PIVOT: Pneumatic Retinopexy vs. Vitrectomy for Primary RRD
Hillier RJ, Felfeli T, Berger AR, et al. The Pneumatic Retinopexy versus Vitrectomy for the Management of Primary Rhegmatogenous Retinal Detachment Outcomes Randomized Trial (PIVOT). Ophthalmology. 2019;126(4):531-539.
The optimal management of a primary, uncomplicated rhegmatogenous retinal detachment (RRD) is a matter of some debate among vitreoretinal surgeons. Recently, Hillier and colleagues examined the functional and structural outcomes of pneumatic retinopexy (PnR) versus pars plana vitrectomy (PPV) for primary RRD. More specifically, the RRD must have contained a single break or group of breaks within 1 clock hour of each other in detached retina above the 8:00 and 4:00 meridians. There could be any size, number, or location of breaks or lattice in attached retina. Macula on and macula off detachments were included, and eyes were included regardless of the status of the posterior hyaloid (i.e. it could be attached or detached).
This was a prospective, randomized trial including 176 patients. The authors’ preferred protocol for PnR included first applying laser to all breaks or lattice in attached retina. Next, breaks in detached retina were either treated with cryotherapy before gas injection or laser retinopexy within 48 hours of gas injection. Finally, an anterior chamber paracentesis was performed with the goal of expressing ³ 0.3 ml of aqueous followed by injection of ³ 0.6 ml of SF6 gas. In the PPV arm, all surgeons used a 23 gauge system and shaved the peripheral vitreous for 360 degrees. It was at the surgeon’s discretion to use SF6, C3F8, silicone oil, or an adjunctive scleral buckle.
For the primary outcome, the PnR group demonstrated superior acuity by 5 letters compared to the PPV group at 1 year. The majority of phakic patients in the PPV group (65%) underwent cataract surgery within 1 year of their detachment repair compared to 16% in the PnR group. Final anatomic success was achieved in approximately 99% of patients in both groups, but the primary anatomic success rate for PnR (81%) was lower than that for PPV (93%). Vertical metamorphopsia was less bothersome in the PnR group than in the PPV group. Among PnR patients, there was no difference in primary anatomic success rate between patients who were phakic vs. those who were pseudophakic.
The results of this study suggest that PnR is a great option for patients with a primary RRD who meet PIVOT criteria; at 1 year of follow up, PnR was associated with better visual outcomes, reduced need for cataract surgery and less vertical metamorphopsia compared to PPV (albeit at the expense of a lower primary anatomic success rate). Nevertheless, as the authors point out, there is an art to PnR (just as there is for PPV), so surgeons should also consider what procedure they are most comfortable with when deciding how to treat a primary RRD.