anesthesia, the surgeon must remind the
anesthesiologist to avoid nitrous oxide in order to
prevent postoperative shrinkage of the intraocular
gas bubble.40
RETINOPEXY
The induction of appropriate adhesion of the
retinal breaks to the underlying RPE and choroidal
layers is a vital step for PR. This process is usually
accomplished with either cryopexy or laser application. Although cryopexy can be performed in
a single session, two separate sessions are usually
required for laser. Experimental studies on the in
vitro peeling force by Yoon and Marmor272 and on
the in vivo adhesive force by Kita et al133 have shown
that laser photocoagulation produces a bond that
approaches normal adhesive tensile strength within
24 hours, possibly related to local effects such as
fibrin formation. There is gradual increase in the
adhesive strength that approximates twice normal
by 2--3 weeks after photocoagulation.142 In vivo
studies also showed an adhesive strength for
diathermy with a time course similar to laser.133
For cryotherapy, however, there is weakening of the
adhesion for the first week possibly due to local
tissue inflammation or edema, before development
of tensile strength similar to the other modalities
during the second week.133 Thus, laser and cryotherapy result in a scar with a similar tensile strength
over the long term. However, laser photocoagulation allows a more rapid bond formation. Cryopexy
is required when there is substantial subretinal fluid
separating the RPE from the retinal break, unless
CHAN ET AL
laser is applied during a second session after
flattening of the retina with intraocular gas tamponade. Small peripheral retinal breaks are more
easily treated with cryopexy, and are usually difficult
to locate and may be obscured by multiple intraocular gas bubbles for laser treatment after gas
injection. ‘‘Fish-egg’’ gas bubbles may be avoided by
using the proper gas injection technique (injecting
the gas with the needle in a vertical and downward
orientation at the uppermost portion of the globe
and toward the center of the eye). Once present,
these annoying gas bubbles may be temporarily
displaced by reversing the head tilt from the original
position, or placing the head upside down to move
the gas bubbles away from the superior fundus for
laser application. Laser is more easily applied for
treating retinal breaks posterior to the equator.
There is also potentially less pigment cell release
into the vitreous cavity with laser than cryotherapy
for treating large retinal breaks and retinal breaks
associated with a bullous RD.43,96
The best technique for transconjunctival cryopexy
involves scleral indentation with the cryo-probe
under the guidance of indirect ophthalmoscopy to
induce RPE apposition to the underlying retinal
break. Yellowish white discoloration of the fundus
created by the freeze-thaw of the cryo-probe
encompasses the choroidal, RPE, and sensory
retinal layers around the margin of the retinal
break. However, one can terminate the freeze as
soon as a dull orange discoloration is visible at the
level of the RPE and choroid alone without changes
of the neurosensory retina, particularly in the
presence of a bullous RD that impedes RPE and
retinal apposition.40,110,111
Application of laser through shallow subretinal
fluid with increased laser power while pressing the
RPE against the retinal layer with forceful scleral
indentation to obtain sufficient laser uptakes may
inadvertently puncture the retina with new
holes.40,110,111,240 In case of laser application after
flattening of the retina with intraocular gas, it is best
to prepare a detailed diagram with clear landmarks
to pinpoint the locations of the breaks ahead of
time, and their locations may be further obscured by
multiple gas bubbles after gas injection. As mentioned previously, these gas bubbles may be avoided
with the proper gas injection technique, or displaced with the appropriate head posture subsequently during laser application. Transpupillary
laser indirect ophthalmoscope (LIO) is superior to
slit-lamp delivery of laser in circumventing the
interference of intraocular gas bubbles, particularly
for reaching the retinal breaks on the peripheral
fundus.80--82 The ideal laser application involves the
creation of multiple rows of overlapping lesions with
451
moderate intensity that surround the entire retinal
break. To prevent anterior migration of subretinal
fluid, the surgeon must not neglect adequate laser
application along the anterior margin of the retinal
break. Care must be taken to avoid excessive laser
power when treating through intraocular gas bubbles due to their insulation of heat generated by the
laser. In fact, it is best to avoid performance of laser
through the gas bubbles since the aberrant optical
effects induced by the bubbles may cause inaccurate
or harmful laser application. Laser instead of
cryopexy must be used in case of new retinal breaks
overlying a pre-existing scleral buckle.40,81,82,150
In recent years, transconjunctival diodepexy was
introduced as an alternative to cryopexy or laser for
inducing retinopexy.103 Similar to the latter modalities, this new technique is performed through
indirect ophthalmoscopic guidance. It possesses
certain positive qualities of both laser and cryopexy.
Similar to laser, diodepexy creates immediate visible
chorioretinal adhesions. Transconjunctival diodepexy
may also be applied through a scleral buckle for
retinal uptakes. In addition, it allows safe treatment
through subretinal fluid as in the case of cryopexy.
STERILE PREPPING
Meticulous sterile prepping of the ocular surface
and the surrounding adnexa is critical for prevention of postoperative infections. A common
antiseptic for this task is povidone-iodine.229 The
commercially available 5% povidone-iodine ophthalmic solution (Betadine 5% Sterile Ophthalmic
Prep Solution; Alcon Laboratories, Fort Worth, TX)
minimizes corneal toxicity in comparison to the
regular 10% povidone-iodine solution. However,
Tornambe and Hilton strongly favor 10% instead
of 5% Betadine for sterilization during PR (Personal
communication, Paul Tornambe, MD). The authors
favor painting the lashes and margins of the upper
and lower lids with sterile applicators soaked with
the povidone-iodine solution after application of
a few drops of the same on the globe, although this
measure is not mandatory. Excessive antiseptic
solution on the globe must be rinsed off with saline
or balanced salt solution after a few minutes to
prevent corneal toxicity and abrasion. Sterile gauzes
are used to dry the sterilized lid margins before
placement of a sterile lid speculum. Tornambe has
emphasized the importance of using closed lid
speculum to keep the eye lashes away from the
surgical instruments. In the event of a history of
prior allergic reactions to povidone-iodine, a topical
antibiotic with broad-spectrum coverage may be
substituted.
CHOICE OF SULFUR HEXAFLUORIDE,
PERFLUOROPROPANE, PERFLUOROETHANE,
AND AIR AND GAS RETRIEVAL AND INJECTION
The required size of the intraocular gas bubble
depends on the extent of the retinal breaks. In
general, a 1.0-ml bubble covering close to 3 clock
hours of the retinal surface is usually adequate.40,109,110,240 Because SF6 expands to twice its
size in 24 hours, an initial bubble size of 0.45 to 0.5 ml
is sufficient.40,110,111,240 For intraocular air, a volume
of at least 0.8 ml is required for adequate retinal
coverage.40,110,111,24 Its more rapid absorption and
lack of expansion may lead to inadequate duration
of tamponade of the retinal breaks. Nevertheless,
Carim, Kaplan, Sebag, and Waterhouse et al have
presented in separate reports the successful repair
of RD with the injection of room air for
PR.44,45,128,214,260 A volume of 0.5--1.0 ml of filtered
air was used by these investigators. The potential
disadvantage of a larger volume of the required
injected air is balanced by its quicker resolution, in
comparison to gas. However, the quicker resolution
of the injected air may not allow adequate tamponade of a large break long enough after its
treatment with cryotherapy. Poliner and Tornambe
noted that effective chorioretinal adhesion may take
7--10 days after cryotherapy, too long a duration for
a dissipating air bubble; although breaks treated
with laser may need a shorter duration of tamponade.197 Although only a small volume of perfluoropropane (C3F8) is required due to its expansion to
four times its initial size, its greater half-life in
comparison to SF6 and C2F4 may promote vitreoretinal traction for a longer duration than is desired
and delay air or mountain traveling. In 1992,
Bochow et al reported their results using C2F4 for
pneumatic retinopexy in 17 eyes.31 C2F4 possesses
certain theoretical advantages over SF6 and C3F8. A
smaller volume of C2F4 may be used in comparison
to SF6 due to its greater expansion. It also does not
persist as long as C3F8, but lasts longer than SF6 until
optimal tissue adhesion is achieved for the treated
retinal tear. But as noted previously, C2F4 has not
been approved by the FDA for clinical use in
contrast to the other two gases. In 2000, Doi and
coworkers reported thinning or disappearance of
the outer plexiform layer in the superior retina in
rabbit eyes that received C3F8, but not in rabbit eyes
that received SF6 or air.61 In addition, immunohistochemical examination showed abnormal glutamine distribution of the superior retina in rabbit
eyes injected with C3F8, SF6, or air.61 The clinical
relevance of these findings to human eyes is
unknown. For various reasons mentioned previously,
SF6 possesses sufficiently favorable characteristics
452
for PR. By default, it has become the gas of choice
for most surgeons who perform PR (see preceding
section
on
Mechanisms
and
Basic
Requirements).40,110,111,240
A small amount of gas is delivered from a highpressure gas tank through a step-down device and
via a Millipore filter into a tuberculin syringe. The
step-down device in the form of a pressure-reducing
valve or a low-pressure balloon or catheter allows the
placement of a small volume of gas into the
tuberculin syringe in a controlled fashion. The gas
drawn through a Millipore filter into a syringe can
be diluted due to infiltration with room air, if not
used in a few minutes.118 In case the filtered gas is
not injected immediately, a three-way stopcock with
its valve in the closed position may be applied to the
tip of the tuberculin syringe filled with gas, in order
to preserve its purity for a period of time.
Alternatively, Friedrichsen advocated the temporary
storage of the filtered gas in the sterile interior of
a Vacutainer (Becton Dickinson Inc., Franklin
Lakes, NJ), originally intended for storing blood
products obtained by venipuncture (personal communication, Eric Friedrichsen, MD). He has shown
by mass spectrometry that the purity of the filtered
gas stored in a Vacutainer remains undegraded for
more than 24 hours. Multiple Vacutainers filled with
the filtered gas can be safely transported during air
traveling for mission service in the third world
without the loss of the purity of the gas for a number
of days (Personal communication, Herbert Cantrill,
MD, Minneapolis, MN).
GAS INJECTION TECHNIQUE
The proper gas injection technique requires
injecting the filtered gas bubble contained in
a tuberculin syringe via a short 27- or 30-gauge
needle at 3--4 mm posterior to the limbus into the
vitreous cavity. 40,110,240 To reduce the development
of small intraocular ‘‘fish-egg’’ gas bubbles, the
surgeon should inject the gas at an upper position
of the globe, point the needle perpendicular to the
sclera and downward toward the center of the eye.
After inserting half of the needle to penetrate the
vitreous humor, the needle should be partially
withdrawn until only 1 mm of it is still in the eye.
Brisk injection of gas through the shallowly inserted
needle allows continued gas placement inside the
same single enlarging gas bubble (Fig. 3).40,110,240
The surgeon should also inject the gas away from
a large retinal break, in order to reduce the risk of
subretinal gas migration. ‘‘Fish-egg’’ bubbles have
greater tendency to enter subretinal space through
a retinal tear. Eyes with retinal tears larger than 1
clock hour or more rigid retinal tears are at greater
CHAN ET AL
Fig. 3. Injecting gas at upper position of globe with the
needle oriented perpendicular to the sclera and directed
toward the center of the globe reduces the tendency for
fish-egg formation.
risk for subretinal gas entry. Most surgeons perform
the gas injection with the patient lying in a supine
position. For some eyes, the authors found certain
advantages in performing the gas injection with
the patient in the upright position. For instance, the
upright position during gas injection reduces the
tendency for gas migration and vitreous prolapse
into the anterior chamber when encountering
elevated intraocular pressure, although this technique should be avoided in the presence of a large
retinal tear due to the risk of the formation of ‘‘fishegg’’ gas bubbles. An alternative is to perform preinjection paracentesis for eyes with substantial rise
in intraocular pressure.
