Retinal detachment surgeries, principles and technique of pneumatic retinopexy, current trend in retinal detachment surgeries, development of skills in binocular indirect ophthalmoscopic examination, residency traning presentation, University college hospital Ibadan, Oyo state Nigeria, Vitreo-retinal subspecialty training, West african college of surgeons, federal teaching hospital, Lokoja, Kogi state, Nigeria.

1. Principles and
technique of Pneumatic
Retinopexy (PR)
Presented
By
Dr. Avuru Chukwunalu James
21st August, 2023

2. OUTLINE
• Introduction
• Indications and contraindications
• Advantages and disadvantages
• Procedure/ Techniques
• Complications
• Conclusion

3. Introduction
• Pneumatic retinopexy is an office-based non-incisional
procedure for the repair of selected cases
of rhegmatogenous retinal detachment.
• Repairing of retinal detachments by retinopexy
followed by gas endotamponade was first described by
Rosengren in 1938.
• Modernized and popularized by Hilton and Grizzard
in their 1986 publication and deemed an outpatient
procedure.
• In the USA, 15% of retinal detachments are repaired
by pneumatic retinopexy.

4. Introduction contd
• About 16% of VR surgeons in the
UK and Ireland perform regular PR.
• 40% of all rhegmatogenous RD can
be repaired using PR.
• Under-utilized due to
• Belief: relief of vitreoretinal traction
• Skills in localization of retinal break.
• An alternative to scleral
buckle and pars plana vitrectomy in
selected cases

5. Indications
• Retinal detachment with retinal
break(s) in the superior 2/3 of
the fundus (from 8 to 4
o’clock)
• Single or multiple breaks
within 1 clock hour
• Clear media or mild media
opacity
• No glaucoma history
• Head positioning for 5-8 days
after procedure

6. Contraindications
• RD with breaks in the inferior
4 clock hours
• PVR of Grade C or D.
• Extensive lattice degeneration
or VR adhesions.
• Significant media opacity
• Advanced glaucoma
• Unable to maintain
postoperative head positioning.

7. Contraindications contd
• Travel to a high altitude
soon after surgery
• Pseudophakia or aphakia
(relative contraindication)

8. Advantages of PR
• Outpatient procedure
• Less discomfort than
operating room procedures
• Little to no need for general
anesthesia
• No risk of inadvertent
scleral perforation

9. Advantages of PR contd
• No change in refractive
error
• No risk of diplopia
• Lower risk of
endopthalmitis
• Faster ocular and systemic
recovery
• Lower cost of surgery

10. Disadvantages
• Single-operation success rate is lower than scleral
buckle and PPV(higher frequency of new and
missed retinal breaks).
• PIVOT trial: a single center, randomized clinical
trial (Hillier et al, 2019).
Compared the outcomes of primary PR in 77 eyes
versus primary pars plana vitrectomy (PPV) in 73
eyes with primary RRD.
Single operation anatomic success rate was better in
PPV (93.2%) compared with PR (80.8%).

11. PIVOT trial
• Final anatomic success rate was similar in both groups
PPV(98.7%) and PR (98.6%).
• Visual acuity outcomes with PR were superior to those
obtained with PPV
• The mean best corrected VA at 12 months was 79.9
letters (ETDRS) in the PR group compared with 75
letters in the PPV group.
• Proportion of eyes achieving ≥ 20/40 was 90.3% in PR
and 75.3% in PPV group.
• Patients who had PR scored higher in mental health and
vision-related functioning scores than patients who had
PPV in the first 6 months following procedures.

12. PIVOT trial contd
• Retinal displacement induced
by PR was significantly less
(compared to PPV).
• Vertical metamorphopsia
scores were superior in PR
group too (compared to PPV
group).

13. PR versus scleral buckle
• Study byTornambe et al: macula
involving RRD within 14 days
post-op
• visual outcomes: PR group better
than SB group.
• Chan et al(1986-2007): primary
success rate in retina
reattachment with a single PR
procedure
• in phakics to be between 71% and
84%.
• In pseudophakics to be between
41% and 67%.

14. Disadvantages contd
• Good retinal examination
skills needed
• Not all detachments are
amenable to repair with PR
• Significant patient
cooperation and head
positioning required
• Skills in detection and
management of
postoperative complications
needed.

15. PHASES OF SURGERY
• PR involves
1. Injection of expanding gas bubble and patient’s
head positioning.
 Bubble closes the retinal break.
 Permits resorption of subretinal fluid.
2. Induction of a chorioretinal adhesion around
all retinal breaks with cryopexy, laser, or both.

