Long-term results of office-based pneumatic retinopexy using pure air.

Abstract

The long-term results of office-based pneumatic retinopexy (PR) using only filtered air were evaluated in a case series of rhegmatogenous retinal detachments with more than 3 years of follow-up, on average.
77 cases of primary rhegmatogenous retinal detachments arising from superior tears (mean=1.6 tears) were treated with cryopexy (n=61) or laser (next day, n=16) and intravitreal injection of pure air in an office setting. The macula was detached preoperatively in 37 eyes (48.1%). Outcome measures were single-operation success, final reattachment rates and visual acuity (VA).
Subjects were followed for 6-186 months (mean follow-up = 40.7 months, 46.8% ≥ 2 years, 25% ≥ 5 years). In all cases, the air bubble was gone within 5 days. Single-operation success was achieved in 62/77 (80.5%) eyes. Repeat PR was successful in four cases, increasing the PR reattachment rate to 85.7%. Scleral buckle was performed on the remaining 11 eyes (14.3%), 1 with vitrectomy. The final reattachment rate was 100%. VA improved ≥ 2 Snellen lines in 53.2% of patients, with 50/77 (64.9%) attaining VA ≥ 20/40. Following PR, 87% of subjects had the same or better VA.
Office-based pure-air PR achieves acceptable reattachment rates with good visual outcomes and long-term efficacy. Eliminating the need for expansile gases makes this approach more widely available, decreases recovery time and lowers healthcare costs.

Full text

Page 1

Long-term results of office-based pneumatic
retinopexy using pure air
Kenneth M P Yee, J Sebag
ABSTRACT
Aims The long-term results of office-based pneumatic
retinopexy (PR) using only filtered air were evaluated in
a case series of rhegmatogenous retinal detachments
with more than 3 years of follow-up, on average.
Methods 77 cases of primary rhegmatogenous retinal
detachments arising from superior tears (mean¼1.6
tears) were treated with cryopexy (n¼61) or laser (next
day, n¼16) and intravitreal injection of pure air in an
office setting. The macula was detached preoperatively
in 37 eyes (48.1%). Outcome measures were single-
operation success, final reattachment rates and visual
acuity (VA).
Results Subjects were followed for 6e186 months
(mean follow-up ¼ 40.7 months, 46.8% $2 years, 25%
$5 years). In all cases, the air bubble was gone within
5 days. Single-operation success was achieved in 62/77
(80.5%) eyes. Repeat PR was successful in four cases,
increasing the PR reattachment rate to 85.7%. Scleral
buckle was performed on the remaining 11 eyes
(14.3%), 1 with vitrectomy. The final reattachment rate
was 100%. VA improved $2 Snellen lines in 53.2%
of patients, with 50/77 (64.9%) attaining VA $20/40.
Following PR, 87% of subjects had the same or
better VA.
Conclusions Office-based pure-air PR achieves
acceptable reattachment rates with good visual
outcomes and long-term efficacy. Eliminating the need
for expansile gases makes this approach more widely
available, decreases recovery time and lowers healthcare
costs.
INTRODUCTION
The surgical repair of retinal detachment has
undergone technical advances and improvement in
outcomes. Pioneered by Schepens in America, Fison
in Britain and Gonin in Europe, scleral buckle was
the first technique that achieved good success.1The
most recent surgical option for primary rhegma-
togenous retinal detachment (RRD) is vitrectomy
surgery,2at times in combination with scleral
buckle.
In 1938, Rosengren proposed the use of air
combined with external diathermy to achieve