STEAMROLLER MANEUVER
Yeo et al first described extension of subretinal
fluid under detached retina to an area of attached
retina following intraocular gas injection associated
with PR.274 The steamroller maneuver is designed to
prevent or minimize such an occurrence, particularly in case of potential macular involvement with
the migrating subretinal fluid.40,110,240 Other situations that indicate this maneuver include: 40,110,240
1) avoidance of iatrogenic detachment of attached
retinal breaks; 2) obstruction of appropriate viewing
of critical posterior retinal structures by a bullous
RD; 3) difficult treatment of retinal breaks due to
excessive subretinal fluid under a bullous RD; 4) fish
mouthing or enlargement of a retinal tear caused by
excessive subretinal fluid, complicating its treat-
ment; 5) the need to move subretinal fluid from the
macula in the presence of delayed subretinal fluid
absorption; and 6) the requirement to flatten
a retinal tear against the RPE in the presence of
multiple small bubbles to prevent their subretinal
migration.
Fig. 4 illustrates details of the steamroller technique and clarifies its mechanisms. The patient’s
immediate assumption of the head prone position
after gas bubble injection constitutes the first step of
this maneuver, promptly placing the injected gas on
the macula and minimizing subretinal fluid collection under the posterior retina. As the patient’s
head is slowly elevated over the next 10 to 15
minutes, the subretinal fluid is gradually pushed by
the gas bubbles from the posterior to the superior
fundus, away from the macula, and out through the
superior retinal breaks into the vitreous cavity.
During this process, the retina is gradually flattened
from the posterior to the superior direction. When
the patient’s head finally reaches the upright
position, the gas bubbles are positioned against
the uppermost fundus, re-apposing the retinal
breaks to the underlying RPE, thus simplifying their
subsequent treatment with cryotherapy or laser.
One theoretical risk of the steamroller technique is
the potential release of pigment cells from the
subretinal space into the vitreous cavity.96,101 Thus
the performance of this maneuver after extensive
cryotherapy of retinal breaks runs the risk of excessive
collection of RPE cells in the vitreous cavity and
subretinal fluid, capable of creating unwanted periretinal fibrocellular proliferation and even proliferative vitreoretinopathy (PVR).43,96,101 Tornambe et al
Fig. 4. Steamroller maneuver consists of gradual elevation of head from the prone position after gas injection.
453
advocated the judicious use of the steam roller
maneuver, and the application of cryopexy or laser
after retinal flattening to decrease the chance of
excessive pigment cell release into the vitreous
cavity.240,247,248 They noted that the steamroller
maneuver was utilized in 18% of eyes in the
Pneumatic Retinopexy Clinical Trial. For all those
eyes, cryopexy was applied after the steamroller
maneuver. None of those eyes developed PVR or
visually significant macular pucker.248 In a prospective
study of PR involving 40 eyes with primary RD,271
Yanyali et al reported in 2007 no statistically significant differences in efficacy and safety for 21 eyes
treated with steamroller technique versus 19 eyes
treated with the basic technique. Only one eye (5%)
in each group developed PVR.
THE ROLE AND TIMING OF PARACENTESIS AND
POSTOPERATIVE INTRAOCULAR PRESSURE
MANAGEMENT
Due to its lower tendency for underestimating the
intraocular pressure of a gas-filled eye, applanation
tonometry (including the Tono-Pen [Medtronic,
Inc, Minneapolis, MN]) is preferred for the monitoring of the intraocular pressure after gas injection.153,196 Schiötz tonometry will provide falsely
low IOP readings.12,182
Mild to moderate intraocular pressure rise after
intraocular gas injection is well tolerated by most
eyes without special treatment, as long as perfusion
of the central retinal artery is not compromised at
the end of surgery.40,240 However, corrective measures for elevated intraocular pressure should be
considered for eyes with significant glaucoma or
those at risk for deficient arterial perfusion after
surgery. Simple treatment may include application
of topical and oral hypotensive agents.40,240 However, additional measures may be taken if necessary.
Many surgeons avoid the performance of a paracentesis during PR due to reports in the literature
suggesting increased risk of endophthalmitis associated with paracentesis in general.11,108,125 However,
there is a lack of reports specifically associating
paracentesis during PR with increased incidence of
endophhalmitis or other complications. Complications such as hyphema, iris prolapse, and corneal
endothelial and lens damages may be routinely
avoided when proper paracentesis technique is
utilized. The authors favor the performance of
paracentesis prior to gas injection for the following
reasons: 1) reduced tendency for vitreous displacement into the anterior chamber due to sudden
decompression of the globe; 2) decreased propensity of reflux of gas from the vitreous cavity to
the subconjunctival space; and 3) lower chance of
454
corneal or scleral wound dehiscence. A paracentesis
may also be required after gas injection, if excessive
intraocular pressure is not lowered, and central
retinal artery pulsation persists beyond a few
minutes.
The usual method of paracentesis involves passive
egress of aqueous humor through a 25- or 27- gauge
needle connected to a tuberculin syringe without its
plunger via the limbus. Pars plana paracentesis is
performed on a less frequent basis due to greater
risk of vitreous incarceration into the syringe. To
decrease the latter complication, the plunger of the
syringe is left in place for pars plana paracentesis.
The needle is directed through the pupil, around an
intraocular implant, or through the iris into the
anterior chamber with the pars plana approach. The
following conditions may indicate pars plana instead
of limbal paracentesis: 1) shallow anterior chamber;
2) pre-existing vitreous herniation into the anterior
chamber; 3) pre-existing corneal endothelial decompensation; and 3) presence of an iris-fixated or
anterior chamber implant at risk of contact with the
corneal endothelium.40,110,111,240 The Josephberg
1-port vitrectomy biopsy cutter (Visitec portable
vitrector; Becton Dickinson, Inc, Franklin Lakes, NJ)
allows safe and effective vitreous removal to make
room for a sizable volume of intraocular gas
injection with the patient sitting in an upright
position at the slit lamp in the office setting. This
device can be considered if a large volume of gas
injection is required. The Intrector (Insight Instruments Inc., Stuart, FL) is the latest 23-gauge
version of this device.
Due to the risk of harmful vitreoretinal traction,
a vitreous tap via the pars plana is rarely necessary,
and reserved for inadequate lowering of excessive
intraocular pressure following aqueous paracentesis
alone in eyes with liquefied vitreous. Sufficient
liquid vitreous is usually present in a highly myopic
or syneretic eye for such a maneuver to be safely
performed.40,110,111,240 The sequential injection of
two smaller bubbles to achieve a larger intraocular
gas volume may avoid acute intraocular rise and the
need of a paracentesis.
FREQUENCY AND TIMING OF POSTOPERATIVE
VISITS AND POSTOPERATIVE CARE
After applying topical antibiotic-steroid and cycloplegic medications, the operated eye is patched.
Drawing an arrow on the outer surface of the eye
patch corresponding to the axis of the retinal breaks
is a useful means of reminding the patient of the
appropriate head tilt for the required postoperative
period.40,110 The patient is encouraged to check the
proper orientation of the arrow pointing at the
CHAN ET AL
ceiling by looking into a mirror from time to time.
An alternative is the application of the Tornambe
leveler(Escalon Medical Corp., New Berlin, WI),
a reliable device that reminds the patient of the
proper head posture after surgery. Previous reports
advocated maintaining the correct head posture for
at least 5 days.40,110,111,240 Three days of proper head
positioning may be sufficient for some eyes.110
However, we ask our patients to maintain the proper
head positioning for at least a week to achieve the
best outcome, considering the published data of 7
to 14 days for formation of a scar with the optimal
tensile strength after retinopexy.133,142,197,272 The
authors usually allow the patient to take a break
from the required head tilt for 15 minutes every
hour during this period. However, the patient is
reminded not to assume a supine position that may
lead to any contact between the intraocular gas
bubbles and the lens and shallowing of the anterior
chamber.40,110,111 Close monitoring of the operated
eye after surgery is required to ensure optimal
improvement and minimal complications. The
authors favor examining the patient the day after
surgery, 1 week later, 2--3 weeks later, and every
month thereafter for the next few months. More
frequent examinations may be required for some
cases. In case of laser therapy for induction of
retinopexy, it should be applied as soon as the
retinal breaks are flattened by the gas bubbles. This
is usually performed 24--48 hours after gas injection.
Most of the subretinal fluid absorbs within 72 hours
after closure of the retinal breaks.40,110,111,240
Surgical Outcome
ANATOMICAL AND VISUAL OUTCOMES
In the retrospective review of their first 100 cases
of PR performed by multiple clinical centers, Hilton
et al reported an initial 91% reattachment rate, and
a 6-month single-operation success of 84%.112
Fourteen (14) of the 16 failures were successfully
repaired with subsequent SBP, resulting in a final
98% rate of retinal reattachment with multiple
operations. For eyes with pre-operative macular
detachment, 65% achieved 20/20 to 20/50 visual
outcome. For eyes with extramacular detachment,
86% accomplished stable or improved vision after
surgery. They emphasized that the advantages
offered by PR include reduced tissue trauma, fewer
complications, no hospitalization, and lower expenses. In a subsequent report of more complex RD
with retinal characteristics exceeding the basic
criteria for PR (multiple breaks in multiple quadrants, breaks exceeding 1 clock hour, and PVR C1 or
C2), Tornambe et al reported single-operation
successes of 75%.249 Phakic eyes fared better than
aphakic or pseudophakic eyes. Eighteen percent of
phakic eyes failed, whereas 38% of aphakic and
pseudophakic eyes failed. Eight eyes that failed were
successfully reattached with additional surgery (five
with SBP and three with vitrectomy). Vision was
improved in 75%, unchanged in 17%, and worse in
8% after surgery. Visual improvement was achieved
in 58% of macula-on RD, and 79% of macula-off RD.
Whereas 23% of eyes had a VA of 20/40 or better
before surgery, 48% of eyes achieved a final VA of
20/40 or better after surgery. Despite their favorable
results, others reported less successful outcome. In
a series of 51 consecutive eyes, Chen et al reported
a single-operation success of 63%, and the results
were much better for phakic eyes (74%) than
nonphakic eyes (41%).51 For their eyes with
macula-on RD, the vision was stabilized or improved
in 71%, and decreased in 4%. For their macula-off
RD, a VA of 20/20 to 20/50 was achieved in 52 % of
eyes.
To overcome confounding variables inherent in
a retrospective study, Tornambe and Hilton organized the Retinal Detachment Study Group to
prospectively compare the results of PR with scleral
buckling.243 SBP was performed for 95 eyes, and PR
was performed for 103 eyes. They reported singleoperation successes of 82% for SBP eyes versus 73%
for pneumatic retinopexy eyes. The difference was
not statistically significant. With reoperations, 98%
of SBP eyes, and 99% of PR eyes achieved retinal
reattachment. Phakic eyes did better than nonphakic eyes for both groups. Single-operation
successes were found in 90% of phakic eyes that
underwent SBP, and 75% of phakic eyes that
underwent PR, whereas 73% of nonphakic eyes
after SBP and 67% of nonphakic eyes after PR
achieved the same. Regarding the visual outcome,
those eyes with a duration of macular detachment of
14 days or less, postoperative VA of 20/50 or better
at 6 months was achieved in 80% of the PR eyes, but
only 56% of the SBP eyes (p 5 0.01). For eyes with
macular detachment of 7 days or less, post-operative
VA of 20/50 or better at six months was attained in
83% of the PR eyes and 62% of the SBP eyes (p 5
0.01).243 For eyes with a duration of macular
detachment of 3 days or less, postoperative VA of
20/50 or better at 6 months was achieved in 91% of
PR eyes and 64% of SBP eyes (p 5 0.05). Despite no
statistical differences in preoperative VA, restoration
of VA was more rapid after PR. And despite lower
single-operation successes with PR, the final anatomic and visual outcomes of PR eyes were not
disadvantaged by the initial PR for this study. In
a consecutive series of 101 eyes with simple primary
RD that underwent PR, Ambler et al reported 77%
single-operation successes.8 Their phakic eyes and
455
those nonphakic eyes with an intact posterior
capsule had an 84% success rate in comparison to
a 56% success rate for their nonphakic eyes with an
opened capsule. Their analysis of eyes that initially
failed with PR showed that the final visual outcome
was not adversely affected by PR. Retinal reattachment was eventually accomplished with multiple
procedures for all 23 eyes that experienced initial
failure after PR. The two-year study of the multicenter PR clinical trial showed continued visual
improvement over the long term, so that 94% of
eyes with macula-on RD, and 90% of eyes with
macula-off RD achieved VA of 20/50 or better after
2 years; thus, implying the importance of more than
1 year of follow-up.248 In their summary of 1,274
eyes in 26 published reports on PR performed
between 1986 and 1989, Hilton et al found singleoperation successes for PR to be ranging from 53%
to 100%, with the average at 80%.40,114,240 There was
one study involving only 4four eyes that reported
a 100% success rate for PR in that series. They also
reported final success rates ranging from 92--100%
with the average at 98% after PR in their summary.40,114,240 In 1995, Grizzard et al performed
retrospective analyses on 107 consecutive eyes that
underwent PR in their practice together with
a literature review of 25 statistical series on PR with
primary attention to failures.97,98 They performed
univariate and multivariate analyses and calculated
odds ratios for risk factors using logistic regression.
