This letter is in response to the correlative articles published in the Journal in June 2012 analyzing regional variations in the United States when choosing among different techniques for retinal detachment (RD) repair. As the indications for each technique remain controversial, we hope to contribute to this matter with our experience and data gathered from several Spanish studies.
According to Hwang’s article, entitled “Regional practice patterns for retinal detachment repair in the United States,” pneumatic retinopexy (PR) is a very popular technique, especially in certain areas like the Northeast. In contrast and counter to expectations, scleral buckling (SB) is not performed as often nationwide. Ryan’s reply, through the article “How we currently choose to repair retinal detachment in the United States Medicare population,” provides interesting clues regarding the interpretation of the conclusions in Hwang’s study. There are 2 main reasons for the choice of PR over SB. The first is economic. PR is less expensive to perform than is SB. The second reason is experience. Based on their surgical training, younger retinologists are less experienced with SB, and thus they tend to overuse vitrectomy.
In Spain, we have observed the same phenomenon. The Retina 1 Project, a prospective multicenter study initially conceived to identify proliferative vitreoretinopathy risk factors, showed that over a 4-year interval there is an increasing tendency to use vitrectomy. Such a finding was justified neither by a higher incidence of more complex cases nor by the pursuit of better outcomes.
The Retina 1 Project involved 17 hospitals in Spain and Portugal, with the participation of many expert eye surgeons. In the course of this project, we obtained important feedback on our daily routine practice and its outcome. The feedback not only enabled us to perform better surgeries, but it also allowed us to objectively criticize our public health care system regarding the organization and training of the youngest doctors.
Some of the explanations given by Ryan relating to the US preference for vitrectomy are similar to those we observed in Spain, such as the lack of experience in SB among young ophthalmologists. Furthermore, a national survey carried out in public health care hospitals in Spain has concluded that during night shifts, access to operating rooms and qualified nurses in eye surgery is very limited. This, of course, adversely affects the choice of the surgical technique and even the timing of the surgery. However, the economic impact in the choice of surgical technique by retinologists in Spain is not a factor because the public health care system does not have cost restrictions in the treatment of RD.
Retina surgeons in the United States, in Spain, and probably in many other countries, regardless of the cause, currently choose the treatment for their patients with RD. Unfortunately, the surgeons are often unaware of evidence-based indications that one surgical approach may be more appropriate than another. We agree with Ryan in the fact that there are well-established indications for the use of certain techniques, for example, vitrectomy in pseudophakic patients. We strongly urge the biomedical community to develop a consensus regarding selection of appropriate surgical procedures for repair of RD that present with different parameters.