retinal reattachment.3
As currently performed,
pneumatic retinopexy (PR) typically involves an
intravitreal injection of long-acting, expanding gas.
Sulphur hexafluoride (SF6) or perflouropropane
(C3F8) haveaverage intraocular
12 days and 38 days, respectively.4It has been
shown that intravitreal SF6and especially C3F8can
cause irreversible damage to the retina and impair
retinal function in rabbits.5Expanding gases have
also been shown to cause breakdown of the
bloodeocular barrier and may induce an inflam-
durationsof
matory response due to mechanical damage,6e8
findings that were not evident with pure air.5 9This
may explain why previous studies,4 10e12which
showed good clinical success with expanding gas
PR, have also shown a higher incidence of macular
pucker and proliferative vitreoretinopathy (PVR)
following PR with SF6and C3F8as compared to
pure air.13
To date, the long-term clinical outcome of pure-
air PR has not been the subject of extensive study.
Previous long-term studies of PR using SF6and C3F8
expansile gases found a single-operation success of
83% and 85.9% and a final reattachment rate of
98.7% and 100%, respectively.10 11The present
study was undertaken to determine the long-term
clinical outcomes of office-based PR using only
pure air.
MATERIALS AND METHODS
Patient population
There were 77 eyes in 76 patients (45 men, 31
women) with primary RRD and no evidence of
vitreous haemorrhage or proliferative vitreoretin-
opathy preoperatively. The mean age of the study
population was 61.3613.2 years. All RRDs arose
from retinal tears located at or above 9:00 and 3:00
in the superior peripheral fundus. Inferior (below
the 3:00 and 9:00 meridian) tears in attached retina
were observed preoperatively in 11 (14.3%) eyes
and treated with cryopexy at the time of PR. No
cases had retinal tears with only a rim of retinal
elevation, as all cases had subretinal fluid elevating
the retina for at least 1 clock hour in extent. The
average number of clock hours of elevated retina
was 4.662.5. Of the 77 eyes, 26 (33.8%) had
multiple tears, but none were more than 3 clock
hours apart. The average number of tears was
1.661.0. Fifty-one of 77 (66.2%) patients were
phakic, 23/77 (29.9%) were pseudophakic, and 3/77
(3.9%) were aphakic (table 1).
Operative procedure
Informed consent was obtained and strict patient
confidentiality was maintained throughout the
study. Retrobulbar anaesthesia was administered in
the office without an anaesthetist and without
cardiovascular monitoring using 2% Xylocaine
(Hospira Inc, Lake Forest, Illinois, USA) injected
into the retrobulbarspace
Atkinson needle (BD, Franklin Lakes, New Jersey,
USA) inserted via an inferior orbital approach.
Indirect ophthalmoscopy was performed with 360o
scleral depression of the peripheral fundus. Retinal
cryopexy(Frigitronics,
USA) was performed about the tear(s) in 61 cases
(79.2%). In 16 cases, peripheral retinal laser
witha25-gauge
Trumbull,Connecticut,
Doheny Eye Institute,
University of Southern
California, Los Angeles,
California, USA
Correspondence to
Dr J Sebag, Professor of Clinical
Ophthalmology, University of
Southern California, VMR
Institute, a Medical Corporation,
7677 Center Avenue, suite 400,
Huntington Beach, CA 92647,
USA;
jsebag@VMRinstitute.com
Accepted 31 July 2011
Published Online First
6 September 2011
1728 Br J Ophthalmol 2011;95:1728e1730. doi:10.1136/bjophthalmol-2011-300114
Clinical science
group.bmj.com on January 20, 2012 - Published by bjo.bmj.comDownloaded from

