Pneumatic Retinopexy in a Progressive Rhegmatogenous Retinoschisis Retinal Detachment

Pneumatic retinopexy (PR) is effective for selected retinal detachments (RDs). Pneumatic retinopexy has failed in a previously reported case of retinoschisis-related RD.¹ The successful management of a patient with progressive rhegmatogenous retinoschisis RD with pneumatic retinopexy is described.

On August 27, 1998, a 52-year-old woman referred for retinal evaluation described photopsias, floaters, and a "curtain" in the right eye of 3 weeks' duration. Best-corrected visual acuity was 20/40 OD. Bullous retinoschisis extended from the 7- to 11-o'clock positions and an RD bisected the fovea. Two large outer wall holes (OWHs) measuring 16 × 9 mm extended from the 7:30- to the 10:30-o'clock positions 8 mm anterior to the fovea. No inner wall hole (IWH) was visible with indirect ophthalmoscopy. Goldmann lens identified 3 pinpoint IWHs at the 10-o'clock position. There were no full-thickness breaks.

Inner wall holes were treated with transcleral cryotherapy and 0.6 mL of filtered air was injected through the temporal pars plana. The next day, both the RD and schisis cavity were flat. Laser photocoagulation was applied around the OWHs (Figure 1). Ten months later, visual acuity was 20/30 OD. The retina and schisis cavity remained flat.

Pneumatic retinopexy is not a popular procedure for the repair of symptomatic retinoschisis-related RDs. These detachments, in which subretinal fluid extends well beyond the schisis cavity are rare and progressive. Surgical repair with pars plana vitrectomy, retinotomy, and fluid gas exchange; scleral buckle; or simultaneous subretinal fluid drainage and intravitreal gas injection with cryopexy has been advocated.^1,2 This case suggests surgical intervention with attendant risk need not be considered the standard or first option in all cases.

Histopathologic study findings concluded retinoschisis-related RDs may be caused by OWHs alone.³ However, RDs in these studies were limited to the area within or slightly beyond the schisis cavity and by definition they were not progressive rhegmatogenous RDs. Clinical studies are divided with respect to the observation of IWHs in symptomatic progressive RDs.^1,2,4 Because contact lens examination was not always performed, it is possible that tiny IWHs below the resolution of indirect ophthalmoscopy may have been present but unrecognized in some cases. The importance of the IWH for the formation of progressive rhegmatogenous RDs may be underestimated.

Because OWHs are considered the important breaks, the goal has been to close OWHs with vitreoretinal surgical techniques. While OWHs alone may cause limited "schisis detachments," IWHs may be more important in progressive rhegmatogenous RDs. They should be sought especially in patients with symptoms of acute vitreoretinal traction. The IWHs not visible with indirect ophthalmoscopy may be identified with Goldmann lens examination. Pneumatic retinopexy should be considered before more aggressive surgical techniques when full-thickness breaks or IWHs are identified superiorly. The initial goal of treatment should be to close these IWHs. Whether or not additional laser demarcation of OWHs is necessary to prevent redetachment is uncertain.

Advantages of PR include lower risk of surgical complication and lower cost. Pneumatic retinopexy has failed in a similar case.¹ However, it is uncertain whether IHWs were treated specifically. Further investigation will confirm whether PR is an effective, less invasive way to manage progressive rhegmatogenous retinoschisis RDs.

Corresponding author: Tamara R. Vrabec, MD, Retina Service, Wills Eye Hospital, Ninth and Walnut streets, Philadelphia, PA 19107 (e-mail: TRVRDMD@aol.com).