Delhi Journal of Ophthalmology

Pneumoretinopexy In Unusual Situations: Our Experience

Kalpana Badami Nagaraj, Shilpa Y Devegowda, Kavitha L Tumbadi, Bhavna Govindaraj, 
Ridhi Bhandary, Spurti Nataraj Vishrutha Sushekar
Department of Vitreoretina, Minto Ophthalmic Hospital & Regional Institute Of Ophthalmology, Chamarajpet, Bengaluru, India

Corresponding Author:

Kalpana Badami Nagaraj 
HOD Ophthalmology &  Chief of Department of Vitreoretina, DOMS, DNB, FMRF (Shankar Nethralaya), FRCS (Glasgow)
Minto Ophthalmic Hospital & Regional Institute Of Ophthalmology, Chamarajpet, Bengaluru: 560014. badamikal@gmail.com 

Received: 03-NOV-2019

Accepted: 21-OCT-2020

Published Online: 12-MAR-2021

DOI:http://dx.doi.org/10.7869/djo.622

Abstract
Aim: To report the anatomical and visual outcome in patients who underwent pneumoretinopexy (PnR) as a primary procedure in unusual situations. 

Material Method: A prospective interventional analysis of 5 patients who underwent PnR as the primary treatment for rhegmatogenous retinal detachment ( RRD), where either scleral buckling / vitrectomy was advised. Of the 5 patients with RRD, 1st had left eye subtotal RRD with superotemporal break of more than 1 clock hour size with grade A PVR changes, 2nd had left eye subtotal RRD with superonasal break with grade A PVR changes with torticollis, 3rd had left eye near total RRD with superotemporal break with grade A PVR changes, 4th was one-eyed with right eye total RRD with superior break with grade C PVR changes, and 5th had right eye temporal RRD with 2 retinal breaks which were more than 2 clock hours apart with grade A PVR changes. Trial of PnR with appropriate head positioning was done in all patients. Patients were followed up on postoperative day 1, 1 week, 1 month and 6 months. Anatomical and visual outcomes were assessed. 

Results: All patients had good anatomical and visual outcomes. 

Conclusion: PnR can be considered as a primary treatment option in some simple RRDs with early PVR changes, even though they are not the ideal indications. It can also be useful in the management of RRDs, where there is a limitation for scleral buckling / vitrectomy.

Keywords :Pneumatic retinopexy cryopexy, head positioning

Introduction
Pneumoretinopexy (PnR) is a minimally invasive, nonincisional surgical procedure used to treat Rhegmatogenous Retinal Detachment (RRD), first described by Rosengren in 1938.1 It consists of injecting an expandable gas intravitreally, and applying retinal cryotherapy or laser photocoagulation to seal retinal breaks.2 15% of retinal detachments are repaired by PnR in the USA,3 and 16% were repaired in UK and Ireland.4 Anatomical success rates of over 90% can be achieved with appropriate patient selection and postoperative positioning.5 There maybe certain situations where scleral buckling / vitrectomy is the ideal option, but due to associated limitations PnR can be tried. In our study, PnR has been tried in unusual indications like 2 breaks in 2 quadrants and retinal tears of more than 1 clock hour size, which is similar to other studies.6 However, PnR was done successfully for the first time in total RRD and in RRD with torticollis in our study, which has not been reported in literature to the best of our knowledge till date.

Case Series
Case 1 : A 19 year old girl came with complaints of gradual painless diminution of vision in left eye since 10 days. Examination revealed left eye best corrected visual acuity (BCVA) of counting fingers close to face. Anterior segment was normal. Dilated fundus examination revealed subtotal RRD extending from 10 ‘o clock to 4 ‘o clock, involving macula, with a single large ( > 1 clock hour) superotemporal break, with grade A (Proliferative Vitreo Retinopathy) PVR changes. Right eye had BCVA of 6/6 with normal anterior segment and fundus. Scleral buckling was planned in the left eye. As physician did not give fitness for surgery in view of systemic co-morbidities like anemia with splenomegaly with fungal vaginitis with neurofibromatosis type 1, PnR was tried, in order to avoid PVR progression. Cryopexy was done to the retinal break and 0.3 ml C3F8 pure gas was injected through the pars plana route. Appropriate postoperative head positioning was advised. On postoperative day (POD)1, left eye retina was attached, vision was counting finger 1 meter, which improved to 6/60 at 1 month and 6/36 at 6 months (Figure 1a and 1b).