They reported 69% single successes, and 98% final
successes. Missed breaks were found in 14.9% eyes,
reopened breaks in 11.2% of eyes, and unclosed
breaks in 4.6% of eyes. Risk factors correlating with
failure included male sex (adjusted odds ratio [OR]
5 2.65), eyes with preoperative visual acuity worse
than 20/50 (adjusted OR 5 1.21), eyes with four
quadrants of RD or total RD (adjusted OR 5 2.03),
aphakic or pseudophakic eyes (adjusted OR 5
1.91), and eyes with additional pathologic findings
(adjusted OR 5 3.14). In their series, poor visual
outcome was associated with initial visual acuity of
less than 20/50 (adjusted OR 5 15.7), and eyes with
four quadrants of RD or total RD (adjusted OR 5
5.01). In 2007, Kulkarni et al140 also found a greater
tendency for males than females to develop recurrent RD after PR (32% versus 15.3%, p 5 0.07).
Both Grizzard and Kulkarni advocated better
patient education in proper head tilt positioning
for patients undergoing PR that might correct the
discrepancy in success rates between males and
females.98,140 With proper instruction for strict
posture compliance, even teenagers with RD may
respond well to PR, as reported by Chen and Hwang
in 2007.52 In 1997, Tornambe retrospectively analyzed the characteristics and results of his series of
456
302 eyes that underwent PR. 241 He found a singleoperation success of 68% for all cases, and final
success of 95% after additional surgery. When cases
fitting the PR multicenter clinical trial (PRCT)
criteria were selected and staged supplemental
360-degree retinopexy was performed, the single
operation success rate was raised to 85%.241 However, detractors of PR have criticized the low initial
success rate of only 55% for eyes undergoing focal
retinopexy during PR for that series in comparison
to other series, and they also pointed out the lack of
a prospective study to confirm the efficacy of 360degree retinopexy for PR. In that series, 86% of eyes
reattached with single PR procedure achieved visual
acuity (VA) $20/40, whereas only 52% of eyes that
underwent multiple procedures achieved the same.
For macula-on RD, 85% achieved VA $20/40, but
only 66% macula-off RD achieved the same. For eyes
with macular detachment within 7 days, 73%
recovered VA $20/40.
In a subsequent retrospective study in 1998, Han
and coworkers reported less favorable outcome for
PR in their comparison of 50 eyes that underwent
SBP with 50 eyes that underwent PR.104,105 Singleoperation successes were significantly higher for
SBP eyes (84%) in comparison to PR eyes (62%),
(p # 0.01). They found reoperation rates to be
significantly higher for PR eyes (38%) in comparison to SBP eyes (14%), (p # 0.01). They used
multivariate analysis with logistical regression to
show that PR was the sole factor predictive of retinal
detachment after a single procedure. However, they
reported final retinal reattachment rate to be similar
for both groups (98%), consistent with previous
studies. They also found the final VA and rates of
PVR to be similar for phakic eyes that underwent PR
in comparison to eyes that underwent SBP. However,
nonphakic eyes that underwent PR had a higher
rate of single-operation failure, a higher rate of PVR
(p # 0.05), and worse visual outcome in comparison
to phakic eyes that underwent PR and phakic eyes
that underwent SBP (p # 0.01). Tornambe criticized
Han for lumping macula-on and macula-off RD
together in his visual analysis, despite more maculaon eyes in the SBP group (48%) in contrast to the
PR group (36%), possibly biasing the latter group in
the visual analysis. He also questioned the familiarity
of the surgeons to PR in Han’s series, because many
of them contributed only a few cases each to the
series.250 Han replied that the regression analysis
utilized for the visual analysis had already adjusted
for the baseline visual acuity, macular status, and
other factors related to vision. Subsequent stratification of their eyes with RD according to macular
status and pre-operative vision as suggested by
Tornambe showed no significant differences in the
CHAN ET AL
visual outcome between SBP and PR eyes.104 Han
also contended that surgical experience did not
influence the outcome in their series, because the
anatomic success rate was similar for the four
surgeons who performed 88% of the PR cases versus
the five surgeons who performed the remaining
procedures.104,105,250
Table 2 summarizes the surgical outcomes of
published reports of PR involving nine or more eyes
for the repair of RD found in the world literature
from 1986 to 2006.3,5,6,8,15,19,21,25,27,31,32,34,37--40,44,46,
47,49,51,52,62--66,68,69,71--75,77--82,89,95,97,98,100,104,105,111,
112,121,128,129,132,134,137,140,141,143,144,148,150,152,159,162,
164,166,167,168,169,172,175,178--181,185,191--194,200,202,209,214,
216,220,225,234,235,241--243,248,249,251,252,257,259,261,271,273,
275--278.
This series includes 4,138 eyes among 81
reports from the world literature. The average single
operation success was 74.4%, and the average final
surgical success was 96.1%. There was an average of
11.7% of missed or new breaks, and 5.2% of
proliferative vitreoretinopathy. Table 3 summarizes
the visual outcomes of the same series found in the
same 81 reports throughout this 21-year period,
which varied from surgeon to surgeon. Although
such a retrospective review summarizing a large
number of clinical series consisting of dissimilar
numbers of patients performed by multiple surgeons of diverse experience with PR in vastly
different settings likely introduces multiple confounding variables (e.g., inconsistent and incongruous reports of visual outcome) that are difficult to
control, it provides an accurate collective overview
of PR on the world stage over the past two decades.
Nevertheless, caution should be exercised when
interpreting the results of many of these reports due
their uncontrolled nature and small numbers of
study subjects. The places of origin of these 81
reports include the following: West Coast USA (18),
Midwest USA (9), East Coast USA (3), Western
Europe (30), Eastern Europe (8), Asia (10), South
America (1), Africa (1), and Middle East (1).
COST ANALYSIS FOR PNEUMATIC RETINOPEXY
VERSUS SCLERAL BUCKLING
Hilton et al and Tornambe et al have repeatedly
emphasized the cost-effectiveness of PR in comparison to scleral buckling and vitrectomy for repairing
RD in multiple reports.40,110,240,241,243,248 In his
retrospective review of 302 cases, Tornambe calculated that the average total cost of PR and subsequent reoperations for the entire series was 59%
in comparison to SBP as the first procedure and
subsequent reoperations. When the same comparison was made for selected cases of PR fitting
the PR clinical trial criteria that underwent staged
Surgical Outcome (1986 to 2007)
Single Operation
Success (SOS)
Author
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
Dominguez (1986)
Hilton (1986)
Dominquez(1987)
Gnad(1987)
Hilton (1987)
Lemmen (1987)
Menchini (1987)
Van Effenterre (1987)
Algvere (1988)
Bovey(1988)
Chen (1988)
Lowe (1988)
McAllister (1988)
Menchini (1988)
Mortensen (1988)
Tornambe(1988)
Tornambe(1988)
Binder (1989)
Brinton(1989)
Chan (1989)
Friberg(1989)
Kelly (1989)
Kusuki(1989)*
Lemmen (1989)
Liggett(1989)
Miyakawa(1989)
Dos Santo Motta (1989)
Packo(1989)
Poliner(1989)
Rashed (1989)
Sato (1989)
Sato (1989)*
Termote(1989)
Terubayashi (1989)
Vygantas (1989)
Zakka (1989)
Zegarra(1989)
Skoog (1989)
Location
4
Madrid, Spain
Oakland, California1
Madrid, Spain4
Vienna, Austria4
Cologne, Germany4
Udine, Italy4
Paris, France4
Stockholm, Sweden4
Lausanne, Switzerland4
Portland, Oregon1
San Francisco, California1
Cleveland, Ohio2
Udine, Italy4
Odense, Denmark4
Poway, California1
Poway, California1
Vienna, Austria4
Loma Linda, California1
Pittsburq, Pennsylvania2
Sacramento, California1
Nagasaki, Japan6
Cologne, Germany4
Los Angeles, California1
Tokai, Japan6
Rio de Janeiro, Brazil7
Chicago, Illinois2
Poway, California1
Cairo, Eqypt8
Niigata, Japan6
Niigata, Japan6
Brussels, Belgium4
Kyoto, Japan6
Des Plaines, Illinois2
Cleveland, Ohio2
Linköping, Sweden4
Finals Success
New Breaks
No. Eyes
No. Eyes
%
No. Eyes
%
No. Eyes
31
20
43
27
100
62
36
60
58
27
51
55
56
9
12
34
40
37
70
38
14
268
12
54
30
23
21
33
39
10
30
12
20
31
12
20
56
52
29
18
40
24
84
53
31
51
49
18
32
45
40
7
10
28
30
28
57
30
12
217
7
27
16
17
16
27
24
8
19
7
17
25
8
16
40
41
93.55
90.00
93.02
88.89
84.00
85.48
86.11
85.00
84.48
66.67
62.75
81.82
71.43
77.78
83.33
82.35
75.00
75.68
81.43
78.95
85.71
80.97
58.33
50.00
53.33
73.91
76.19
81.82
61.54
80.00
63.33
58.33
85.00
80.65
66.67
80.00
71.43
78.85
30
20
42
27
98
56
N/A
59
55
27
N/A
54
56
N/A
11
33
38
37
68
38
14
265
10
50
N/A
23
21
33
37
10
29
11
19
31
11
19
56
47
96.77
100.00
97.67
100.00
98.00
90.32’
N/A
98.33
94.83
100.00
N/A
98.18
l00.00
N/A
91.67
97.06
95.00
l00.00
97.14
l00.00
100.00
98.88
83.33
92.59
N/A
100.00
100.00
100.00
94.87
100.00
96.67
91.67
95.00
100.00
91.67
95.00
100.00
90.38
N/A
2
2
1
7
11
0
4
7
8
11
6
11
N/A
N/A
4
5
5
11
5
N/A
N/A
0
12
2
2
N/A
9
3
0
2
0
3
4
N/A
2
9
N/A
%
N/A
10.00
4.65
3.70
7.00
17.74
0.00
6.67
12.07
29.63
21.57
10.91
19.64
N/A
N/A
11.76
12.50
13.51
15.71
13.16
N/A
N/A
0.00
22.22
6.67
8.70
N/A
27.27
7.69
0.00
6.67
0.00
15.00
12.90
N/A
10.00
16.07
N/A
PVR
No. Eyes
%
N/A
1
1
0
3
3
0
1
6
2
5
3
1
N/A
1
3
4
3
3
0
0
N/A
0
3
1
2
N/A
0
6
0
1
0
1
2
N/A
1
1
4
N/A
5.00
2.33
0.00
3.00
4.84
0.00
1.67
10.34
7.41
9.80
5.45
1.79
N/A
8.33
8.82
10.00
8.11
4.29
0.00
0.00
N/A
0.00
5.56
3.33
8.70
N/A
0.00
15.38
0.00
3.33
0.00
5.00
6.45
N/A
5.00
1.79
7.69
457
(Continued)
TABLE 2
458
TABLE 2
Continued
Author
Tornambe (1989)
Ambler (1990)
