Three very different methods are currently used to repair acute retinal detachments. Elsewhere in this issue of the Journal , Hwang reviews data obtained from Medicare part B summaries, finding regional differences in the choice of procedure for repair of retinal detachment. The author gives us an interesting snapshot of practice patterns in the current era regarding retinal detachment repair in patients 65 and older. Several limitations exist in the study, however. First, we cannot determine, within the group of patients who underwent vitrectomy, what percentage of this group also had placement of a scleral buckle. Second, we have no data regarding outcomes, nor do we know whether the procedure performed was primary or a reoperation, particularly if pneumatic retinopexy was chosen initially. Third, we have no data regarding lens status. Interesting findings in this study are the high rate of pneumatic retinopexy use, especially in the Northeast, and the remarkably low rate of scleral buckling alone nationwide.
Review of Literature on Pneumatic Retinopexy and Vitrectomy vs Scleral Buckling
The single-procedure reattachment rate for surgical treatment of retinal detachment was much higher for scleral buckling than pneumatic retinopexy in most studies. Han and associates reported a single-procedure reattachment rate in 1998 for scleral buckling of 84%, compared to 62% in pneumatic retinopexy eyes. In 2011, Schaal and associates reported success in 86% of scleral buckle cases and 63% for pneumatic retinopexy. Chan and associates found success rates with a single operation of 71% to 84% in phakic patients and 41% to 67% in nonphakic patients, surveying multiple reports regarding pneumatic retinopexy. This study found the final anatomic and visual outcomes not to be disadvantaged by initial choice of pneumatic retinopexy. The Medicare database used by Hwang does not reveal the lens status of the patients, but a review of 440 consecutive primary retinal detachments showed 48% of patients 65 and older to be pseudophakic (Ryan EH et al. Scleral buckling remains valuable for retinal reattachment. Paper presented at Retina Society, San Francisco, California, September 24, 2010, p. 71). Given the likely similar incidence of pseudophakia in this population of Medicare beneficiaries, pneumatic retinopexy as a surgical choice would be expected to have the highest incidence of initial failure.
A recent large randomized prospective trial from Europe compared scleral buckling to vitrectomy for moderately complex retinal detachment. The study found scleral buckling to predict a better visual outcome than vitrectomy for retinal reattachment in phakic patients. Lens status may play a role, as cataract progression following vitrectomy is typical in phakic patients and occurs sooner with advancing age. A similar prospective study, the Retina 1 project, found vitrectomy to have a higher likelihood than scleral buckling of poor (<20/100) visual outcome regardless of lens status.
In the large European study, pseudophakic patients had better anatomic success rates with vitrectomy than scleral buckling, while visual outcomes were similar. They conclude that vitrectomy is the preferred method for retinal reattachment in pseudophakic patients. It is currently unclear whether vitrectomy combined with scleral buckling is more effective than vitrectomy alone anatomically for repair of retinal detachment, and the study did not address this question. Schaal found single-surgery success rates of 90% for vitrectomy and 94% for combined scleral buckling and vitrectomy.
Pneumatic Retinopexy’s Surprisingly High Use
Two findings regarding the use of pneumatic retinopexy are surprising. First, the utilization of pneumatic retinopexy in the Northeast was highest. Hwang’s expectation had been that pneumatic retinopexy would be more popular on the West Coast. A 1997 survey had indicated a much higher utilization of pneumatic retinopexy on the West Coast than elsewhere in the country. The current higher usage in the Northeast may represent a growth in popularity there, but could also represent declining popularity in the West. Second is the overall rate of pneumatic retinopexy use, which was greater than that of scleral buckling alone (15% vs 11%). Of the 3 procedures reviewed in this study, pneumatic retinopexy has the lowest initial success rate. Given the even lower success rate in pseudophakic patients, which is likely half the population in this study, the numbers of Medicare-age patients treated with this procedure seem quite high. Is surgeon convenience or likely surgical outcome driving the choice of this procedure?
Pneumatic Retinopexy’s Surprisingly High Use
Two findings regarding the use of pneumatic retinopexy are surprising. First, the utilization of pneumatic retinopexy in the Northeast was highest. Hwang’s expectation had been that pneumatic retinopexy would be more popular on the West Coast. A 1997 survey had indicated a much higher utilization of pneumatic retinopexy on the West Coast than elsewhere in the country. The current higher usage in the Northeast may represent a growth in popularity there, but could also represent declining popularity in the West. Second is the overall rate of pneumatic retinopexy use, which was greater than that of scleral buckling alone (15% vs 11%). Of the 3 procedures reviewed in this study, pneumatic retinopexy has the lowest initial success rate. Given the even lower success rate in pseudophakic patients, which is likely half the population in this study, the numbers of Medicare-age patients treated with this procedure seem quite high. Is surgeon convenience or likely surgical outcome driving the choice of this procedure?
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