Page 2

photocoagulation (Novus 2000 Laser with indirect ophthalmo-
scope; Coherent, Palo Alto, California, USA) was administered
during the first few postinjection days, after the retina was
reattached. Using full-strength Betadine (Alcon, Fort Worth,
Texas, USA), the external globe and fornices were sterilised and
then irrigated with balanced salt solution. A total of 0.8 cc of
filtered (0.45 mm pore size; Millipore, Billerica, Massachusetts,
USA) air was injected via a stab incision through the infer-
otemporal or inferonasal pars plana (3.5e4.0 mm posterior to
the limbus) using a 30-gauge needle. Indirect ophthalmoscopy
was used to visually position the needle tip in order to ensure
the formation of a single large bubble with a moderately slow
injection. A paracentesis was performed at the limbus with a
30-gauge needle. Patients were instructed on proper head posi-
tioning so that the retinal tears were in the uppermost position.
They were asked to maintain that position continuously with
the exception of meals and hygiene until the bubble dissipated,
which occurred within 5 days in all cases.
RESULTS
A minimum of 6-month follow-up evaluation was obtained in
76 cases. One patient died 3 months postoperatively. The
follow-up duration ranged up to 186 months, with an average
follow-up period of 40.7642.1 months. Nearly half (46.8%) of
the cases had a follow-up duration of 2 years or more. Nineteen
of 77 eyes (24.7%) had a follow-up duration of 5 or more years,
and 13/77 (16.9%) had 10 or more years of follow-up.
There were no systemic or ocular complications related to the
retrobulbar anaesthesia. Complete retinal reattachment was
achieved in 62/77 (80.5%) eyes after a single PR procedure with
pure air. Of the 11 patients with inferior (below 3:00 and 9:00
o’clock) tears in attached retina, 10/11 (90.9%) had successful
retinal reattachment in one procedure by air PR performed in
combination with cryopexy of the inferior tears. Reattachment
was achieved in a single operation in 42/51 (82.4%) phakic, 22/
26 (84.6%) pseudophakic and 1/3 (33.3%) aphakic patients. Four
patients required a second pure-air PR procedure due to a new/
missed tear in the superior fundus, and one of these patients
required a third PR to treat a new superior tear 18 months after
the first procedure. This patient had high myopia with a refrac-
tive error of ?6.00 dioptres. Eleven of 77 (14.3%) cases required
a scleral buckle operation due to a new/missed tear in the infe-
rior fundus. Two scleral buckle patients (2.6%) underwent
vitrectomy surgery status post PR, one of which was the only
patient (1/77¼1.3%) who developed a premacular membrane
inducing macular pucker. No cases of PVR developed following
office-based pure-air PR. The final attachment rate after
reoperations was 100%.
Figure 1 shows that there was improvement in vision from
a Snellen visual acuity of $20/40 in 29/77 (37.7%) cases preop-
eratively to 50/77 (64.9%) cases postoperatively. Visual acuity
increased two or more lines in 53.2% (41/77) of cases, while 26/
77 (33.8%) of cases had the same (within two lines) preoperative
and postoperative visual acuities. Thus, 67/77 (87%) of the
patients in this study had the same or better visual acuity at the
end of the evaluation period. Forty-four of 51 (86.3%) phakic
patients, 21/23 (91.3%) pseudophakic patients and 2/3 (66.6%)
aphakic patients had the same Snellen VA or better.
DISCUSSION
While previous studies2
usefulness of pure air, which is often used intraoperatively
during vitrectomy surgery, this study demonstrates the long-
term efficacy of office-based PR using pure air. The approach
achieves a single-operation reattachment rate comparable to PR
using long-acting expansile gases. Furthermore, the long-term
1314have shown the short-term
Table 1
Summary of clinical data
Number
(unless otherwise indicated)
Average age (years)
Men
Women
OD
OS
Phakic
Pseudophakic
Aphakic
Myopia (> ?6 dioptres)
Extent (clock hours)
Tears
Cryopexy applied
Laser applied
SOS
Repeat air PR success
Scleral buckle
Length of FU (months)
FU at least 6 months
FU at least 24 months
FU at least 60 months
FU at least 120 months
Macula off
Macula on
Inferior tears in attached retina
Cases of inferior tears needing SB
Postop premacular membrane
Postop proliferative vitreoretinopathy
Preop VA 20/40 or better
Postop VA 20/40 or better
VA unchanged (within 2 lines)
VA improvement ($2 lines)
61.3613.2
45
31
43
34
51
23
3
10
4.662.5
1.661.0
61
16
62
4
11
40.7642.1
76
36
19
13
37
40
11
1
1
0
29
50
26
41
59.2%
40.8%
55.8%
44.2%
66.2%
29.9%
3.9%
13.0%
79.2%
20.8%
80.5%
5.2%
14.3%
98.7%
46.8%
24.7%
16.9%
48.1%
51.9%
14.3%
9.1%
1.3%
0.0%
37.7%
64.9%
33.8%
53.2%
FU, follow-up; OD, right eye; OS, left eye; PR, pure-air pneumatic retinopexy; RD, retinal
detachment; SB, scleral buckle; SOS, single-operation success; VA, Snellen visual acuity.
Figure 1
postoperatively. Points above the diagonal line represent improvements
in VA, and points below the line represent worsened VA. Points on or
within 1 Snellen unit of the line represent no change. The arrow indicates
a patient with an inferior tear requiring a secondary scleral buckle and
vitrectomy surgery. The triangle marker indicates the one case of
postoperative premacular membrane requiring vitrectomy surgery. A
plus sign indicates cases requiring a secondary scleral buckle operation.
Scattergram of visual acuity (VA) preoperatively and
Br J Ophthalmol 2011;95:1728e1730. doi:10.1136/bjophthalmol-2011-3001141729
Clinical science
group.bmj.com on January 20, 2012 - Published by bjo.bmj.comDownloaded from