16. Two steps vs one step procedure
• One step surgery done in the same surgery session (the same
day)
• inducing chorioretinal adhesion with cryopexy
• intraocular gas injection
• Two steps surgery
• Intraocular gas injection is done first
• Then induction of chorioretinal adhesion with laser
retinopexy is done 24-48hrs post intraocular gas injection
when the retina is flat.

17. Choice: cryopexy or laser
retinopexy
• Lasers preffered for
• Small pupil
• Clear media
• More posterior breaks
• Retinal cryopexy is
technically easier for
 Higher media opacity
 peripheral breaks,
especially for small or hard-
to-find breaks.

18. Pre-operative planning-materials
• Instruments
Sterile Gloves
Betadine solution (5% and
10%)
Xylocaine 1%/Marcaine
0.5%
2% Lidocaine
Antibiotic/steroid ointment
Lid speculum
Conjunctival forceps
Cotton-tipped applicators
Two tuberculin syringes
with two 27g 1/2-inch
needles(or 30 gauge)
Laser or Cryotherapy unit
Intraocular gas (SF6 or
C3F8)
Millipore filter, 0.22 µm
Indirect ophthalmoscope

19. Choice of Gas
 Depends on required
Level of expansion
Duration of gas tamponade
Availability
Cost
• Most commonly utilized
intraocular gases.
• SF6
• C3F8 (larger or multiple
breaks)
Used in their pure (100%
concentration) form but
usually diluted when used
in vitrectomy surgery.

20. Intraocular gasses

21. Ocular Examination
findings- Needed as a guide
 Reconfirm all areas of
pathology
Visual acuity
Intraocular pressure
Anterior segment
examination
Fundus examination
Media clarity
Status of Optic disc
Status of the macular
Configuration of SRF
Localization of break
Fundus diagram

22. Anaesthesia
• Subconjunctival anaesthesia +
topical drops : No cryotherapy
• Retrobulbar or peribulbar
anaesthesia
• comfortable scleral depression,
• cryotherapy to any quadrant
• reduces chances of vaso-vagal
response
• General anesthesia(rarely)
• avoid nitrous oxide gas in general
anaesthesia: shrinkage of
intraocular gas bubble.

23. Procedure
• Comfirm pupil is dilated
• Instill 3-5 drops of topical
anesthesia into the eye.
• Insert lid speculum.
• Subconjunctival anaesthesia to
the quadrant with retinal break.
• 5% povidone-iodine solution (3-
5 drops) instilled and irrigated
with saline after 5 minutes.

24. Single sitting procedure-one step
• Topical anaesthesia + retrobulbar
block / peribulbar anaesthesia
• External eye and fornices prepared
(as above).
• Trans-conjunctival cryopexy under
visualization via BIO
• around retinal breaks
• degenerative lesions.

25. Cryotherapy
• MECHANISM: Uses
• freezing temperature to convert
liquids to solids
• intracellular and extracellular
water to ice.
• Leads to tissue death and a
sterile inflammatory reaction.

26. Cryopexy procedure contd
• STEPS: Check cryoprobe by
freezing and unfreezing a few
times.
• Place probe over conjuctivo-
scleral area with view of retinal
break.
• Initiate freezing
• Observe for retina whitening.
• Spray water on cryoprobe, wait
for complete melting of ice-ball
before removing from sclera.
• Thaw and repeat again around
retinal breaks and degenerative
lesions.

27. Procedure contd-AC paracentesis
• Done to lower the intraocular
pressure.
Stabilize the eye with a cotton-
tip swab
Use 27 or 30-gauge needle
attached to a tuberculin syringe
to enter the AC at the
inferotemporal limbus.
0.3-0.5ml of aqueous humor is
withdrawn.
Softens the eye
Less chances of fish-eggs
bubble formation.

28. Procedure- gas prepation(
wuthdawal into syringe)
• 0.3 mL (C3 F8) or 0.5-0.6mL
(SF6)
• Filtered through a millipore
filter (0.22 µm) into a 1-mL
syringe with a 27- or 30-
gauge needle.

29. Procedure- postioning during gas
injection
• Patient lying in a supine
position( majority of cases).
• Patient lying in the upright
position (rarely)
• In patients with elevated
intraocular pressure;
reduces tendency for
a. gas migration into
anterior chamber.
b. vitreous prolapse into the
anterior chamber.

30. Procedure contd
• Injection site: 3mm, 3.5mm
and 4mm
• Patient in the supine position;
 inject through a superior
quadrant and away from
the most bullous area of
detachment
• Needle
• perpendicular to the sclera
• point downward toward the
center of the vitreous
cavity.