Figure 1: (1a) pre operative and (1b) after PnR 

Case 2: A 28 year old male came with chief complaints of painless diminution of vision in left eye since 6 days. On examination, left eye BCVA was hand movements. Anterior segment was normal. Dilated fundus examination revealed subtotal RRD extending from 3 o’ clock to 10 o’ clock, involving macula with single small superonasal break with grade A PVR changes. Right eye had BCVA of 6/60 and myopic fundus. As he had left sided torticollis , maintaining supine position during surgery was difficult. As patient was comfortable lying down in the left lateral position, PnR was tried. Cryopexy was done to the retinal break and 0.3ml C3F8 was injected via pars plana route. Appropriate postoperative head positioning was advised. On POD 1, left eye retina was attached, vision was counting finger 4m, which improved to 6/60 at 1 month, and 6/24 at 6 months (Figure 2a and 2b).


Figure 2: (2a) pre operative and (2b)  after PnR  


CASE 2: Torticollis patient PnR

Case 3: A 58 year old male presented with left eye gradual painless diminution of vision since 1 month. Examination revealed left eye BCVA was hand movements. Anterior segment was normal. Patient was pseudophakic. Dilated fundus examination revealed near total RRD with single small superotemporal break with grade A PVR . Right eye had BCVA of 6/36 with anterior segment and fundus normal. A trial of PnR was done as he had minimal PVR changes. Cryopexy was done to the retinal break and 0.3ml C3F8 was injected via pars plana route. Appropriate postoperative head positioning was advised. On POD 1, left eye had minimal residual fluid inferiorly with macula on, vision was counting fingers 2 metres. On followup, subretinal fluid (SRF) completely absorbed by day 4. Vision improved to the 3/60 at 1 month and 6/60 at 6 months (Figure 3a and 3b). 


Figure 3: (3a) pre operative  and (3b) after PnR 

Case 4: A 75 year old male came with chief complaints of gradual painless diminution of vision in the right eye since 3 months. On examination, right eye had vision of light perception. "Anterior segment" was normal. Patient was pseudophakic and one-eyed. Dilated fundus examination revealed total RRD with single superior break with grade C PVR changes (early star folds in 2 quadrants). Due to age related risk of long surgical procedure, PnR was tried. Cryopexy was done to the retinal break and 0.3ml of C3F8 was injected via pars plana route. Appropriate postoperative head positioning was advised. On POD 1, right eye had residual SRF inferiorly, which got absorbed totally in 1 week. Vision was counting finger 1.5 metres, which improved to 1/60 at 1 month, and 3/60 at 6 months (Figure 4a and 4b).


Figure 4: (4a) pre operative and (4b) after PnR

Case 5: A 59 year old male presented with complaints of painless diminution of vision in right eye since 1 month. Examination revealed right eye BCVA of hand movements. Anterior segment was normal. Dilated fundus examination revealed temporal RRD extending from 8 ‘o clock to 12 ‘o clock, with macula off, with 2 breaks, one at inferior limit and the other at superior limit of the detachment with grade A PVR changes. Left eye had BCVA of 6/36 and stable retina. PnR was tried. Cryopexy was applied to both the breaks and 0.3ml C3F8 was injected via pars plana route. Patient was advised face down with left lateral position. On POD 1, right eye retina was attached, vision was counting fingers ½ m, which improved to 6/60 at 1 month, and 6/24 at 6 months (Figure 5a and 5b).


Figure 5: (5a) pre operative and (5b) after PnR

Discussion 
Pneumoretinopexy is primarily indicated for the repair of uncomplicated RRD. The ideal patients are those with retinal breaks involving superior 8 clock hours of fundus, and 1 break or a group of breaks within 1 clock hour. Chan et al quoted an anatomical success rate of 71% to 84% in phakic patients, and 41% to 67% in pseudophakic patients. Hilton et al reported a high success rate of 90%.8,9 An Indian study done by Dhami et al reported a success of 60%.10 A multicenter randomised controlled trial comparing PnR and scleral buckling (SB) revealed visual success ( postoperative vision > 20/50 at 6 months) of 80% in PnR and 56% in SB. Satisfactory results can still be achieved with expanded indications (multiple breaks in multiple quadrants, large tears upto 2½ clock hours in size and RRD with moderate pvr) provided sequential alternation of head positioning to tamponade all retinal breaks is done.7 Patients with compromised conjunctival or scleral intergrity can also be candidates for PnR.