Berrod (1990)
La Torre (1990)*
Morin (1990)
Pecold (1990)
Santillo (1990)*
Balestrazzi (1991)
Emi (1991)
Foscosi(1991)
Pecold (1991)
Tornambe (1991)
Wedrich(1991)
Algvere(1992)
Bochow(1992)
Pavlovic(1992)
Freyler(1993)
Sebag(1993)
Trillo (1993)
Grizzard (1995)
Carstocea(1995)
Gribomont(1996)
Mulvihill (1996)
Kishimoto(1997)
Tornambe (1997)
Sharma (1997)
Fiser(1998)
Han (1998)
Lisle (1998)
Assi (1999)
Snady-McCoy(1999)
Abecia (2000)
Eter (2000)
Friberg (2000)
Kovacevic (2001)
Kleinmann (2002)
Böhm (2003)
Chanq (2003)
Yospaiboon (2005)
Zaidi (2006)
1
Poway, California
Cleveland, Ohio2
Nancy, France4
Florence, Italy4
Marseille, France4
Poznan, Poland5
Rome, Italy4
Roma, Italy4
Sakai, Japan6
Rome, Italy4
Poznan, Poland5
Poway, California1
Vienna, Austria4
Stockholm, Sweden4
St. Louis, Missouri2
Belgrade, Serbia5
Vienna, Austria4
Huntington Beach, California1
Genoa, Italy4
Tampa, Florida3
Bucarest, Romania5
Brussels, Belgium4
Dublin, Ireland4
Osaka, Japan6
Poway, California1
Madras, India6
Prague, Czekoslovakia5
Milwaukee, Wisconsin2
Odense, Denmark4
London, England4
Providence, Rhode Island3
Zaragoza, Spain4
Bonn, Germany4
Pittsburq, Pennsylvania2
Rijeka, Croatia5
Rehovot, Israel9
Bratislava, Slovakia5
Khon Kaen, Thailand6
San Francisco, California1
No. Eyes
103
101
56
23
29
35
29
9
54
37
40
93
24
51
17
46
89
45
55
107
16
63
10
67
302
36
13
50
36
31
32
219
78
40
28
44
30
11
116
61
No. Eyes
75
78
37
17
26
29
17
6
38
30
32
N/A
17
44
12
27
65
38
46
74
7
49
7
30
205
25
11
31
30
19
19
179
51
36
22
33
23
9
76
33
New Breaks
PVR
%
No. Eyes
%
No. Eyes
%
No. Eyes
%
72.82
77.23
66.07
73.91
89.66
82.86
58.62
66.67
70.37
81.08
80.00
N/A
70.83
86.27
70.59
58.70
73.03
84.44
83.64
69.16
43.75
77.78
70.00
44.78
67.88
69.44
84.62
62.00
83.33
61.29
59.38
81.74
65.38
90.00
78.57
75.00
76.67
81.82
65.52%
54.10
102
101
N/A
N/A
N/A
32
N/A
9
53
37
35
93
24
50
17
45
89
45
53
105
7
63
9
62
286
33
13
49
35
26
32
215
77
40
N/A
42
28
11
107
61
99.03
100.00
N/A
N/A
N/A
91.43
N/A
100.00
98.15
100.00
87.50
100.00
100.00
98.04
100.00
97.83
100.00
100.00
96.36
98.13
43.75
100.00
90.00
92.54
94.70
91.67
100.00
98.00
97.22
83.87
100.00
98.17
98.72
100.00
N/A
95.45
93.33
100.00
92.24
100.00
24
11
10
0
N/A
0
N/A
1
2
5
2
N/A
1
3
3
N/A
24
4
9
16
N/A
11
1
N/A
99
0
1
N/A
5
7
N/A
18
4
5
3
2
N/A
0
N/A
13
23.30
10.89
17.86
0.00
N/A
0.00
N/A
11.11
3.70
13.51
5.00
N/A
4.17
5.88
17.65
N/A
26.97
8.89
16.36
14.95
N/A
17.46
10.00
N/A
32.78
0.00
7.69
N/A
13.89
22.58
N/A
8.22
5.13
12.50
10.71
4.55
N/A
0.00
N/A
21.31%
3
1
9
0
2
4
2
0
0
1
0
N/A
2
1
2
N/A
4
1
2
5
0
8
2
N/A
29
1
1
6
1
4
0
8
4
0
3
6
N/A
1
N/A
0
2.91
0.99
16.07
0.00
6.90
11.43
6.90
0.00
0.00
2.70
0.00
N/A
8.33
1.96
11.76
N/A
4.49
2.22
3.64
4.67
0.00
12.70
20.00
N/A
9.60
2.78
7.69
12.00
2.78
12.90
0.00
3.65
5.13
0.00
10.71
13.64
N/A
9.09
N/A
0.00
CHAN ET AL
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
Location
Finals Success
Single Operation
Success (SOS)
459
5.2
360-degree retinopexy, the average cost was as little
as 28% of cases undergoing SBP first.241
EVIDENCE-BASED ANALYSIS OF PNEUMATIC
RETINOPEXY VERSUS SCLERAL BUCKLING
11.7
Sharma and Robbins used utility analysis methodology to analyze the quality of life associated with
PR versus SBP, in order to compare the costeffectiveness of the two procedures.218 Using the
Markov model and a Monte Carlo simulation, they
found PR confers an improvement of 1.86 qualityadjusted life months (QALMs), a 7.4% increase in
comparison to SBP during a 3-year period. Thus,
their calculations based on combining all VA
outcomes and clinical complications from the PR
multicenter clinical trial into a single analysis
determined that PR is the preferred treatment
method over SBP.
96.1
19
148
40
3728
51.8
100.00
98.67
100.00
2
26
4
464
7.4
10.50
17.30
21.00
0
5
2
182
2.6
0.00
3.30
5.00
Complications and Their Management
74.4
Minimum of 9 eyes per series for inclusion; N/A5not available.
*Series involving macular holes
1
Western US(18)
2
Midwest US (9)
3
East Coast US (3)
4
Western Europe (30)
5
Eastern Europe (8)
6
Asia (10)
7
South America (1)
8
Africa(1)
9
Middle East (1).
79
80
81
Chen (2007)
Kulkarni (2007)
Yanyali (2007)
Chang-hua, Taiwan6
New Brunswick, New Jersey3
Istanbul, Turkey5
Total
Average
19
150
40
4138
16
115
25
3010
37.6
84.21
76.67
70.00
NEW OR MISSED BREAKS AND SURGICAL FAILURE
In their survey of 26 reports with 1,274 patients that
underwent pneumatic retinopexy, Brinton and Hilton reported a 13% incidence of new or missed
retinal breaks.40,242,243 Some investigators have attempted to differentiate between ‘‘new’’ from
‘‘missed’’ retinal breaks.40,76,114,195,241 According to
their definition, retinal breaks found in area of
previous RD during repeat surgery not detected
during the initial PR constitute ‘‘missed’’ breaks.
However, breaks located in an area of new retinal
detachment distant from the original breaks are
considered ‘‘new’’ breaks. In a retrospective review of
13 cases, Poliner et al reported two cases of new breaks
associated with extension of the RD to previously
uninvolved quadrants within two days after PR.195
They ascribed the early new retinal breaks and RD to
traction on condensed vitreous distal to the sites of
the original breaks following intraocular gas injection. In 1988, Chen et al reported new breaks
occurring in 11 of 31 eyes (21%) after PR.51 In
1989, Tornambe et al also reported 23% new or
missed breaks for the PR eyes in contrast to 13% of
this complication for SBP eyes in their multicenter PR
study.243 Tornambe’s subsequent study of 302 eyes
reported 14% missed breaks and 19% new breaks.241
These rates are in contrast to the historical rates of
1.8% to 20.8% after non-pneumatic retinopexy
techniques for repairing retinal breaks and retinal
detachment in previous reports.26,35,55,57,83,94,97,
157,158,199,204,219,222,266
New or missed breaks may
develop in any quadrants. However, 76% are located
in the superior 8 clock hours of the retina, and 52%
are found within 3 clock hours of the original
460
TABLE 3
Visual Outcome (1986 to 2007)
Authors
1
2
Dominquez (1986)
Hilton (1986)
No. Eyes
51
55
35% $ 20/50
54.8% $ 20/50
71% $ Pre-op
N/A
McAllister (1988)
Menchini (1988)
Morternsen (1988)
56
9
12
69% $ 20/50
N/A
N/A
25% $ Pre-op
N/A
N/A
16
17
18
19
20
Tornambe (1988)
Tornambe (1988)
Binder (1989)
Brinton (1989)
Chan (1989)
34
40
37
70
38
N/A
79% $ Pre-op
N/A
N/A
N/A
N/A
58% $ Pre-op
N/A
N/A
N/A
21
22
23
Friberg (1989)
Kelly (1989)
Kusuki (1989)*
14
268
12
N/A
N/A
N/A
N/A
N/A
N/A
24
Lemmen (1989)
54
25
26
27
Liggett (1989)
Miyakawa (1989)
Motta (1989)
30
23
21
28.0% Post-op VA
$ 20/50: 92% O Pre-op
N/A
80% $ 20/50
N/A
87.1% $ 20/50; 41.9%
$ Pre-OP; 29% O Pre-op
N/A
61.5% $ 20/50
N/A
28
29
Packo (1989)
Poliner (1989)
33
39
N/A
N/A
N/A
N/A
11
12
Chen (1988)
Lowe (1988)
13
14
15
43
27
100
62
36
60
58
27
Other Categorization
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Post-op VA O Pre-op VA 74.1 %;
Post-op VA 5 Pre-op VA 14.8 %;
Post-op VA ! Pre-op VA 11.1 %
N/A
83.6% O Pre-op VA; 10.9% 5 Pre-op;
5.5% # Pre-op
N/A
Post-op VA O Pre-op VA 5 100%
Post-op O Pre-op VA 5 83.3%;
Post-op VA $ 20/40 5 66.7%;
Post-op VA $ 20/120 5 16.7%
N/A
N/A
N/A
N/A
(SOS) Median VA 5 20/30;
(Re-op) Median VA 5 20/70
N/A
N/A
66.67% O Pre-op VA; 16:67% 5 Pre-op VA;
16.67% ! Pre-op
N/A
N/A
65.2% $ 20/50 for entire series
All SOS eyes final VA $ Pre-op;
5 Re-op eyes final VA: 2 $ Pre-op;
3 ! Pre-op
N/A
N/A
CHAN ET AL
N/A
N/A
RD, 65% $ 20/50
N/A
N/A
60% $ 20/40
74%, VA O 20/50
N/A
Dominguez (1987)
Gnad (1987)
Hilton (1987)
Lemmen (1987)
Menchini (1987)
Van Effenterre (1987)
Algvere (1988)
Bovey (1988)
N/A
50% $ 20/70; 50% $ 20/200
Macula-on
N/A
50% Post-op VA unchanged;
20% Post-op VA improved 2
or 3 lines
N/A
N/A
RD, 41% $ Pre-op VA
N/A
N/A
20/100 # 60% # 20/40
N/A
N/A
3
4
5
6
7
8
9
10
31
20
Macula-off
Visual Outcome
Rashed (1989)
Sato (1989)
Sato (1989)*
Termote (1989)
Terubayashi (1989)
Vygantas (1989)
Zakka (1989)
Zegarra (1989)
Skoog (1989)
Tornambe (1989)
10
30
12
20
31
12
20
56
52
103
40
41
42
43
44
45
46
47
48
49
50
51
52
53
Ambler (1990)
Berrod (1990)
La Torre (1990)*
Morin (1990)
Pecold (1990)
Santillo (1990)*
Balestrazzi (1991)
Emi (1991)
Foscosi(1991)
Pecold (1991)
Tornambe (1991)
Wedrich
Algvere(1992)
Bochow (1992)
101
56
23
29
35
29
9
54
37
40
93
24
51
17
54
55
56
Pavlovic (1992)
Freyler (1993)
Sebag (1993)
46
89
45
57
58
Trillo (1993)
Grizzard (1995)
55
107
59
60
61
Carstocea (1995)
Gribomont (1996)
Mulvihill (1996)
62
63
64
Kishimoto (1997)
Tornambe (1997)
Sharma (1997)
16
63
10
N/A
302
36
N/A
N/A
N/A
80% $ 20/50
N/A
N/A
N/A
N/A
N/A
(#14days)80%$ 20/50;
(#3 days) 91% $ 20/50
66% O 20/50
N/A
N/A
N/A
N/A
N/A
N/A
72.7% $ 20/50
N/A
N/A
(#14 days) 89% $ 20/50
28.5%: 20/50-20/100; 43% $ 20/40
65% $ 20/40
87.5% VA OPre-op; VA 2 or O lines
N/A
N/A
N/A
Macular hole series; Final VA 20/60 to 20/240
N/A
N/A
N/A
N/A
N/A
N/A
N/A
97% O Pre-op VA
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
66.7% O 20/40; 88.9% O Pre-op VA
46% O 20/22
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
85 % O 20/50
N/A
N/A
N/A
N/A
N/A
N/A
87% O 20/50
N/A
N/A
94% $ 20/40
90%: 20/25-20/20
N/A
77.8% 5 Pre-op VA;
22.2% O Pre-op VA
N/A
N/A
N/A
Post-op O Pre-op VA
N/A
Pre-op 5 Post-op VA
N/A
N/A
N/A
N/A
N/A
91.5% $ Pre-op VA
N/A
N/A
66% $ 20/40
N/A
N/A
85% $ 20/40
N/A
30
31
32
33
34
35
36
37
38
39
Post-op VA $ 20/50 5 56.5%
Post-op VA $ 20/40 5 57.3%
Post-op VA O Pre-op 2 lines or more 66.7%;
Post-op VA 5 Pre-op VA 31.1%;
Post-op VA ! Pre-op VA 2.2%
N/A
73.9% $ 20/30; VA # 20/400 for 9.45%
SOS, 27.3% Re-op (P #0.05); age: negative
correlation to VA (r 5 "0.37, P # 0.001); þ
correlation for Pre-op & Post-op VA (r 5
0.5, P #0.001).
