13 Pneumatic Retinopexy versus Vitrectomy as Primary Procedure for Retinal Detachments Both procedures represent an intraocular approach. The rationale for both to be used as primary procedure for uncomplicated detachments is the following: An analysis of pneumatic retinopexy versus a temporary external buckle for uncomplicated detachments has already been done (see Chapter 11, pp. 271–287). It was found that because intraocular gas causes a break down of the blood aqueous barrier, PVR will occur 20 times more frequently and secondary breaks 10 times more frequently than after a balloon buckle [2]. As a consequence re-operations will be more frequent than after external buckling. To reduce the higher redetachment rate of pneumatic retinopexy, Tornambe [3] suggested adding 360° of coagulation to the periphery of the retina, thus providing a virtual cerclage consisting of circular coagulations. However, with this change pneumatic retinopexy has lost its appealing simplicity. – The traction on the operculum of the tear can be severed with the vitrector. – Removing the vitreous might eliminate vitreoretinal proliferation, a main cause for failure with the gas operation. These reasons alone appear to represent an advantage of vitrectomy over the gas operation. However, let us recall what we know already about vitreous traction on a horseshoe tear. Rarely does it represent a problem for reattaching the retina with an external buckle. – Thus, removing the vitreous attachment to the operculum is rarely required to reattach a retina. Most of the time, traction on the operculum can be overcome in the long-run by anterior coagulation alone, as demonstrated by the long-term results with the temporary balloon buckle which is removed after 1 week. – But with vitrectomy we relieve traction on the tear ab interno by cutting the operculum off and adding an internal gas tamponade which will be there during retinal scarring. Years ago as prophylaxis, attached horseshoe tears were even buckled, sometimes with a cerclage [4] or by a radial buckle with a cerclage [5]. However, today nobody would consider a prophylactic buckle even though up to 2% of horseshoe tears may detach after prophylactic coagulation. – Consequently, performing a primary vitrectomy to remove the vitreous attachment to the tear does not seem reasonable either. Here is another question that might arise in relation to vitrectomy: • To remove the traction on the tear • To remove the posterior and the anterior vitreous • Otherwise you are likely to get anterior loop proliferations causing even larger amounts of postoperative PVR and reoperations. – Such a vitrectomy would be then an extensive intraocular procedure with a significantly higher rate of complications.
13.1 Background
If both are good for complicated detachments, i.e., pneumatic retinopexy, or more correctly termed expanding-gas operation [1], for a giant tear and vitrectomy for a detachment with PVR, why not try them for detachments with small tears and detachments without PVR?
The obvious answer is that the morbidity of the 2 procedures is excessive when compared to the morbidity of an extraocular minimal buckling procedure.
Additional reasons were suggested for using vitrectomy as a primary procedure:
Which information confirms these statements?
– Among 500 detachments treated by a temporary balloon buckle, 70% were caused by horseshoe tears, and after removal of the balloon, only 2% of the tears redetached [2].
Or how can it be defined in another way?
– With segmental buckling we relieve traction on the tear ab externo by placing a buckle underneath it and leaving it there for at least the duration of retinal scarring.
Of course you can select a vitrectomy for retinal re-attachment. But is it any better than just performing the gas operation alone?
Before presenting the data on this topic, let me discuss with you another issue.
Or would you rather seal it simply by laser or cryopexy?
There is little doubt that coagulation alone is the proper treatment.
– It seems unreasonable to buckle 98 eyes to save 2 eyes from a buckle operation at a later date.
Does primary vitrectomy not, after all, reduce the rate of PVR or reoperations when compared to pneumatic retinopexy?
– To begin with, you should take into account the fact that when performing a vitrectomy in addition:
If an acute horseshoe tear is sent to you, would you still consider relieving traction by vitrectomy or even by an external buckle before a detachment occurs?