31. Procedure contd
• Insert the needle (depth of 6-7
mm) into the vitreous cavity.
• then partially withdraw until
only 2-3 mm remains in the
vitreous.
• Slowly and continously inject
the gas into the same single
enlarging gas bubble (avoids
formation of “fish-egg”
bubbles).
• Injected away from any large
retinal break

32. Procedure contd
• During needle withdrawal,
• place a cotton-tipped
applicator over the
perforation site
• rotate patient’s head to
prevent gas from escaping
through the puncture site.
• Perform indirect
ophthalmoscopy to
• confirm the placement of
the gas into the vitreous
cavity
• assess the perfusion of the
central retinal artery
• confirm light perception.

33. Procedure contd
• If central retinal artery
remains non-pulsatile 10
minutes after gas injection,
• paracentesis is repeated to
reduce the risk for
ischemic retinal damage
• Antibiotic or
antibiotic/steroid ointment
combination applied to the
eye
• Patching is optional

34. Head positioning
• Patient’s head is immediately
positioned so that the gas
bubble is apposed directly to the
break
• Macular threatening retinal
detachment:
• consider the steamroller
technique to prevent
subretinal fluid displacement
into the macula.

35. Head positioning-steamroller
technique
• Head is initially turned to a face-
down position.
• Gradually change position over
10-15minutes until the retinal
break is uppermost.
• Allows the bubble to roll
toward the retinal break.
• Pushes the subretinal fluid
away from the macula and
back into the vitreous cavity
through the retinal break.
• Flattening the retina.

36. Steamroller technique-
disadvantage
• Potential for proliferative
vitreoretinopathy
development.
• RPE cells within the
subretinal fluid pushed
back into the vitreous
cavity.

37. Head positioning after surgery
• Instruct the patient on
the proper head-
positioning
• Clock hour drawing
• an arrow in the clock
hour of the retinal
tear
• head positioning so
that the "arrow" is
pointing straight up.

38. Post-surgery head positioning
contd
• Family member can take a
picture of
• head position while in
the office
• reference this picture
at home to properly
position.
• To maintain head position
for up to 16 hours per day
for 5-8days.

39. When fish egg bubbles form
• May be caused by
Injection of gas too
quickly
Needle too deep into the
vitreous during injection
• Gentle tapping on the eye to
make the bubbles coalesce.
• positioning the bubbles away
from the break for 24 hours
allow them to coalesce
prevent subretinal gas.

40. Gas migration- Canal of Petit/
anterior hyaloid
• May occur if
needle not inserted deeply
enough
needle inserted too anteriorly.
• Bubble seen floating behind the
lens (“donut sign” or “sausage
sign”)
• MGT: observe face-down
positioning for 24-48hrs
gas migrate into the vitreous
as it expands

41. Anterior hyaloid gas drainage
• If above fails:
passive drainage via
previous gas insertion site
 with a 27-gauge needle
on a plungerless 3-cc
syringe partially filled
with 1cc of sterile water.
Reinjection of gas with
proper needle placement can
be done.

42. Gas migration contd- Gas in the
anterior chamber
• May be due to
lens capsular rent
zonular compromise
a. Pupillary dilation followed
by face-down positioning
b. Anterior chamber
paracentesis with a 27-gauge
needle.

43. Subretinal gas migration
• May occur if
a. injection site is too close to
retina break
b. Inappropriately injection
under the retina
c. Injected with formation of
“fish egg" bubbles
d. Retinal breaks larger than 1
clock hour
• A small amount of subretinal gas
can be resorbed without
positioning.

44. Subretinal gas migration
• Larger bubble requires head positioning:
a. Positioning for 24hrs so that bubbles migrate away
from the tear.
b. Patient lying in a supine position to release subretinal
gas into the vitreous by;
tilting the head so that the break is at the most
superior position
gentle scleral depression may release the
subretinal gas into the vitreous cavity.
• Pars plana vitrectomy and removal of subretinal gas to
avoid expansion in the subretinal space and tear.`

45. Intraocular pressure changes post
injection
• Not a significant problem after the intraocular injection of
less than 0.5 mL of gas.
• Immediate elevation of intraocular pressure to levels
between 30 and 50 mm Hg is common,
• Pressure however returns to normal after 90 minutes.
• A 0.3% incidence of ischemic optic neuropathy following
elevated IOP post PR was reported by Tornambe (1997).
• Elevation of IOP beyond normal can be managed with
additional anterior chamber paracentesis or
topical/systemic IOP-lowering drops.