N/A
95%$ Pre-op VA: 92% $ 20/50
80% Post-op VA O Pre-op VA;
20% Post-op VA ! Pre-op VA
N/A
N/A
Post-op VA $ 20/60 5 47.2%;Successful eyes:
Post-op VA $ Pre-op 5 66.7%
461
(Continued)
462
TABLE 3
Continued
Visual Outcome
No. Eyes
65
Fiser (1998)
13
66
67
68
69
70
71
Han (1998)
Lisle (1998)
Assi (1999)
Snady-McCoy (1999)
Abecia (2000)
Eter (2000)
72
73
74
75
76
Friberg (2000)
Kovacevic (2001)
Kleinmann (2002)
Böhm (2003)
Chang(2003)
40
28
44
30
11
77
Yospaiboon(2005)
78
Macula-off
Macula-on
Single eye 5 20/67
91.7% (11/12 eyes) $ 20/40
47% $ 20/50
65% $ 20/50
45 % $ 20/40
90% $ 20/50
33.3% $ 20/40
(SOS) Mean VA 5 20/35;
(Re-op) Mean VA 5 20/56
N/A
N/A
N/A
66.7% $ 20/50
N/A
76% $ 20/50
23.1 % $ 20/50
100% $ Pre-op
N/A
56.2% $ 20/40
(SOS) Mean VA 5 20/29;
(Re-op) Mean VA 5 20/31
N/A
N/A
N/A
80% $ 20/50
N/A
116
N/A
N/A
Zaidi (2006)
61
N/A
N/A
79
Chen(2007)
16
84.6% $ 20/40
80
Kulkarni(2007)
150
77.6% $ 20/50
83.3%5 20/70
16.7% 5 20/70
83% $ 20/50
81
Yanyali(2007)
N/A
N/A
50
36
31
32
219
78
40
Other Categorization
Post-op
Post-op
Post-op
Post-op
N/A
N/A
N/A
Post-op
N/A
N/A
VA
VA
VA
VA
$ 20/29 5 76.9%;
O Pre-op VA 5 61.5%;
5 Pre-op VA 5 30.8 %;
! Pre-op VA 5 7.7%
VA $ 20/40 5 81.3 %
N/A
N/A
Post-op VA O 20/60 5 61.9%
N/A
Post-op O Pre-op 100%;
Post-op mean VA 5 3 lines O Pre-op
84.1% with improved VA; 26.1%$ 20/60;
54.2% $ 20/60 to 20/200
Mean final VA for SOS eyes 5 20/25;
Mean final VA for Re-op eves 5 20/100
65.4%: pre-op O post-op
31.6%: pre-op 5 post-op
Macula off: 88.4% $ 20/50 for SOS eyes
Macula on: 87.8% $ 20/50 for SOS eyes
Basic group: Final VA: 20/80
Steamroller group: 20/63
Authors
N/A Not available; RD 5 retinal detachment; SOS 5 single-operation success.
series involving macular holes.
*
CHAN ET AL
463
causative break(s).117 In their multicenter prospective study, Tornambe et al attributed the majority of
new breaks to initial incomplete posterior vitreous
detachment, because 59% of new breaks develop
during the first postoperative month.243 New or
missed retinal breaks invariably induce reaccumulation of subretinal fluid. If not managed appropriately,
they result in surgical failure. New breaks located in
the superior quadrants and not widely separated
(more than 1 or 2 clock hours apart) associated with
limited subretinal fluid, may be successfully treated
with additional cryotherapy or laser and gas injection.
Otherwise, scleral buckling or vitrectomy is frequently required to repair the surgical failure. In his
report of 302 eyes over a 12-year period, Tornambe
found that risk factors associated with increased
tendency for surgical failure include: aphakia and
pseudophakia, multiple retinal breaks, and detachment involving more than 50% of the retina.241 He
advocated circumferential (360-degree) laser retinopexy along the vitreous base and ora serrata to
decrease the incidence of missed or new breaks and
enhance the rate of surgical success.241 He reported
85% single operation success for PR after 360-degree
retinopexy, in contrast to 55% after focal retinopexy
alone. Critics of PR have cited Lincoff’s study on
cynomulgus monkeys’ eyes that showed the stretching and tearing of vitreous lamellae by an expanding
intraocular gas bubble, leading to preretinal membrane formation.155 Lincoff et al also found reduction of concentration of vitreous hyaluronic acid
following intravitreal injection of an expansile gas
bubble in rabbit eyes. They reported a decrease of
18.6% of hyaluronic acid concentration after a 90%
vitreous displacement by the expansile gas.155 However, proponents of PR have emphasized that such
ultrastructural and biochemical changes of the
vitreous are only of theoretical concern and have
not resulted in adverse clinical manifestations associated with PR. They also indicated that although PR
may be associated with a higher incidence of new
breaks, the final anatomical and visual outcomes of
the operated eyes are not adversely affected, and that
the frequency of PVR is equal to SBP (see subsequent
section on PVR).6,105,114,115,131,240,241,243,248 Rarely,
a giant retinal tear may form after pneumatic
retinopexy.270
CATARACT PROGRESSION
Cataract development or progression is uncommon after PR.114,115,131,135,136,184,243,267 In their
multicenter randomized trial comparing PR with
encircling scleral buckling, the RD Study Group
reported cataract development for only one eye
after PR, due to anterior lens capsular touch during
paracentesis.243 In their report of 2-year follow up of
the multicenter PR trial, Tornambe et al indicated
cataract progression in 4% of eyes after PR, in
contrast to 18% of eyes after SBP.248 Tornambe also
reported in his 12-year analysis of 302 cases the
overall incidence of cataracts to be within 1% after
PR.241 In their prospective study published in 1994,
Mougharbel et al confirmed the general lack of
cataract progression after PR.184 By using slit-lamp
examination and Scheimpflug photography, Koch
et al detected small but insignificant degradation of
lens transparency in eyes that underwent PR in
comparison to non-operated eyes after 2 months of
follow-up.135 After 6 months, the difference became
statistically significant for the anterior lens cortex.136
However, subsequent study by the same group of
investigators showed no correlation between PR and
cataract formation or progression in 33 eyes that
were followed prospectively for 2 years after PR.184
This complication can be minimized by careful
placement of the paracentesis needle away from the
lens and the avoidance of contact between the
intraocular gas and the lens by proper head
positioning after PR.
SUBCONJUNCTIVAL GAS
Subconjunctival gas is an infrequent occurrence
due to either incomplete penetration of the sclera
by the needle for gas injection or outward leakage of
gas through the needle track for the gas injection.114,131,267 Hilton et al reported this complication in only three eyes in a review of 1,274 cases of
PR.114 This complication is usually associated with
insignificant clinical effects. A small amount of
subconjunctival gas usually resolves without clinical
consequences. A large amount of subconjunctival
gas can be easily released from the subconjunctival
space with a needle or a small conjunctival incision.
To minimize this complication, the surgeon should
ensure proper insertion of the needle for gas
injection into the vitreous cavity, and immediately
place a cotton applicator on the needle track during
withdrawal of the injection needle.114,131,267 Rotating the head immediately after withdrawal of the
needle so that the injection site is no longer at the
highest position may also move the intraocular gas
bubble away from the injection site and reduce the
tendency for the leakage of the injected gas from
the injection site into the subconjunctival space.
VITREOUS LOSS
Friberg et al reported a small bead of formed
vitreous on the globe surface corresponding to the
external opening of the needle track following
pneumatic retinopexy in three cases.82,114 Factors
464
that may lead to subconjunctival gas may also lead to
this minor complication. Thus the prevention of this
complication can be accomplished by taking the
same precautions as stated in the preceding
paragraph.
SUBRETINAL GAS
‘‘Fish-egg’’ gas bubbles may migrate through
retinal breaks into the subretinal space, particularly
in the presence of large breaks or breaks with rigid
or scrolled edges.40,114,131,137,171,241,243,267 All six
cases reported by McDonald et al involved ‘‘fishegg’’ bubbles.171 Hilton indicated that any eyes with
large retinal breaks larger than 1 clock hour in size
are associated with an increased risk of subretinal
gas after PR.40,114,131 An expanding subretinal gas
bubble may reopen a retinal break. Injection of the
gas bubble at an uppermost location of the globe
and in a brisk fashion reduces the chance of
forming ‘‘fish-egg’’ bubbles (see the section Gas
Injection Technique).40,114,131,137,240,267 In the presence of a large retinal break (more than 1 clock
hour), the patient’s head should be tilted so that the
injection site is uppermost and away from the break.
Thus, any resultant intraocular ‘‘fish-egg’’ bubbles
would not rise toward the retinal break. For an eye
with intravitreal fish-egg bubbles in the presence of
a large horizontal tear, the patient’s head should be
positioned in such a way that the bubbles migrate
away from the tear. The surgeon should wait for the
‘‘fish-egg’’ bubbles to coalesce (usually taking 24
hours) before allowing the gas to contact the retinal
break. This maneuver does not work so well when
a large retinal tear is located at the superior fundus.
In that situation, the steam-roller technique is used
to flatten the large retinal tear against the RPE first,
before allowing gas contact with the tear. Although
the flicking of the globe with moderate firmness has
been advocated to be a useful technique for
breaking up ‘‘fish-egg’’ bubbles, the authors have
found this maneuver to be frequently ineffective.
Upon the migration of ‘‘fish-egg’’ bubbles under the
retina, certain correctives measures may be taken.
