What are we to do with the results by Day and associates? Using real-world Medicare billing data, they report that scleral buckling (SB) and pars plana vitrectomy (PPV) have the highest 1-operation success rate (80%) and that pneumatic retinopexy (PR) has the lowest (60%) success rate, as well as reporting that the greatest morbidity occurs with PPV. Does this mean we should select SB first?

It depends on the goal of retinal detachment surgery! We believe the 3 most important goals, in order of importance, are (1) restoration of predetachment vision, (2) morbidity, and (3) cost. This study did not address vision, but found morbidity rates to be lowest with PR. Logic suggests that the operation with the lowest reoperation rate would be the best and most cost effective. But is this true? It depends on the reoperation.

The Pneumatic Retinopexy Clinical Trial, which prospectively compared SB with PR, reported similar anatomic results 19 years ago, with single-operation success rates of 73% for PR and 82% for SB. But, 87% of eyes treated with PR were attached with only an additional office-based procedure, such as laser, cryopexy, or another pneumatic. Only 13% of eyes required a trip to the operating room, and better visual acuity resulted for eyes treated with PR. Pneumatic retinopexy commonly is performed as a staged procedure. Did the authors distinguish a planned second, office-based procedure from truly failed pneumatic operations requiring surgery? The authors alarmingly also note they could not separate a reoperation from a procedure on the fellow eye. Finally, the authors focused only on additional retinal operations, and excluded iatrogenic cataract surgery as a reoperation.

Which operation is the most cost effective? Assume that for every failed operation, the rescue operation is a successful SB or PPV procedure. Using this study’s data, of 10 eyes with retinal detachment treated with SB or PPV, 2 require a second trip to the operating room. Thus, ultimately to attach 10 eyes with SB or PPV, there would be 12 trips to the operating room, 12 surgical fees for PPV or SB, and 12 payments to the anesthesiologist as well as other charges for testing mandated by the surgical facility. In the case of PR, 4 of 10 procedures fail, so only 4 would require a trip to the operating room. Although more operations were required for the PR group (14 vs 12), the total cost to the payer would be much less, because PR uses the operating room and anesthesiologists (4 vs 12) 66% less often and requires a surgical procedure (10/14) 71% of the time, which is 50% less expensive than PPV or SB.

At first glance, this article implies that SB or PPV is the operation of first choice, and that PR is the last. Using the same data, we conclude the opposite.