Page 3

efficacy has been shown by this study to be on the order of
years. Although some studies using long-acting expanding gas
have had single-operation success rates as low as 54%12and
59.4%,15pure-air PR achieves a single-operation success rate of
80.5%, a repeat PR success rate of 85.7% and a final reattach-
ment rate of 100%, which are comparable to other studies of
expanding gas PR.4It is not clear why some studies had such
low success rates, but clinical experience has underscored the
importance of case selection and careful preoperative examina-
tion of the fundus. To that end, this study excluded subjects
with vitreous haemorrhage and early PVR, factors known to
predispose to recurrent retinal detachment (RD). The most
common cause of recurrent RD following PR is the formation of
a new retinal tear,16although some of these are likely to have
existed at initial presentation. Prior to PR in our study, inferior
tears were identified in 11/77 (14.3%) eyes, a finding that if
undetected could have resulted in recurrent RD. Only 1/11
(9.1%) patient with inferior tears required a secondary operation
(scleral buckle with vitrectomy), while 10/11 (90.9%) patients
with inferior tears were reattached after a single PR that
included cryopexy of the inferior tears in attached retina at the
time of PR.
Vision improvement following pure-air PR is comparable to
that of PR using expansile gases,4with 86% of patients attaining
the same or better visual acuity postoperatively and nearly two-
thirds (50/77) attaining visual acuity $20/40. More than half
(41/77) of patients improved by two lines or more. Some cases
of superior RD with macular attachment improved because RD
repair resolved the overhanging superior retina which substan-
tially blocked the macula, lowering visual acuity. This study
furthermore demonstrates that these beneficial results are
sustained over long periods of time, with nearly half of the cases
observed for 2 years or more and a fourth of cases observed for
5 years or more.
While PR has previously been shown to be an effective
treatment for primary rhegmatogenous RD,4the common use of
long-acting expansile gases can cause changes to the retina and
ciliary body5and is associated with postoperative PVR in up to
10% of cases and premacular membranes with pucker in 3%.4In
our study, no patients developed PVR and only 1/77 (1.3%)
developed a premacular membrane with macular pucker,
confirming previous findings with pure-air PR13and suggesting
that short-term internal tamponade can yield long-term benefits
with a low risk of complications and untoward sequelae.
However, a potential drawback of pure-air PR is the need for
a larger volume injection and consequent obligatory paracentesis
in each case. In spite of this, there were no complications in any
of the 77 cases related to the larger injection volume or the
paracentesis. Also, the short duration of internal tamponade
provided by pure air may be considered a limitation. Clinical
experience has shown, however, that even relatively extensive
retinal detachments flatten after a day or two, while an air
bubble can remain for up to 5 days.4 13 14Clinical experience17 18
has also shown that, with proper case selection and good patient
compliance (positioning), a couple of days are all that is needed
to attain successful retinal reattachment.
Office-based PR with pure air achieves a high success rate for
primary RD in a relatively short period of time without incur-
ring surgical and hospital-related costs. The use of unmonitored
retrobulbar anaesthesia as opposed to monitored or general
anaesthesia contributes to a quicker recovery, reduced costs and
greater accessibility. This study suggests that retrobulbar
anaesthesia is a safe option in an office setting without patient
monitoring and the supervision of an anaesthetist. The wide-
spread availability of air makes this approach practical in
healthcare settings that do not have an inventory of expansile
gases. Furthermore, PR with expansile gases prolongs the
recovery time during which patients must maintain proper head
positioning and cannot travel to high altitudes or by plane.
Thus, office-based pure-air PR makes possible the repair of RD in
underdeveloped countries with limited healthcare resources.
Furthermore, in these times when the ‘developed’ world is
grappling with the rising costs of healthcare, there is great value
to simplifying the RD repair process and lowering healthcare