46. Postoperative/follow up Care
• Head positioning for 5-8 days to orient gas bubble at the site of the
tear(s).
Must position for 16 hours per day, with 15-minutes breaks each
hour.
• Antibiotic or antibiotic/steroid eyedrops four times per day, usually
for 1 week
• Examine patient daily until the retina is attached; if the retina is not
attached by 2nd day post-op, suspect causes of failure.
• New break, missed break, small gas size, patient not positioning
adequately may cause early failure
• Peripheral inferior subretinal fluid may persist for weeks to
months though with a decreasing trend of SRF quantity.

47. Retinal Laser retinopexy
• Dilate the pupil
• Laser delivery system: Use slit lamp or
LIO
• Instill topical anaesthetic and position
patient.
• Laser: Argon blue-green, Nd-YAG
Lasers
• Duration of 0.1 to 0.2 seconds
• spot sizes of 200 to 500 microns
• Surround retinal break with 2-3 near-
confluent rows of laser.
• Supplemental lasers until SRF is
completely resolved

48. Postoperative/follow up Care contd
• 1st day post-op.
• Fifth day or 1week post-op.
• 2 weeks post-op.
• Monthly follow-up for 3 months.
• Every 3 months for a minimum of 6 months.
• Management of postoperative complications and
additional surgery if indicated.

49. Complications-subconjunctival gas
• May be due to
incomplete penetration of the
sclera by needle
leakage of gas from injection
site.
• Treatment is not required.
• Prevent subconjunctival gas by
 Proper needle insertion into
the vitreous cavity
 Immediate placement of
cotton-tipped applicator on
the injection site after
removal of the needle.

50. Complications-Corneal wound
dehiscence
• Risk factors: previous cornea
wound/scars
• Full-thickness corneal wounds
never regain their original tensile
strength.
• After intravitreal gas injection,
sudden rise in IOP may be up to
180 mm Hg
Can stress and rupture corneal
scars.
• Reduced by slowly injecting a
smaller gas volume in patients
with risk factors.

51. Complications-Surgical failure due
new or missed breaks:
New breaks with re-RD
reported post PR at a rate of 7-
22%.
New or missed breaks occur
mostly in the superior 8 clock
hour (76% ).
Treat with additional gas
injection + cryotherapy or laser
retinopexy.
Inferior quadrants new breaks
 with scleral buckling
and/or PP vitrectomy.

52. Complications-cataract progression
• Not common after pneumatic
retinopexy (PR).
• No significant difference in
lens opacity (operated vs non-
operated eyes) at 2 months post
PR.(Koch et al,1991)
• Minimized cataract
Careful placement of the
paracentesis needle
Avoiding contact between
the intraocular gas and the
lens (adequate head
positioning).

53. Complications-endophthalmitis
• Incidence post PR is very
low (0.97% cases of
staphylococcal
endophthalmitis reported by
Tornambe and Hilton
(1989).
• Can be reduced by
a. meticulous with the
sterile techniques.
b. use of 5% povidone
iodine solution prior to
intraocular injection of
gases

54. Complications- Intraocular/ orbital
hemorrhage
• Intraocular hemorrhage is rare
• May be due to
injury anterior ciliary vessels
(injection site)
rupture of scleral vessels
(cryotherapy)
• Reduce by
avoiding injection along the
vertical and horizontal meridians
(anterior ciliary vessels).
Tip of cryoprobe should be
allowed to thaw before removal
from the ocular surface.

55. Complications- Choroidal
detachment (CD)
• Not common post PR
• Incidence of 3% post PR (Tornambe
and Hilton,1989).
• Suspect CD if prolonged and severe
pain occur shortly after gas injection
(gas injected into suprachoroidal
space).
• Pain: stretching of the ciliary nerves
by the gas.
• Prevent CD by
Avoiding hypotony during
paracentesis
Reducing excessive cryotherapy

56. Complications-cystoid macular
edema
• Not common after pneumatic
retinopexy.
• Risk factors include history of
uveitis, prior cataract extraction,
and macular detachment.
• Can be reduced by avoiding
excessive retinopexy
• Medical treatment: Topical
steroidal and nonsteroidal anti-
inflammatory medications.

57. Complications-Macular hole
• May be due to vitreomacular
traction during the
perioperative period.
• Expansion of the intraocular
gas produces a vitreomacular
detachment
• Stress of shifting of a large
amount of subretinal fluid
under the macular.
• Treatment is by conventional
surgical techniques such as
PPV.

58. Epimacular fibrosis and macular
pucker
• Incidence of 4% of
asymptomatic epimacular
membrane post PR has been
reported.
• Minimize risk by avoiding
excessive cryotherapy
laser retinopexy

59. Complications-Proliferative
vitreoretinopathy
• Incidence: 9.6-9.8% post PR
(9.8% Chen et al, 1988)
• No difference in incidence of
PVR (cryotherapy versus
laser): 9.6%, Tornambe, 1997.
• May be caused by
Excessive release of RPE
cells into the vitreous
Gas bubbles
• PVR post PR can be treated
with PPV and membrane
stripping.