In our case series, PnR was done as a trial in all patients, even though they were not the usual indications. 1st patient had left eye single large break (> 1 clock hour in size) in the supertemporal quadrant. Even though scleral buckling was planned, due to lack of physician’s clearance for surgery, PnR was tried and it was successful. Tornambe et al have also reported satisfactory outcome in cases with large retinal breaks. 2nd patient had left eye single superonasal break with left sided torticollis. Scleral buckling could not be planned as he had difficulty in maintaining supine position during surgery. PnR was tried as he was comfortable in the left lateral position. Anatomical and visual outcomes were satisfactory during followup. Though PnR was considered to be a relative contraindication in torticollis due to difficulty in maintaining appropriate head posture, it was found to be successful in our patient. This is reported for the first time in literature, to the best of our knowledge. 3rd patient had left eye near total RRD with small single superotemporal break. As patient had grade A PVR, PnR was tried. During early postoperative period, minimal SRF was found inferiorly, which got absorbed within 1 week. Retina remained attached during followup, with good visual outcome. As per literature, PnR has never been tried in near total RRD till date. 4th patient was one-eyed with total RRD with single superior break with grade C PVR changes (early star folds in 2 quadrants). Tamponading the break with face down positioning was easy for the patient. Also, in order to avoid age related complications of long surgical prodcedure, PnR was tried. Both anatomical and visual outcomes were satisfactory. However, Tornambe et al reported good outcome in only one quadrant RDs. Chan et al report reported successful outcome with PnR for RRD with limited grade C PVR changes, however extent of RD is not known. 5th patient had 2 breaks which were more than 3 clock hours apart. PnR was tried. Appropriate head positioning was advised. Both anatomical and visual outcomes were satisfactory during followup. Similar cases with successful outcomes were reported by Tornambe et al. No postoperative complications were noted in all our patients. The anatomical and visual outcomes were satisfactory in all patients during immediate postoperative period and followup.

Conclusion
Pneumoretinopexy remains an excellent option in the management of some simple RRDs with minimal PVR. It’s success in simple RRDs is well known. However, it’s extended indications in certain situations could still be successful. 

References 
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  2. Stephen Stewart and Wing Chan. Pneumatic retinopexy: patient selection and specific factors. Clin Ophthalmol. 2018;12:493-502.
  3. Hwang JC. Regional practice patterns for retinal detachment repair in the United States. Am J Ophthalmol. 2012;153(6):1125-1128.
  4. Assi AC, Chateris DG, et al. Practice patterns of pneumatic retinopexy in the United Kingdom. Br J Ophthalmol. 2001;85(2):244.
  5. Chan CK, Lin SG et al. Pneumatic retinopexy for the repair of retinal detachments: a comprehensive review (1986-2007). Surv Ophthalmol. 2008;53(5):4r3-478.
  6. Tornambe PE, Hilton GF. Pneumatic retinopexy. A multicenter randomised controlled clinical trial comparing pneumatic retinopexy with scleral buckling. The Retinal Detachment Study Group. Ophthalmology. 1989;96(6):772-783.
  7. Chang TS, Pelzek CD, et al. Inverted pneumoretinopexy. Ophthalmology. 2pp3;110(3):589-94.
  8. Hilton GF, Das T, et al. Pneumatic retinopexy: principles and practice. Indian J Ophthalmol. 1996;44(3);131-143. 
  9. Hilton GF, Grizzard WS. Pneumatic retinopexy. A two-step outpatient procedure without con-junctival incision. Ophthalmology. 1986;93:626-41.
  10. Dhami A, et al. Pneumatic retinopexy outcomes as primary or secondary surgical option for treating rhegmatogenous retinal detachment. Indian J Ophthalmol. 2018;66(3):420-25.

CITE THIS ARTICLE

Nagaraj KB, Devegowda SY, Tumbadi KL, Govindaraju B, Bhandary R, Sushekar SNVPneumoretinopexy In Unusual Situations: Our Experience.DJO 2021;31:43-46

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Nagaraj KB, Devegowda SY, Tumbadi KL, Govindaraju B, Bhandary R, Sushekar SNVPneumoretinopexy In Unusual Situations: Our Experience.DJO [serial online] 2021[cited 2021 Jul 28];31:43-46. Available from: https://www.djo.org.in/articles/31/3/Pneumoretinopexy-In-Unusual-Situations-Our-Experience.html