Retinal detachment surgery: how does the surgeon choose between pneumatic retinopexy, scleral buckle and vitrectomy?

"My relative had retinal detachment surgery with a band, but the doctor told me I need a vitrectomy. Why is my operation different, and which one is better?" This is a very reasonable question, and we hear it often. The short answer is that no single operation is best for every patient with a retinal detachment. Each operation has advantages and limits, and each detachment has features that make one operation more suitable than the others. In this article we explain the three main operations, and what makes the surgeon choose one of them for your particular case.

What are all the operations trying to do?

Whatever the method, the goal is the same: to close the tear through which fluid has passed behind the retina, to put the retina back in place, and then to hold it there until it heals. The tear is usually sealed with laser or freezing treatment around it, which creates a strong scar, rather like a "weld." But this scar only forms if the retina is touching the wall of the eye. So the operations differ in how they bring the retina back to the wall and keep it there until healing is complete.

The three operations, one by one

Pneumatic retinopexy

A small gas bubble is injected into the eye in the operating room. Because gas floats upwards, the doctor asks the patient to keep the head in a particular position so that the bubble presses on the tear. The tear is treated with laser or freezing.

Who is it usually suitable for?

A detachment caused by a single tear, or tears close together, in the upper part of the retina, in a patient who can keep the head position precisely for several days (Hillier et al., 2019).

What does the research show?

In a clinical trial comparing pneumatic retinopexy with vitrectomy in patients suitable for both, average vision after one year was better with pneumatic retinopexy, and there was less distortion of lines. Later cataract operations were much less frequent. But the success of the first procedure was lower (about 81% versus 93%), meaning more patients needed a second procedure. With additional treatment, the retina was back in place in about 99% of patients in both groups (Hillier et al., 2019).

When pneumatic retinopexy was compared with a scleral buckle, a large review found that pneumatic retinopexy may have a lower reattachment rate and a higher chance of the detachment coming back. But the evidence was limited and did not rule out no real difference (Hatef et al., 2015).

Scleral buckle

A soft silicone band is fixed on the outside wall of the eye, under the eyelids where nobody can see it. It pushes the wall of the eye inwards towards the tear, as if you pressed a finger into a rubber ball from outside. The tear is treated with freezing or laser, and fluid may be drained from under the retina or gas injected.

Who is it usually suitable for?

Mainly an eye that still has its natural lens (no previous cataract surgery), and some cases with tears in the lower part of the retina (Starr et al., 2023).

What does the research show?

In a large European trial, vision improved more with a buckle in eyes with their natural lens, and cataract developed less often than after vitrectomy (Heimann et al., 2007). In a large American study from real-world practice in this group of eyes, the first operation succeeded in about 92% with a buckle (Ryan et al., 2020). A review of reports from that study confirms the importance of the buckle in eyes with their natural lens, in older patients, and for lower tears (Starr et al., 2023).

What should you know?

Your glasses prescription may change after the operation, because the buckle can make the eye slightly longer (Brazitikos et al., 2005).

Vitrectomy

The vitreous gel that is pulling on the retina is removed from inside the eye through very small openings. The retina is then flattened back into place, the tear is treated with laser, and gas, which is absorbed on its own over time, or silicone oil, which usually needs removing in a later operation, is left in the eye. We explain this operation in our article on vitrectomy.

Who is it usually suitable for?

An eye that has had cataract surgery before, eyes with bleeding that blocks the view, large or posterior tears, and cases where scar tissue has formed and is pulling on the retina.

What does the research show?

In eyes that have had cataract surgery, the first operation succeeded more often with vitrectomy than with a buckle, with less need for additional surgery (Heimann et al., 2007; Brazitikos et al., 2005). In cases with severe scar tissue on the surface of the retina, silicone oil did better than one type of gas in an older but important trial (Silicone Study Group, 1992).

What should you know?

If your eye still has its natural lens, a cataract is expected to form after the operation. In the trial mentioned above, cataract surgery was performed within the first year in about 65% of eyes with a natural lens after vitrectomy, compared with 16% after pneumatic retinopexy (Hillier et al., 2019).

What makes the surgeon choose a particular operation for you?

When examining the patient, the surgeon first looks at several questions, and each one can change the choice:

Does the eye have its natural lens or an artificial one?

This is one of the most important factors, as the study results show (Heimann et al., 2007; Brazitikos et al., 2005).

Where are the tears, and how many are there?

A single upper tear is very different from lower, multiple or widely separated tears (Hillier et al., 2019; Starr et al., 2023).

Is there bleeding or scar tissue?

Scar tissue pulling on the retina usually needs vitrectomy and may need silicone oil (Silicone Study Group, 1992). See our article on silicone oil in the eye.

Has the detachment reached the macula, and since when?

This decides how urgent the operation is and affects the vision expected afterwards (Yorston et al., 2021).

Can the patient keep the head position and attend follow-up?

Pneumatic retinopexy, for example, depends heavily on the patient's cooperation.

The choice of operation is not based on the result of one study. Studies compare operations in specific groups of patients, whereas the real decision is based on the details of each patient's eye. So the surgeon discusses with the patient the options that suit their case, and why a particular operation is thought to be best for them.

The figures quoted apply to the patients who took part in these studies and are not a guaranteed result for any patient.

Anatomical success and functional improvement

After any of the three operations, we talk about two different results. Anatomical success means the retina is back in place and stays attached. Functional improvement means how much vision returns. The first can be achieved without vision returning to what it was, especially if the macula was detached for some time. In a large British study of patients whose macula had detached and whose surgery then succeeded, only about half reached a good level of vision, and how long the macula had been detached was the most important factor that can be influenced (Yorston et al., 2021).

That is why two operations can be equally "successful" anatomically, and yet vision afterwards can differ a great deal from one patient to another.

After surgery: what differs by type of operation?

• With gas (in pneumatic retinopexy or after vitrectomy): vision is very poor until the gas is absorbed. Flying and traveling to high altitudes are not allowed until the gas has completely gone, and any anesthesiologist must be told about it (Moorfields Eye Hospital NHS Foundation Trust, 2020). You may need a particular head position for several days. See our article on the gas bubble after retinal surgery.
• With silicone oil: some hospitals advise not flying for two weeks after surgery unless the surgeon allows it, and the oil usually needs a simple later operation to remove it after several months (Moorfields Eye Hospital NHS Foundation Trust, 2020).
• With a scleral buckle: there may be pain or bruising around the eye in the first days, which is particularly common after a buckle (Moorfields Eye Hospital NHS Foundation Trust, 2020), and the glasses prescription may change (Brazitikos et al., 2005).

In every case, go back to the doctor immediately if you develop severe or increasing pain, increasing redness, a new drop in vision, or a new shadow in your vision.

Questions you can ask your surgeon

1. Has the detachment reached the macula?
2. Why did you choose this operation for my case in particular?
3. Will I need a particular head position, and for how many days?
4. Will gas or oil be used? If oil, when will it be removed?
5. What is the chance that I will need another operation?
6. Could a cataract develop after the operation?

Summary

Pneumatic retinopexy, scleral buckle and vitrectomy are all successful operations when chosen for the right patient. Each has its advantages and its price: a head position, a change in glasses prescription, a later cataract, or the possibility of a second procedure. No single method suits every case, and the aim is to choose the most suitable treatment for each case after a careful examination and a frank discussion with the patient, with realistic expectations for both the anatomical result and the improvement in vision.

This information is for health education and does not replace a medical examination.