Modified Pneumatic Retinopexy With Fluid Drainage Shows High Success for Retinal Detachment

A modified form of pneumatic retinopexy that actively drains fluid from beneath the retina achieved retinal reattachment after a single operation in 51 of 53 eyes with primary rhegmatogenous retinal detachment, according to a retrospective case series published in the journal Eye and Vision. The single-surgery anatomical success rate of 96.23% was accompanied by significant improvement in best-corrected visual acuity three months after surgery, and the procedure eliminated the need for the expansile gas bubbles and prolonged postoperative positioning that burden patients undergoing conventional pneumatic retinopexy.

Rhegmatogenous retinal detachment occurs when liquefied vitreous passes through a full-thickness retinal break, allowing the neurosensory retina to separate from the underlying retinal pigment epithelium. Risk factors include posterior vitreous detachment, cataract surgery, myopia, degenerative retinoschisis, lattice degeneration, and ocular trauma. The condition affects between 6.3 and 17.9 people per 100,000 each year, with incidence rising with age, and it can cause permanent vision loss if the macula, the region responsible for sharp central vision, becomes detached. Current primary surgical options are pars plana vitrectomy, scleral buckling, and pneumatic retinopexy, and which of these is optimal remains a matter of ongoing debate among retinal surgeons.

Conventional pneumatic retinopexy has well-documented advantages. It is an efficient, minimally invasive outpatient procedure, and a prospective multicenter randomized trial comparing it with scleral buckling found no significant difference in single-surgery reattachment rates, with better visual acuity at six months and two years in the pneumatic retinopexy group. However, the conventional technique requires strict postoperative positioning for at least five days and up to three weeks so that subretinal fluid can be slowly resorbed through the retinal pigment epithelium pump. An intravitreal gas bubble can also impair vision for several weeks, and supplemental gas injections may be needed. The research team at the Eye Hospital of Wenzhou Medical University sought to overcome these limitations by adding transscleral drainage of subretinal fluid to the procedure.

The modified technique, which the authors trace conceptually to methods described as early as 1911 and refined by Rosengren in 1938, combines three steps. After laser photocoagulation is applied around retinal breaks in attached retina, a localized conjunctival incision exposes the sclera, and subretinal fluid is drained transsclerally with a 22-gauge needle at the site of maximal retinal elevation adjacent to the breaks. Filtered air, rather than expansile gas, is then injected into the vitreous cavity through a 30-gauge needle inserted four millimeters behind the limbus. Drainage and air injection are repeated to maximize fluid evacuation while preserving the largest possible air bubble. Patients maintain a position keeping the breaks uppermost for only three to five days, and laser treatment around the breaks is completed within 12 to 24 hours of surgery. The entire procedure was performed under topical and subconjunctival anesthesia, without sedation or regional blocks, and the median surgical duration was 19 minutes.

The study reviewed 53 consecutive eyes of 53 patients treated between March and October 2025 who met the eligibility criteria from the Pneumatic Retinopexy versus Vitrectomy trial, known as PIVOT. These criteria restrict treatment to eyes with one or more retinal breaks confined to a single clock hour within the superior meridians between the 8 and 4 o’clock positions. Patients with clinically significant proliferative vitreoretinopathy, prior detachment repair, inability to comply with positioning, very shallow detachments, or poor visualization of the peripheral retina were excluded. The cohort had a mean age of 43.13 years, ranged from 15 to 70 years, and was nearly evenly split between sexes. Fifty-two of the 53 eyes were phakic, meaning the natural lens was still in place. Twenty eyes had macula-off detachments, the more serious presentation, while 33 had macula-on detachments.