costs.17 18
Acknowledgements Thanks to Sherry Christofferson for all your insight and
guidance with this work.
Competing interests None to declare.
Ethics approval This was a retrospective case series which reviewed the clinical
results of one option of treating retinal detachment. Informed patient consent was
obtained in each case, and strict patient confidentiality was maintained throughout the
study.
Contributors Kenneth M.P. Yee was responsible for data collection, data analysis and
writing the manuscript. Doctor Jerry Sebag performed all examinations and surgical
procedures as well as writing the article and is the guarantor of this manuscript.
Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES
1.
Gonin J. Divergences of principles and differences of technics in the treatment of
retinal detachment. Am J Ophthalmol 1934;17:74e9.
2.
Mura M, Tan SH, De Smet MD. Use of 25-guage vitrectomy in the management of
primary rhegmatogenous retinal detachment. Retina 2009;29:1299e304.
3.
Rosengren B. Results of treatment of detachment of the retina with diathermy and
injection of air into the vitreous. Acta Ophthalmol 1938;16:573e9.
4.
Chan CK, Lin SG, Nuthi AS, et al. Pneumatic retinopexy for the repair of retinal
detachments: a comprehensive review (1986-2007). Surv Ophthalmol
2008;53:443e78.
5.
Juzoji H, Iwasaki T, Usui M, et al. Histological study of intraocular changes in rabbit
after intravitreal gas injection. Jpn J Ophthalmol 1997;41:278e83.
6.
Ogura Y, Tsukada T, Negi A, et al. Integrity of the blood ocular barrier after
intravitreal gas injection. Retina 1989;9:199e202.
7.
Lincoff H, Kreissig I, Jakobiec F, et al. Gas vitrectomy in a primate model. Graefes
Arch Clin Exp Ophthalmol 1986;224:215e17.
8.
Lincoff H, Horowitz J, Kreissig I, et al. Morphological effects of gas compression on
the cortical vitreous. Arch Ophthalmol 1986;104:1212e15.
9.
Silvanus MT, Moldzio P, Bornfeld N, et al. Visual loss following intraocular gas
injection. Dtsch Arztebl Int 2008;105:108e12.
10.
Lisle C, Mortensen KK, Sjølie AK. Pneumatic retinopexy: a long term follow-up
study. Acta Ophthalmologica Scand 1998;76:486e90.
11.
Eter N, Bo ¨ker T, Spitznas M. Long-term results of pneumatic retinopexy. Graefes
Arch Clin Exp Ophthalmol 2000;238:677e81.
12.
Zaidi AA, Alvarado R, Irvine A. Pneumatic retinopexy: success rate and
complications. Br J Ophthalmol 2006;90:427e8.
13.
Sebag J, Tang M. Pneumatic retinopexy using only air. Retina 1993;13:8e12.
14.
Sinawat S, Ratanapakorn T, Sanguansak T, et al. Air vs perfluoropropane gas
pneumatic retinopexy. Arch Ophthalmol 2010;128:1243e7.
15.
Day S, Grossman DS, Mruthyunjaya P, et al. One-year outcomes after retinal
detachment surgery among medicare beneficiaries. Am J Ophthalmol
2010;150:338e45.
16.
Mudvari SS, Ravage ZB, Rezaei KA. Retinal detachment after primary pneumatic
retinopexy. Retina 2009;10:1e5.
17.
Hilton GF, Das T, Majji AB, et al. Pneumatic retinopexy: principles and practice.
Indian J Ophthalmol 1996;44:131e43.
18.
Lincoff H, Kreissig I. Changing patterns in the surgery for retinal detachment: 1929
to 2000. Klin Monatsbl Augenheilkd 2000;216:352e9.
PAGE fraction trail=3
1730Br J Ophthalmol 2011;95:1728e1730. doi:10.1136/bjophthalmol-2011-300114
Clinical science
group.bmj.com on January 20, 2012 - Published by bjo.bmj.com Downloaded from

Page 4

doi: 10.1136/bjophthalmol-2011-300114
September 6, 2011
2011 95: 1728-1730 originally published online Br J Ophthalmol

Kenneth M P Yee and J Sebag
retinopexy using pure air
Long-term results of office-based pneumatic

http://bjo.bmj.com/content/95/12/1728.full.html
Updated information and services can be found at:
These include:
References

http://bjo.bmj.com/content/95/12/1728.full.html#ref-list-1
This article cites 18 articles, 3 of which can be accessed free at:
service
Email alerting
the box at the top right corner of the online article.
Receive free email alerts when new articles cite this article. Sign up in
Collections
Topic
(379 articles)Public health
?
(967 articles) Ophthalmologic surgical procedures
?
(1213 articles) Retina
?

Articles on similar topics can be found in the following collections
Notes

http://group.bmj.com/group/rights-licensing/permissions
To request permissions go to:

http://journals.bmj.com/cgi/reprintform
To order reprints go to:

http://group.bmj.com/subscribe/
To subscribe to BMJ go to:
group.bmj.com on January 20, 2012 - Published by bjo.bmj.comDownloaded from