Placing the patient in a supine position and tilting
his or her head so that the break is at the most
superior position, followed by gentle scleral depression on the globe may release the subretinal gas
into the vitreous cavity. Three of McDonald’s cases
were managed successfully with this method.171
Corrective measures should be taken immediately,
because it is virtually impossible to displace the
trapped gas from the subretinal space once the ‘‘fishegg’’ bubbles coalesce and expand in the subretinal
space. Under certain circumstances, persistent small
subretinal gas bubbles can be managed by scleral
CHAN ET AL
buckling alone. In 1988, Lewen and Eifig reported
successful repair of a retinal detachment with a small
subretinal gas bubble under a superior retinal break
at 12 o’clock with an encircling 240 band augmented
with a superior 279 circumferential segmental buckling element and intravitreal air, after subretinal fluid
drainage.151 Finally, a vitrectomy with internal drainage is the most direct and effective way of eliminating
the trapped subretinal gas. This approach is particularly appropriate in the case of a pseudophakic or
aphakic eye without the risk of post-vitrectomy
cataract progression. Three of McDonald’s cases
required a vitrectomy, and one case underwent scleral
buckling for management of this complication.171
GAS ENTRAPMENT IN PRE-HYALOID SPACE
Occasionally, the injected gas is trapped in the
shallow pre-hyaloid or sub-pars plana space. This
potential space (Canal of Petit) is bordered centrally
and anteriorly by Wieger’s hyaloideocapsular ligament and the lateral and posterior lens surface,
laterally by the anterior pars plana epithelium, the
pars plicata of the ciliary body, and the lens zonules,
and posteriorly by the anterior vitreous hyaloid face
(Fig. 5). 40,110,114,115,131,231,240,264,267 When viewed
through the lens, the trapped bubble appears as
a partial ring behind the peripheral edge of the
lens, otherwise known as the ‘‘sausage sign’’ or
‘‘donut sign.’’40,231,264,267 No specific treatment is
required for a small amount of trapped gas, which
should dissipate rapidly.114 Having the patient
assume a head prone position may allow a large
and expanding trapped bubble to break through
the anterior hyaloid face into the vitreous cavity and
rise toward the retinal breaks. Maintaining the facedown posture overnight almost always resolves this
problem. Under certain circumstances, the trapped
bubble is removed by a method described by
Hilton.40,110,114,115,131,231,240,264,267 This maneuver
involves the insertion of a short 27-gauge needle
connected to a plungerless tuberculin syringe filled
with some balanced salt solution or saline through
the eye wall into the trapped bubble. The patient’s
head should be tilted so that the needle penetration
site is uppermost. Bubbling of gas through the fluid
in the syringe indicates the successful elimination of
the trapped gas.40,110,114,115,131,231,240,264,267 To reduce the chance of repeating the same complication, re-injection of gas into the vitreous after
release of trapped pre-hyaloid gas should be
performed at an area away from the original site
of complication.114 To prevent this complication,
the surgeon must verify the penetration of the
vitreous cortex with the inserted needle before gas
injection during pneumatic retinopexy.231,233,264
465
minimize such a complication (see preceding
paragraphs on Gas Injection Technique and Intraocular Pressure Management).
ENDOPHTHALMITIS
Fig. 5. Inadvertent trapping of gas in the pre-hyaloid
space (Canal of Petit) may result in the ‘‘donut sign’’ or
‘‘sausage sign.’’
Positioning the needle deeper into the vitreous
cavity before gas injection may also reduce the
chance of this complication, although deeper injection may result in ‘‘fish-egg’’ bubbles that may
migrate through a large retinal tear into the
subretinal space (see preceding section).
ANTERIOR CHAMBER GAS ENTRAPMENT AFTER
PNEUMATIC RETINOPEXY
This complication is an extension of pre-hyaloidal
gas entrapment. In 2001, Taher and Haimovici
reported a case of intravitreal gas migration into
the anterior chamber of a phakic eye that underwent pneumatic retinopexy.233 They theorized
that the gas was inadvertently injected into the
potential space between the lens and the anterior
hyaloid face (Canal of Petit) as described by
Steinmetz et al (see previous paragraph).231,233
They further conjectured that a forceful injection
of a relatively large volume of gas (0.6 ml) into this
small space created a pressure gradient that led to
zonular dehiscence and entrapment of the gas in
the anterior chamber. Taher et al recommended
anterior chamber paracentesis to evacuate the
trapped gas in order to avoid excessive intraocular
pressure rise and gas-induced lenticular opacities.233
The same measures that reduce the tendency for
entrapment of pre-hyaloid gas also decrease the
likelihood of this complication (see preceding
paragraph). In addition, keeping the patient in an
upright position during gas injection may also
Similar to scleral buckling for repairing RD, the
incidence of endophthalmitis following PR is very
low.67,114,115,131,243,267 The rates of endophthalmitis
among these series varied. In their multicenter
randomized study of PR versus scleral buckling,
Tornambe et al reported only a single case of
staphylococcal endophthalmitis for the 103 eyes that
underwent PR.243 They attributed improper sterilizing techniques (including diluted Betadine) to have
contributed to the infectious process for that case.
In 1987, Eckhardt reported a case of endophthalmitis due to Staphylococcus epidermidis following PR.67
He attributed the cause of the infection to entry of
the organism through the scleral injection site for
that case. Meticulous attention to sterile surgical
techniques and postoperative topical antibiotics are
measures that reduce the likelihood of this
complication.
MACULAR HOLE AND OTHER NEW POSTERIOR
BREAKS
Macular hole development has been reported to
occur after retinal detachment repairs by various
surgical procedures.16,40,107,161,183,208,221,243,254 Surgical procedures associated with the formation of
a macular hole include not only pneumatic retinopexy, but also SBP, vitrectomy, and even after YAG laser
for posterior capsulotomy.16,28,41,85,107,161,183,208,221,
243,254
In 1988, Runge et al and Avins et al presented
case reports of macular hole formation following
pneumatic retinopexy.16,208 Vitreomacular traction
during the perioperative period is thought to play
a role in its pathogenesis.16,208 Those eyes that
developed a macular hole after PR were found to
have vitreomacular attachment before surgery and
vitreomacular detachment after surgery induced by
the expanding intraocular gas. It has been speculated
that the fellow eye of patients that previously developed a macular hole may have greater tendency
for macular hole formation after pneumatic retinopexy.16,267 The most likely mechanism for macular
hole formation in those eyes is thought to be the
tracking of an expanding gas bubble between the
retina and the posterior vitreous hyaloid face toward
the macula.16,208 A secondary mechanism involves
the stress induced on a fragile macula by the
shifting of a large amount of subretinal fluid under
it due to the expanding gas bubble.208 Runge et al
advocated careful biomicroscopic evaluation of the
466
vitreomacular relationship followed by careful
avoidance of injecting gas under the posterior
hyaloid face to prevent the development of a macular hole related to the first mechanism.208 In case
of significant vitreomacular traction, they suggested
the technique of liquid vitreous--gas exchange
described by Blankenship et al for myopic eyes with
a retinal detachment associated with a macular
hole.29,208 To reduce the possibility of the second
mechanism, the steam roller maneuver can be
attempted.208 In his series of 302 eyes, Tornambe
reported a 1% incidence of macular hole formation
after PR.241 Conventional surgical techniques for
repairing idiopathic macular holes can be utilized
with good successes for treating macular holes
related to pneumatic retinopexy.53,107,130 Hejny et
al reported favorable outcome with vitrectomy for
managing a macular hole that developed after
pneumatic retinopexy.107
In 1988, Freeman and coworkers reported three
cases of new posteriorly located retinal breaks other
than a macular hole following PR.76 Similar to
Runge et al, they believed the pathogenesis of this
occurrence to be related to preoperative incomplete
posterior vitreous detachment (PVD) and the intraoperative or postoperative tracking of gas under the
posterior hyaloid face. They reported an incidence
of 4--6% of this complication after PR. All three of
their cases were successfully treated with additional
surgery, resulting in good visual outcome. In 2002,
Sharma reported a case of posterior radial extension
of the nasal margin of a retinal break within 3 weeks
after PR using C3F8, likely due to retrograde vitreous
dissection under the posterior hyaloid face by the
expanding gas bubble.215
CHAN ET AL
UVEITIS AND VITREOUS HAZE
Uveitis after PR is usually mild and of no lasting
clinical relevance.114,131,232,257 There has been no
report of severe uveitis associated with PR. Hilton
and Tornambe reported one case of mild uveitis
following PR that cleared spontaneously within
3 weeks.114,115,131,243,267 Van Effenterre et al reported six eyes that developed vitreous haze for 3 to
8 days after PR.257 Judicious application of cryotherapy or laser should reduce the occurrence of
postoperative uveitis.
CYSTOID MACULAR EDEMA
The occurrence of cystoid macular edema (CME)
is uncommon after PR.117,120,137,255,267 Treatment
for CME associated with PR is similar to treatment
for CME associated with SBP. Those eyes with uveitis
and increased vitreous pigmentary dusting may have
greater tendency for postoperative CME. Avoidance
of excessive retinopexy during PR may reduce this
complication. Topical steroidal and nonsteroidal
anti-inflammatory medications and periocular steroidal medical therapy are usually effective for
treating this complication. In 2007, Tunc et al
reported an 11% incidence of CME following PR,
in contrast to 29% after scleral buckling.255 They
noted a significant correlation of pseudophakia with
CME for the PR eyes (27%, p 5 0.02). The lower
incidence of CME associated with pneumatic retinopexy may explain the more frequent and rapid
visual recovery of pneumatic retinopexy in comparison to scleral buckling.176,241,267
INTRAOCULAR HEMORRHAGE
Intraocular hemorrhage due to PR is rare.114,
Temporary hyphema developed in one eye
following PR in the multicenter PR study.243 One
eye also developed vitreous hemorrhage that resolved spontaneously with a final visual acuity of 20/
20. Hilton and Tornambe advocated intraocular gas
injections away from the anterior ciliary vessels
along the vertical and horizontal meridians, in
order to reduce the chance of ocular surface and
vitreous hemorrhage.40,114,115,131,243,267 In the multicenter PR trial, peripheral subretinal hemorrhage
developed in one eye, possibly due to the fracturing
of intraocular vessels by the release of the cryoprobe
before its appropriate thawing.243 The final visual
outcome was still excellent (20/40). There has been
no report of submacular hemorrhage after PR.
Careful handling of the cryoprobe is recommended
to reduce this potential complication. The cryoprobe should not be removed from the eye until
appropriate thawing of the ice ball on the cryoprobe
and the surrounding surface of the globe is
115,243,267
INCARCERATION OF IRIS AND VITREOUS
The sudden release of aqueous during paracentesis in the presence of marked intraocular
pressure elevation after gas injection may lead to
iris and vitreous incarceration at the paracentesis
wound and anterior vitreous prolapse, particularly if
the patient is in the supine position.114,115,131,243,267
This complication may be prevented by one or more
of the following measures: 40,114,115,131,267 1) performing paracentesis via the limbus before gas
injection; 2) creating a small paracentesis wound
and sealing the wound with a cotton applicator
upon the release of the paracentesis needle; 3)
performing the paracentesis via the pars plana
instead of limbus to remove either aqueous or
vitreous; or 4) keeping the patient in an upright
position during the paracentesis (see preceding
paragraphs on Gas Injection Technique and Intraocular Pressure Management).
467
evident.114,115,131,267 The rare occurrence of subretinal hemorrhage associated with PR is in contrast
to a 3.0--4.5% rate of the same complication
associated with SBP.55,110,114,116
VITREOUS AND SUBRETINAL PIGMENT RELEASE
The release of pigment granules into the vitreous
cavity and subretinal space occurs on a routine basis
during the process of a rhegmatogenous RD.109,131
In fact, pigment ‘‘fall-out’’ under the retina and
‘‘tobacco dusting’’ of pigments in the vitreous cavity
may be encountered after both SBP and PR for the
repair of RD.109,131 The amount of pigment release
can be influenced by the extent of cryotherapy and
laser during surgery.43,109,131 Although pigment
release is frequently a benign phenomenon, too
much pigment release may increase the risk of
PVR.43,96 Thus excessive cryotherapy or laser should
be avoided during PR. As discussed in the preceding
section, the steamroller technique may enhance
pigment migration into the vitreous cavity, and
therefore should be applied judiciously (please also
see the subsequent section on proliferative
vitreoretinopathy).39,40,110,247
EPIMACULAR FIBROSIS AND MACULAR PUCKER
The incidence of epimacular fibrosis (EMF) after
PR is relatively low.105,112,114,131,240--243 The multicenter PR study reported a 4% incidence of
asymptomatic EMF (mild macular pucker) for the
103 eyes that underwent PR.243 In contrast, asymptomatic EMF developed in 3% of eyes and symptomatic EMF (severe macular pucker) developed in
2% of eyes that underwent scleral buckling in that
study. Similar to the case of PVR, avoidance of
excessive cryotherapy and laser treatment may
minimize the tendency for this complication. In
1989, Sato et al analyzed 42 eyes with RD that
underwent PR with and without cryopexy.211 They
found that of the 20 eyes that underwent cryopexy, 5
eyes (25%) developed a macular pucker, whereas
none of the non-cryopexy eyes developed a macular
pucker (p ! 0.05). They proposed the potential
cause of this difference to be the excessive release of
RPE cells into the subretinal space and vitreous
cavity.211 However, Saran and Brucker found no
statistical difference in the frequency of epimacular
membranes in eyes with retinal breaks treated with
cryopexy versus laser.210 The management of macular pucker after PR is similar to the treatment of
this condition associated with other clinical situations, with usually good outcome.