Fluid egressed from the scleral incision in all 53 patients, and no conversion to an alternative procedure was required intraoperatively. At three months, the single-surgery anatomical success rate was 96.23%, with 51 of 53 eyes attached. Median best-corrected visual acuity improved significantly from a preoperative logarithm of the minimum angle of resolution of 0.10 to 0.02, a change the authors reported as statistically significant. In the macula-off subgroup of 20 eyes, the anatomical success rate was 100%, and visual acuity improved from a median of 0.75 logMAR preoperatively to 0.20 logMAR at three months. The difference in success between the macula-off and macula-on subgroups, the latter at 93.9%, was not statistically significant. None of the patients required cataract surgery during the three-month follow-up.

Complications were limited but noteworthy. Two eyes with macula-on detachments, or 3.77%, developed recurrent retinal detachment identified at the two-week visit; both were subsequently treated successfully with pars plana vitrectomy, one reaching 20/20 vision and the other 20/25 at follow-up. One patient, or 1.89%, developed a secondary epiretinal membrane that reduced vision from 20/32 to 20/100, and vision returned to 20/32 after vitrectomy with membrane peeling and lens implantation. Two eyes developed small subretinal hemorrhages adjacent to the drainage site that were not clinically significant. The authors attributed the favorable safety record to continuous scleral indentation combined with immediate air injection, which stabilizes intraocular pressure, but they cautioned that vitreous incarceration with subtle traction remains a theoretical risk of the new drainage step that future studies must monitor. Notably, the modified procedure avoids anterior chamber paracentesis, eliminating a risk of iatrogenic angle-closure glaucoma associated with conventional pneumatic retinopexy.

Ten of the 53 surgeries were performed in an inpatient operating room and 43 in a standard outpatient ophthalmic surgical suite, with assignment based simply on availability and nursing schedules rather than case complexity. The authors argue that because the technique requires no operating microscope, no binocular indirect ophthalmoscope, and no expansile gas, it could be particularly valuable in remote or resource-limited settings where intraocular gas is often unavailable. Two eyes in the series that had persistent detachment after conventional pneumatic retinopexy performed elsewhere achieved complete reattachment after the modified procedure, suggesting it may also serve selected patients with failed initial pneumatic repair, though the authors described extending the technique to inferior breaks as premature and overly speculative.

The authors themselves emphasize substantial caveats. The retrospective, single-center design and small sample limit generalizability, the minimum follow-up was only three months, and the stringent PIVOT eligibility criteria inherently select patients well suited to pneumatic retinopexy, so the high success rate likely reflects careful patient selection as much as technical advantage. Prior studies report pneumatic retinopexy success rates of 81% to 90% in selected populations, and the authors note that direct comparison with historical benchmarks for vitrectomy and buckling is precluded by differences in study design and patient selection. They also raise a biological question: post hoc analyses of the PIVOT trial suggest that slower reattachment via natural fluid absorption may protect photoreceptors, with faster vitrectomy-associated reattachment linked to more outer retinal folds and damage. Rapid drainage might therefore carry long-term visual trade-offs that only prospective randomized trials using optical coherence tomography, with concurrent control groups and longer follow-up, can resolve.

Subject of Research: A modified pneumatic retinopexy technique with transscleral subretinal fluid drainage for treating primary rhegmatogenous retinal detachment

Article Title: Outcomes of modified pneumatic retinopexy with transscleral subretinal fluid drainage for primary rhegmatogenous retinal detachment

Article References: Pan, Q., Liu, R., Pan, H., Liu, M., Wei, J., Zhang, S., Hu, X., Zhang, Z., Chen, W., & Zhang, Z. (2026). Outcomes of modified pneumatic retinopexy with transscleral subretinal fluid drainage for primary rhegmatogenous retinal detachment. Eye and Vision, 13(1), Article 37. https://doi.org/10.1186/s40662-026-00506-z

Image Credits: AI Generated

DOI: 10.1186/s40662-026-00506-z

Keywords: retinal detachment, pneumatic retinopexy, subretinal fluid drainage, vitrectomy, visual acuity, macula-off detachment, retinal surgery, ophthalmology, PIVOT trial, laser photocoagulation, outpatient surgery, case series