60. Complications-Musculoskeletal
• Due to consistent head tilt for a prolonged period.
• Worse among elderly patients.
• They include cervical spine injury, neck muscles and
lower back pain, ulnar nerve neuropathy.
• They are minor and temporal problems.
• PREVENTIVE MEASURES: Use of pillow, cushion,
table, desk (with the correct height)
• TREATMENT: analgesics, heating pad, muscle relaxants
to relieve musculoskeletal discomfort.

61. Pneumatic retinopexy in inferior
Breaks
• PR ; an adjunctive role for RD
with inferior breaks.
• Studies involving maintaining
an inverted posture for 8 hours
following PR
Restricted to highly
motivated patients.
IOP increases significantly
in the head-down position
(not indicated in
glaucomatous eyes)

62. PR in inferior Breaks contd
 After PR for inferior retinal
breaks post failed scleral
buckle; posturing with a
combined
10° Trendelenburg
position
10° neck hyperextension
10° ocular supraduction
• Had 88% success rate
(Mansour et al, 2005).

63. Pneumatic retinopexy in inferior
Breaks contd
• Lateral recumbent posture:77% success rate with
inferior detachments. (Hwang et al, 2011)
• Use of a temporary buckle in the inferior fornix
combined with a face-down position with 5°–10° of
neck flexion achieved 88% primary
reattachment success. (Cheng et al, 2013).
• Previous SB or PPV has been done in majority of these
patients
 therefore, success in PR as a primary procedure for
RD with inferior retinal breaks have only few
reported successful cases.

64. Adaptability to our environment
• Cost
• Complications
• Visual prognosis
• Skills
• Time of presentation

65. Conclusion
• Pneumatic retinopexy is currently underutilized
despite its effectiveness in selected cases.
• Adequate skills in BIO examination, localization of
retinal breaks and patient’s motivation to head
positioning are essential.
• Success involves adequate surgeon’s experience,
good patient selection, patience and effective doctor-
patient communication.

66. REFERENCES
• Lihteh Wu. Pneumatic Retinopexy. Medscape. Updated: Mar 13, 2023
[accessed Aug 12th, 2023]. Available from
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26, 2023 2023.[accessed Aug 12th, 2023]. Available from
https://eyewiki.aao.org/Pneumatic_Retinopexy.
• Wong TY. SNG C, Lim L. The ophthalmology examinations review.
Pneumatic retinopexy. 2nd Ed. Singapore: World Scientific Publishing;
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• Mandelcorn ED, Manusow JS, Mandelcorn MS. Pearls for Performing
Pneumatic Retinopexy. Retina specialist. November 13, 2015[ Accessed
August 15, 2023]. Available from https://www.retina-
specialist.com/article/pearls-for-performing-pneumatic-retinopexy
• Stewart S, Chan W. Pneumatic retinopexy: patient selection and specific
factors. Clin Ophthalmol. 2018 Mar 16;12:493-502. doi:
10.2147/OPTH.S137607. PMID: 29588570; PMCID: PMC5859893
• Silva RA, Blumenkranz MS. Prophylaxis for Retinal Detachments.
AAO. Oct 29, 2013. [Accessed August 15, 2023]. Available from
https://www.aao.org/education/munnerlyn-laser-surgery-
center/prophylaxis-retinal-detachments

67. REFERENCES contd
• Tornambe PE. Pneumatic retinopexy. Surv Ophthalmol. 1988 Jan-
Feb;32(4):270-81. doi: 10.1016/0039-6257(88)90175-0. PMID:
3279561.
• Chan CK, Lin SG, Nuthi AS, Salib DM. Pneumatic retinopexy for
the repair of retinal detachments: a comprehensive review (1986–
2007) Surv Ophthalmol. 2008;53(5):443–478.
• Cheng HC, Lee SM, Lee FL, Liu JH, Kuan CH, Lin PK. Short-
term external buckling with pneumatic retinopexy for retinal
detachment with inferior retinal breaks. Am J
Ophthalmol. 2013;155(4):750.e1–756.e1.
• Hwang JF, Chen SN, Lin CJ. Treatment of inferior
rhegmatogenous retinal detachment by pneumatic retinopexy
technique. Retina. 2011;31(2):257–261.
• Mansour AM. Pneumatic retinopexy for inferior retinal
breaks. Ophthalmology. 2005;112(10):1771–1776.

68. THANK YOU