MACULAR FOLDS
Macular folds may rarely occur when a superiorly
positioned intraocular gas bubble displaces large
amount of subretinal fluid associated with a bullous
retinal detachment inferiorly, resulting in retinal
redundancy involving the posterior fundus.267 The
steamroller maneuver is most effective in avoiding
this complication (See preceding paragraph on this
technique under the section of Surgical
Techniques).267
PROLIFERATIVE VITREORETINOPATHY
The reported rates of PVR after PR varied
depending on the clinical series.39,40,105,110,114,
115,131,240,242,243,267
The multicenter PR trial reported a 3% incidence of PVR for the PR eyes in
comparison to a 5% incidence of the same for the
SBP eyes.243 There was no statistical difference in
the incidence between the two groups. In their
summary of 1,274 eyes in 26 published reports of
PR, Hilton et al cited an average rate of 4% for PVR
after PR.114 However, Chen et al reported a 9.8%
incidence of PVR in a prospective series of 51 eyes
that underwent PR.51 In his review of 302 eyes that
underwent PR over 12 years, Tornambe also noted
a 9.6% incidence of PVR associated with PR.241 He
found no difference in the incidence of PVR
between those eyes that underwent cryotherapy
versus laser in his series. He also found a lack of
influence in the size and the duration of the
intraocular gas bubble in the incidence of
PVR.131,241 Similar to PVR associated with other
surgical techniques for repairing RD, eyes with PVR
after PR can be managed successfully with vitrectomy and membrane stripping with or without SBP,
and gas or silicone oil tamponade. Campochiaro et
al and Griffiths and Richardson speculated excessive
release of subretinal pigments into the vitreous
cavity to be the most likely cause for PVR after
PR.43,96 Thus the avoidance of excessive cryotherapy
or laser treatment, and the application of retinopexy
after flattening of the retina with gas in case of large
amount of preoperative subretinal fluid are
recommended.39,40,110,112,114
CHOROIDAL DETACHMENT
Choroidal detachment is uncommon after
PR.114,131,240,242,243 Tornambe et al reported an
incidence of 3% of choroidal detachment for the
PR eyes in comparison to an incidence of 17% for
the scleral buckling eyes in the multicenter PR
study.243 The difference in the incidence of choroidal detachment between the two groups was
statistically significant (p 5 0.001)114,243 However,
none of those cases resulted in any clinically
468
significant adverse outcome (e.g., angle closure).114,131,243 In his review of 302 cases performed
over 12 years, Tornambe reported an overall 2%
incidence of choroidal detachment after PR.241 Mild
choroidal detachment after PR usually resolves
spontaneously without any clinical consequences,
as in all of such cases in the multicenter PR
study.114,131,243 This complication may be reduced
by avoiding hypotony due to too much aqueous
release during paracentesis and excessive cryotherapy.114,131 In 2000, Baker and Hainsworth reported
a case of suprachoroidal gas associated with pneumatic retinopexy.18 Jabaly-Habib et al also reported
two similar cases of unintentional gas injections into
the suprachoroidal space during pneumatic retinopexy in 2003.123 Prolonged and severe pain shortly
after suprachoroidal gas injection is a typical manifestation of this complication.123 Re-tapping the
same injection site with needle connected to
a plunger-less syringe may allow immediate removal
of gas trapped in the suprachoroidal space. This
rare complication may be prevented by meticulous
techniques, especially under the guidance of indirect ophthalmoscopy to ensure the location of the
needle tip in the vitreous cavity during gas injection.
MYOPIC SHIFT
Tornambe et al noted a 68% incidence of myopic
shift of 1 diopter or more after SBP in comparison
to 3% of the same after PR in the multicenter PR
trial.242,243 This high rate associated with SBP was
largely related to the utilization of an encircling
element for buckling cases in that trial.114,243 The
rate is expected to be much lower with segmental
instead of encircling scleral buckling techniques.224
The etiology of the myopic shift in the few PR cases
was unknown, but possibly due to increased nuclear
sclerosis of the lens after surgery.114
INTRAOCULAR PRESSURE RISE AND GLAUCOMA
Although Abe et al reported an intraocular
pressure (IOP) elevation of as much as 180 mm
Hg during PR,1 such extreme IOP rise usually lasts
only for a brief interval even without any corrective
measures.56 As stated in the preceding section
Intraocular Pressure Management, mild to moderate IOP rise is well tolerated by the average eye with
no or minimal corrective measures after PR. Hilton
et al stated that with the exception of eyes with
advanced or endstage glaucoma, temporary IOP
elevation during or after PR usually does not lead to
any retinal or optic nerve damages.40,240 In the
multicenter PR trial, one patient developed the rare
complication of malignant glaucoma after disobeying instructions by sleeping on his back with his face
CHAN ET AL
up. Apparently this patient had a PC IOL and
zonular dehiscence in his eye that underwent
PR.114,131,243 Paracentesis followed by face-down
positioning led to resolution of the glaucoma for
that case. The final visual acuity of the affected eye
was 20/20. Hilton et al recommended careful
monitoring of the central retinal artery after intraocular gas injection. In the absence of central
retinal arterial reperfusion after 10 minutes of
observation (i.e., a lack of arterial pulsation), he
advised the performance of paracentesis to immediately lower the IOP.40,110,240 Most importantly, the
surgeon must ensure maintenance of light perception or better vision after the gas injection for the
surgical eye. The authors tend to perform paracentesis during PR on a frequent basis, because it is
associated with minimal morbidities when performed properly (see preceding section on Intraocular Pressure Management).
ISCHEMIC OPTIC NEUROPATHY AND RETINAL
VASCULAR OCCLUSION
This rare complication was reported in 1 of 302
eyes (0.3%) after PR by Tornambe.241 Although not
reported in the literature, branch and central
retinal artery or vein occlusion can theoretically
occur with PR.1,114 Use of subconjunctival anesthesia, careful administration of the peribulbar or
retrobulbar anesthesia, and avoidance of excessive
and prolonged intraocular pressure elevation may
reduce the chance of such occurrences.
DELAYED SUBRETINAL FLUID ABSORPTION
Tornambe reported 15 of 302 eyes (5%) that
developed delayed subretinal fluid absorption after
PR.241 There are two types of residual subretinal
fluid accumulation after PR. The first type is similar
to delayed subretinal fluid absorption after RD
repair by SBP. Chen et al reported substantial
residual subretinal fluid involving the dependent
portion of the RD that took longer than 6 months to
resolve in three eyes after PR.51 They attributed this
complication to choroidal vascular insufficiency,
similar to the same phenomenon found in certain
cases of RD after nondrainage SBP.51,158,205 The
typical characteristics of this type of residual
subretinal fluid consist of shifting of subretinal fluid
to a dependent position and its slow absorption over
a prolonged period. The second type of residual
subretinal fluid after PR is much more subtle in
appearance. In 1989, Chan and Wessels first
reported this type of delayed subretinal fluid
absorption (DSRFA) in 8 of 38 consecutive eyes
with a retinal detachment that were treated with
pneumatic retinopexy.47 The primary characteristic
469
of DSRFA consists of a small loculated pocket of
shallow subretinal fluid not associated with any
retinal breaks. They found heavy cryotherapy and
subretinal pigment precipitates to correlate with
DSRFA. DSRFA may have a negative visual impact
when the macula is involved, because the resolution
of the residual subretinal fluid is usually prolonged,
taking many months. In contrast to the typical
residual subretinal fluid associated with nondrainage scleral buckling, the loculated pocket of DSRFA
related to pneumatic retinopexy is subtle in
appearance and does not shift. Other investigators
also reported similar cases of DSRFA.9,33,60 In 1990,
Ambler and associates described three cases of
DSRFA with good visual outcome.9 Böker et al
reported 6 of 60 eyes with DSRFA after PR in 1991.33
The time for complete absorption of these circumscribed subretinal bullae ranged from 8 to 52 weeks
(mean 22.7 weeks). None of their cases developed
impaired vision as a result of the DSRFA. In 2001,
Desatnik et al reported seven phakic eyes with
DSRFA, with macular involvement in four eyes.60
The time interval for complete fluid absorption
ranged from 10 to 26 months in their report.
Consistent with Chan’s report, they found the rate
of resolution of DSRFA not to be influenced by any
postoperative maneuvers or additional surgical procedures. Complete retinal reattachment eventually
occurs for most eyes on a spontaneous basis. Recent
OCT scanning of the loculated pocket of submacular fluid after RD repair suggests its content to
include photoreceptor byproducts.213 In the absence of worsening of the submacular fluid, it is best
to wait for its resolution instead of reoperation.
surgery associated
wounds.127,253
with
fresh
corneal
limbal
MUSCULOSKELETAL COMPLICATIONS
Due to the rigorous requirement of a consistent
head tilt for a prolonged period, PR may lead to
various musculoskeletal and neurological injuries,
especially for elderly patients already afflicted with
various arthritic and neuromuscular ailments. The
cervical spine and neck muscles are particularly
vulnerable to potential injuries on account of the
head tilt frequently required during PR. In addition,
lower back problems associated with prolonged
turning of the body, and ulnar nerve injury due to
excessive pressure on the elbow corresponding to
the arm that supports the head during the head tilt
may also occur. Such complications are usually
minor and of a temporary nature. In their analysis
of intraoperative and postoperative complications
associated with PR, Hilton et al reported only two
cases of postoperative neck problems.114,131 Nevertheless, meticulous attention should be given for
proper support of the patient’s body to avoid
musculoskeletal injuries related to PR. For instance,
appropriate padding should be provided for the
elbow sustaining the pressure. The patient should
also be advised to avoid prolonged head and body
tilt in mid air without any support. Instead, a pillow,
cushion, a table or desk with the correct height, or
a reclining chair or bed, may supply the required
support and prevent unwanted musculoskeletal and
neurological injuries. If necessary, analgesics and
muscle relaxants may be prescribed to relieve
musculoskeletal discomfort associated with PR.114
HYPOTONY MACULOPATHY
In 1999, Aslanides et al reported an unusual case
of hypotony maculopathy associated with progressive visual deficit 3 months after pneumatic retinopexy.13 The cause of the hypotony (3--5 mm of Hg)
was a subclinical dehiscence of the cataract wound
on the scleral limbus revealed only by ultrasonic
biomicroscopy and indentation gonioscopy. Subsequent surgical repair of the dehiscence with
interrupted 10-0 nylon sutures reversed the hypotony and improved the visual acuity to 20/50.
CORNEAL WOUND DEHISCENCE
In 2000, Jun et al reported two cases of corneal
wound dehiscence during PR due to acute intraocular pressure rise after intraocular gas injection
causing leakage through self-sealing, clear corneal
incisions.127 To avoid this complication, they advised
the performance of paracentesis prior to gas injection for eyes with RD following recent ocular
Contrast of Pneumatic Retinopexy with
Scleral Buckling, Pars Plana Vitrectomy,
and Other Techniques
SCLERAL BUCKLING, TEMPORARY BALLOON,
PARS PLANA VITRECTOMY
Despite the favorable reports of PR, some
surgeons continue to favor SBP over PR for
repairing simple RD.188 Others favor the temporary
balloon buckling technique over PR.20,138,139,154-157,166
There have been multiple criticisms on the
multicenter PR trial. For example, Valone noted
that despite the simple RD, the single-operation
success for the SBP eyes in the multicenter trial was
only 82%, suggesting variations in outcome among
participating surgeons.166,256 He also pointed out
that SBP eyes had a longer duration of macular
detachment than PR eyes, possibly influencing the
visual outcome. Lincoff et al claimed that despite
the validity of the multiple center PR trial statistics,
470
the differences might be due to potentially deleterious effects of encircling buckles, SRF drainage,
and air or gas injection in the SBP eyes, making
their visual prognosis worse.138,154,155 They reported
93% success of 466 eyes with the former procedure,
a much higher single-operation success than PR.
