Pneumatic Retinopexy

Indications:

§ Repair of RD caused by retinal breaks located in the upper 2/3 of the fundus (from 8

to 4 o'clock)

§ Breaks should be w/in 1 clock hour of eachother

§ No breaks with detached retina in the inferior 4 clock hours (in PIVOT study it was

acceptable to perform pneumatic with inferior breaks/lattice in attached retina as long

as retinopexy was applied prior to gas injection)

§ No PVR (grade B or less)

§ Patients must be able to position and not live at altitude/flying/etc

§ No Glaucoma, filtering blebs (avoid cryo in these areas)

Contraindications

§ Inferior breaks with detached retina below the 4 and 8 o'clock positions

§ No PVD (attached vitreous)

§ Inability to find the retinal break(s)

§ Cloudy media - cataract

§ Poor patient cooperation

§ Limited experience with indirect ophthalmoscopy

§ Excessive vitreoretinal adhesions

§ Inability of the pt to position self postoperatively for 3-5 days

§ Inability to follow the pt closely during the first two postop weeks

Inability of the surgeon to manage potential retinal complications

§ Necessity for the pt to fly or visit an area with a rise in altitude above 4000 feet while

gas bubble is present

§ Lattice - Extensive lattice degeneration is a contraindication to pneumatic retinopexy,

given the high risk of new breaks. However, lattice degeneration extending 3 clock

hours or less does not affect the single operation success rate

§ some will consider doing laser to lattice 1d prior then pneumatic

Set-up

§ Gloves, Betadine solution (10%)

§ Xylocaine 1%, Marcaine 0.5%, gentamycin

§ Antibiotic/steroid ointment

§ Lid speculum, conjunctival forceps, cotton-tipped applicators

§ One eye patch (to draw arrow in axis of the retinal break for positioning)

§ Two 1 cc tuberculin syringes, two 30g half-inch needles

§ Gas: SF6, or C3F8

§ One Millipore filter (or can use 3)

§ Cryopexy instruments

§ Laser indirect ophthalmoscope delivery system

Preoperative

Clinical examination and identification of retinal breaks

Anesthesia

Sub conj injection of 2% lidocaine

Procedure

Visualize retinal breaks with the binocular indirect ophthalmoscope

Apply transconjunctival cryopexy to the retinal breaks

Perform anterior chamber paracentesis

• 0.2-0.3 mL of aqueous is aspirated using a 30 G needle

Inject intraocular gas bubble

§ 0.5–0.6 mL of pure SF6 OR 0.35-0.45 mL of C3F8 is injected via the pars plana using a

25 or 30 G needle

*Volume of gas is dependent on provider and pathology. Some use the following rule: 

gas volume = AC tap volume + 0.3cc 

AC tap volume can be as high as 0.5cc in highly myopic eyes 

Visualize the optic nerve head

If it is not perfused, repeat the paracentesis

*If high pressure but with perfusion, can do facedown for 5-10 minutes. Typically aids in normalizing pressure. Do your post-op counseling at that time. 

Check vision, check IOP

Postoperative

§ The patient is asked to posture continuously for 7 days The patients is re-examined on

the first or second postoperative day If the retina is flat on post-op day 1, the patient is

re-examined at 1 week

§ Read the PIVOT study and listen to Rajeev Muni on performing pneumatics

https://www.aao.org/pneumatic-retinopexy?fid=faa49ccf-1cef-454a-a375-84e01efb32bd

Head positioning: Masumi method

1. 1. facedown for:  4-6 hours (macula involving) or 2 hours (non-macula involving) 

   2. 30 minute increments over 2 hours to get to final position (can assist with pillows for support)