How We Currently Choose to Repair Retinal Detachment in
the United States Medicare Population
EDWIN H. RYAN J
HREE VERY DIFFERENT METHODS ARE CURRENTLY
used to repair acute retinal detachments. Else-
where in this issue of the Journal, Hwang
data obtained from Medicare part B summaries, ﬁnding
regional differences in the choice of procedure for repair
of retinal detachment. The author gives us an interest-
ing snapshot of practice patterns in the current era
regarding retinal detachment repair in patients 65 and
older. Several limitations exist in the study, however.
First, we cannot determine, within the group of patients
who underwent vitrectomy, what percentage of this
group also had placement of a scleral buckle. Second, we
have no data regarding outcomes, nor do we know
whether the procedure performed was primary or a
reoperation, particularly if pneumatic retinopexy was
chosen initially. Third, we have no data regarding lens
status. Interesting ﬁndings in this study are the high rate
of pneumatic retinopexy use, especially in the North-
east, and the remarkably low rate of scleral buckling
REVIEW OF LITERATURE ON
PNEUMATIC RETINOPEXY AND
VITRECTOMY VS SCLERAL BUCKLING
THE SINGLE-PROCEDURE REATTACHMENT RATE FOR SUR-
gical treatment of retinal detachment was much higher
for scleral buckling than pneumatic retinopexy in most
studies. Han and associates
reported a single-procedure
reattachment rate in 1998 for scleral buckling of 84%,
compared to 62% in pneumatic retinopexy eyes. In
2011, Schaal and associates
reported success in 86% of
scleral buckle cases and 63% for pneumatic retinopexy.
Chan and associates
found success rates with a single
operation of 71% to 84% in phakic patients and 41% to
67% in nonphakic patients, surveying multiple reports
regarding pneumatic retinopexy. This study found the
ﬁnal anatomic and visual outcomes not to be disadvan-
taged by initial choice of pneumatic retinopexy. The
Medicare database used by Hwang
does not reveal the
lens status of the patients, but a review of 440 consec-
utive primary retinal detachments showed 48% of pa-
tients 65 and older to be pseudophakic (Ryan EH et al.
Scleral buckling remains valuable for retinal reattach-
ment. Paper presented at Retina Society, San Francisco,
California, September 24, 2010, p. 71). Given the likely
similar incidence of pseudophakia in this population of
Medicare beneﬁciaries, pneumatic retinopexy as a sur-
gical choice would be expected to have the highest
incidence of initial failure.
A recent large randomized prospective trial from
Europe compared scleral buckling to vitrectomy for
moderately complex retinal detachment.
found scleral buckling to predict a better visual outcome
than vitrectomy for retinal reattachment in phakic
patients. Lens status may play a role, as cataract pro-
gression following vitrectomy is typical in phakic pa-
tients and occurs sooner with advancing age.
prospective study, the Retina 1 project,
tomy to have a higher likelihood than scleral buckling
of poor (Ͻ20/100) visual outcome regardless of lens
In the large European study, pseudophakic patients had
better anatomic success rates with vitrectomy than scleral
buckling, while visual outcomes were similar.
clude that vitrectomy is the preferred method for retinal
reattachment in pseudophakic patients. It is currently
unclear whether vitrectomy combined with scleral buck-
ling is more effective than vitrectomy alone anatomically
for repair of retinal detachment, and the study did not
address this question. Schaal
found single-surgery success
rates of 90% for vitrectomy and 94% for combined scleral
buckling and vitrectomy.
SURPRISINGLY HIGH USE
TWO FINDINGS REGARDING THE USE OF PNEUMATIC RETI-
nopexy are surprising. First, the utilization of pneumatic
retinopexy in the Northeast was highest. Hwang’s
expectation had been that pneumatic retinopexy would
be more popular on the West Coast. A 1997 survey had
indicated a much higher utilization of pneumatic reti-
See Accompanying Article on page 1125.
Accepted for publication Jan 17, 2012.
From VitreoRetinal Surgery, PA, Edina, Minnesota.
Inquiries to Edwin H. Ryan, Jr, 7760 France Ave S, Suite 310,
Minneapolis, MN 55435; e-mail: email@example.com
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