However, Hilton et al pointed out that the balloon
buckling group in Kreissig’s series had a low incidence of pseudophakia and macular detachment,
predisposing them to a more favorable outcome.
They also noted that Kreissig compared only the
balloon buckling to the initial experience of PR
with a lower success rate. In addition, Hilton
and Tornambe emphasized that complications
encountered with relative frequency with SBP but
rarely or never occur with PR include the
following:113,116,119,177,223,236,262
1. Inadvertent scleral perforation (5%)
2. Subretinal fluid drainage complications119 :
i) subretinal hemorrhage (3.0 to 4.5 %),
ii) retinal incarceration (2.2 to 3.0%),
iv) retinal breaks (0.54 to 4.0%), v) vitreous
loss (0.36 to 3.0%)
3. Extraocular muscular problems inducing diplopia (20 to 50%):177,223,248 In 1989, Smiddy et
al reported extraocular muscle imbalance after
scleral buckling, occurring primarily associated
with encircling procedures.223
4. Refractive and corneal topographic changes
after scleral buckling:219,224,262 Smiddy et al
reported induction of myopic shift with majority of encircling buckling, but radial buckling
infrequently results in significant postoperative
refractive changes.224 In 1999, Weinberger et al
assessed corneal topography by videokeratography for 46 patients that underwent PR (11
eyes), SBP (25 eyes), or vitrectomy (10 eyes).262
They found negligible corneal topographical
changes for eyes that underwent PR and
vitrectomy, but significant changes for those
that underwent SBP.
In their comments on Green et al’s report of
favorable outcome with temporary balloon for
repairing selected RD in 159 eyes, Tornambe and
Hilton pointed out the lack of efficacy of temporary
balloon for macular breaks, posterior breaks, giant
breaks, giant dialysis, recurrent detachment adjacent to a scleral buckle, RD associated with an optic
pit, and breaks in areas of scarred conjunctiva.246
Each of these conditions has been successfully
treated with pneumatic retinopexy under selected
circumstances. Tornambe also pointed out that
pneumatic retinopexy has been reported to successfully treat selected complex RD involving multiple
breaks in multiple quadrants involving more than 30
CHAN ET AL
degrees that would usually require encircling instead of radial buckling if scleral buckling were
chosen to repair such detachments.244 For such RD,
PR but not encircling buckling would avoid a myopic
shift.
Primary pars plana vitrectomy for repairing RD is
associated with higher incidence of cataract formation or progression, intraocular lens subluxation, iris
capture, and flat anterior chamber.42,70,86,87,106,230
DRAINAGE, AIR INJECTION, CRYOTHERAPY, AND
EXPLANT (D-ACE) AND SIMILAR TECHNIQUES
Contemporaneous with the development of PR in
the late 1980s, multiple surgeons in the United
Kingdom advocated an alternative surgical technique combining certain features of both PR and
scleral buckling.163,268 They coined the eponym
‘‘D-ACE’’ to depict the key steps of this procedure:
(1) Drainage of subretinal fluid; (2) injection of
intraocular Air; (3) Cryotherapy for retinal break(s);
and (4) Explant placement. This procedure is
advantageous for more accurate and prompt localization and support of retinal breaks in comparison
to PR for a bullous RD. The proponents of this
procedure reported a single-operation success rate
of 85%, a figure higher than PR. The final success
rates of 97--98% are comparable to PR. D-ACE
provides the advantages of more accurate support of
multiple and large breaks at or anterior to the
equator while avoiding excessive cryotherapy for
a bullous RD in comparison to PR. However,
disadvantages include potential complications relating to subretinal fluid drainage and buckling not
commonly associated with PR, that is, retinal incarceration or perforation, choroidal and subretinal
hemorrhage, and extraocular muscle imbalance and
diplopia.
Purohit et al achieved a 95% single-operation
success in 58 consecutive patients, using a technique
similar to D-ACE that they referred to as ‘‘pneumatic
buckle’’.198 They reported unchanged or improved
final visual acuity in 88% eyes with macula-on RD,
and final visual acuity of 20/20 to 20/50 in 67% eyes
with macula-off RD.
Gündüz and Günalp reported 90% single-operation success in reattaching 30 bullous RD by PR
immediately following drainage of subretinal
fluid.99 One eye developed D3 PVR after additional
SBP, and refused further surgery. Thus, final success
was 96.7%. Final VA was maintained or improved in
96.7% of treated eyes. Terubayashi et al reported
80% success in 31 eyes undergoing a modified PR
technique with the following steps:235 1) lowering of
the intraocular pressure; 2) cryopexy of retinal
breaks; 3) drainage of subretinal fluid; 4) intra-
471
vitreal gas injection; and 5) 2 hours of prone
positioning followed by bed rest.
FLUID--GAS EXCHANGE FOR MACULAR-HOLE
DETACHMENT
A number of surgeons have reported the exchange of intraocular gas for liquid vitreous fluid for
retinal detachment associated with a macular
hole.2,93,203 Gas--fluid exchange is an appealing
technique for repairing a macular hole--induced
RD associated with high myopia, either during the
initial procedure or afterwards. For instance, Blankenship et al advocated exchange of posterior
vitreous fluid with a gas bubble,29 and Ripandelli
et al proposed intraocular gas injection at the same
time as subretinal fluid drainage for such cases.203
The proponents of this technique pointed out that
the greater gas volume attained with this technique
in contrast to a small volume of gas with the pure PR
technique (see previous section on Expanded Use
of Pneumatic Retinopexy for Special Clinical Conditions) allows more effective closure of the macular
holes frequently associated with atrophic or staphylomatous posterior fundi in highly myopic eyes. In
1995, Chan reported the induction of posterior
vitreous detachment followed by gas tamponade
with a small expansile gas bubble for high-risk
impending macular holes and small stage 2 macular
holes.48 In recent years, Jorge et al and Mori et al
also reported the utility of this technique for small
macular holes.126,179 OCT confirmed the closure of
the macular holes for the latter series. Mori reported
that two important factors associated with the
success of this technique include: 1) diameter of
the macular hole of less than 200 microns, and
2) preoperative visual acuity of better than 20/40.179
SUPPLEMENTAL GAS INJECTION FOR FAILED
PNEUMATIC RETINOPEXY, OR PRIMARY OR
FAILED BUCKLING CASES
Multiple surgeons also advocated intraocular gas
injection for failed pneumatic retinopexy, during
primary buckling, or to salvage failed scleral
buckling cases with limited vitreoretinal traction
due to new or missed retinal breaks.81,150,187,216,269
Weinberger et al reported 100% single-operation
success for late-onset recurrent retinal detachment
(6 months to 3 years after the original surgery).263
Eight of the 12 cases had primary PR and 3 had
primary SBP. Final visual acuity remained unchanged in 10 eyes and improved in 2 eyes. Sharma
et al reported 69.4% single-operation success for
failed buckling cases with this technique.216 Multivariate analysis identified two risk factors for failure:
location of retinal break either on the posterior
slope or posterior to buckle (p 5 0.01), and extent
of retinal detachment greater than two quadrants
(p 5 0.02). They pointed out that because 100%
final success was attained in all eyes that underwent
further reoperations, supplementary PR did not
compromise subsequent surgical outcome, a conclusion similar to primary PR. In 2007, McGimsey et al
reported the successful treatment with gas tamponade followed by laser for recurrent rhegmatogenous RD without a detectable retinal hole after
scleral buckling or vitrectomy in six eyes in six
patients172
PNEUMATIC RETINOPEXY FOLLOWED BY
SCLERAL BUCKLING FOR GIANT RETINAL TEAR
DETACHMENT
Ando et al performed PR with SF6 gas followed by
cryotherapy and encircling scleral buckling to six of
nine eyes. Two eyes required additional injection of
SF6 gas, and one eye that developed postoperative
grade C PVR was successfully repaired with a subsequent vitrectomy.10 A final VA of 20/30 was
achieved in eight eyes.
Conclusion
Pneumatic retinopexy has become an important
surgical technique in the modern era of retinal
surgical management for RD. It is primarily indicated for uncomplicated RD with limited retinal
breaks involving the superior 8 clock hours of the
fundus, although more complex RD may be
successfully managed with this technique on a selective basis.40,110,240,248 Qualified candidates must be
willing to maintain a specific head posture for 7 days
or more for optimal outcome with PR. Basic surgical
steps of PR include retinopexy of retinal breaks with
cryotherapy or laser, intraocular gas injection before
or after retinopexy, and maintenance of proper
head posture by the patient for the required time
period after surgery.40,110,240 Proponents of PR have
emphasized its advantages of minimal tissue trauma,
no hospitalization, and reduced expenses, in comparison to scleral buckling and vitrectomy.8,40,
110,111,240,241,243,248
Critics of PR have pointed out
its lower single-operation success rates, so that both
the surgeon and patient need to be prepared for
multiple procedures with PR on a more frequent
basis.104,105,188 Published series of single-operation
success rates of PR ranged from 53% to 100% for
PR.114 Phakic eyes fared better than nonphakic eyes,
with the single-operation successes of 71--84% for
the former and 41--67% for the latter. Despite lower
single-operation successes with PR in comparison to
SBP, the multicenter PR trial and other published
472
reports have shown that the final anatomical and
visual outcomes are not disadvantaged by the initial
PR.240,241,243 An excellent final average anatomical
success rate of 98% was noted in published reports.114 In addition, the multicenter PR trial
showed that cataracts, choroidal detachment, and
myopic shift developed significantly less frequently
with PR than SBP, although missed or new retinal
breaks occurred more often after PR than SBP.243
Regarding the visual outcome, the multicenter PR
trial has shown that those eyes with a duration of
macular detachment of 14 days or less as well as 3 days
or less, achieve a postoperative VA of 20/50 or better
at 6 months more frequently after PR than SBP (p 5
0.01 and p 5 0.05, respectively).243 Recovery of VA was
also more rapid after PR for many cases. Published
reports of PR from 1988 to 1998 showed 35--80% of
eyes with pre-operative macular detachment and 76-100% of eyes with pre-operative macular attachment
achieve a postoperative VA of 20/50 or better with 6
or more months of follow up after surgery. The 2-year
follow-up study of the multicenter PR clinical trial
showed that vision continued to improve over the
long term, so that 90% of PR eyes with macular-off RD
achieved VA of 20/50 or better at 2 years. Thus, that
study showed the importance of more than one year
of follow-up.248
In summary, despite its limitations and shortcomings, multiple clinical studies have clearly shown
important and favorable features of PR, and
established its continued important role in the
armamentarium of the retinal surgeon for managing an RD. The retinal surgeon should carefully
consider all preoperative ocular features unique for
each individual eye with an RD, modify his or her
surgical techniques accordingly, and strive for the
best possible anatomic and visual outcome for each
patient.
The authors have no financial and proprietary
interests in any commercial products mentioned in
this review.
The authors thank Ms. Katherine Kreuter, Mr.
Sandro Cinelli, Elizabeth Szambulan, MD, Doriana
Cosgrove, MD, Paul Inae, MD, Ivan Fišer, MD, Victor
Victorov, MD, and Ms Kelly Schultz for their
expertise in foreign language translation. We also
thank Paul Tornambe, MD, for his thoughtful review
and helpful suggestions for the manuscript before
and after its submission.
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Reprint address: Clement K. Chan, MD, PO Box 2467, Palm
Springs, CA 92263, USA.

Pneumatic Retinopexy for the Repair of Retinal Detachments: A

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