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

Outcomes of modified pneumatic retinopexy with transscleral subretinal fluid drainage for primary rhegmatogenous retinal detachment | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Outcomes of modified pneumatic retinopexy with transscleral subretinal fluid drainage for primary rhegmatogenous retinal detachment QinTuo Pan, RenWan Liu, HuiRong Pan, MeiQi Liu, JiaYi Wei, SaiFei Zhang, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8947548/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 20 You are reading this latest preprint version Abstract Background To evaluate the anatomic and visual outcomes of a modified pneumatic retinopexy (mPnR) technique incorporating transscleral drainage of subretinal fluid for the treatment of primary rhegmatogenous retinal detachment (RRD). Methods This retrospective, single-centre case series included 53 consecutive eyes of 53 patients with primary RRD meeting the Pneumatic Retinopexy versus Vitrectomy trial criteria. All patients underwent mPnR, which consisted of transscleral subretinal fluid drainage, intravitreal air injection, and postoperative laser photocoagulation of retinal breaks. The main outcome measures were single-surgery anatomical success rate and best-corrected visual acuity (BCVA) at 3 months postoperatively. Results The single-surgery anatomic success rate was 96.23% (51/53). Mean BCVA significantly improved from 0.10 (interquartile range [IQR],0.00-0.60) logarithm of the minimum angle of resolution (logMAR) preoperatively to 0.02 (IQR,0.00-0.20) logMAR at 3 months postoperatively (P<0.001). In the macula-off subgroup (n = 20), the anatomic success rate was 100%; BCVA improved from 0.75 (IQR,0.43–1.18) logMAR to 0.20(IQR,0.04–0.30) logMAR (P<0.001). Two eyes (3.77%) with recurrent detachment and one eye (1.89%) with a secondary macular epiretinal membrane required subsequent pars plana vitrectomy. Conclusions The mPnR technique is an effective and safe treatment for primary RRD. The procedure is efficient and minimally invasive, does not require expansile gas, and can be performed in an outpatient setting, supporting its potential for widespread adoption. Trial registration: Not applicable. Modified pneumatic retinopexy rhegmatogenous retinal detachment transscleral subretinal fluid drainage air laser photocoagulation Figures Figure 1 Figure 2 Figure 3 Introduction Rhegmatogenous retinal detachment (RRD), the most common form of retinal detachment, occurs when liquefied vitreous passes through a full-thickness retinal break, resulting in separation of the neurosensory retina from the underlying retinal pigment epithelium. 1 Risk factors for RRD include posterior vitreous detachment, cataract surgery, myopia, degenerative retinoschisis, lattice degeneration, and ocular trauma. 2 The incidence of RRD ranges from 6.3 to 17.9 cases per 100,000 population, and incidence increases with age. 3 Current primary surgical treatments for RRD include pars plana vitrectomy (PPV), scleral buckling (SB), and pneumatic retinopexy (PnR); however, the optimal intervention remains a subject of ongoing debate. 4 Over the past several decades, PPV and SB have been the preferred surgical approaches for RRD, demonstrating favorable single-surgery anatomic success rates. 4,5,6 PnR, first described by Domínguez as an outpatient procedure for RRD repair without conjunctival incision, was later popularized by Hilton and Grizzard. 7,8 A prospective, multicenter, randomized controlled trial comparing PnR with SB demonstrated no significant difference in single-surgery reattachment rates, whereas the PnR group achieved better visual acuity at 6 months and 2 years postoperatively. 9,10 More recent studies have shown that, in selected RRD cases, PnR provides superior functional and anatomic outcomes relative to PPV, with equivalent primary reattachment rates. 11,12,13 Although PnR offers advantages such as procedural efficiency, minimal invasiveness, and reduced resource utilization compared with PPV or SB—which typically require an operating room—its conventional approach requires strict and prolonged postoperative positioning (at least 5 days and up to 3 weeks) to allow subretinal fluid (SRF) resorption. 6 Furthermore, the intravitreal gas bubble can cause sustained visual impairment for several weeks, a period that may be further extended if supplemental gas injections are required. 14 Accordingly, we modified the conventional PnR technique by incorporating transscleral drainage of SRF. This modification facilitates rapid postoperative retinal reattachment, eliminates the need for intraocular expansile gas, and preserves the inherent advantages of PnR. The present study was designed to evaluate the primary anatomic success rate and visual outcomes of this modified pneumatic retinopexy (mPnR) approach in patients with primary RRD. METHODS This single-center retrospective cohort study was approved by the Ethics Committee of the Eye Hospital of Wenzhou Medical University (Approval No. 2025-043-X-02-01). All procedures adhered to the tenets of the Declaration of Helsinki. The medical records of consecutive patients who presented to the Eye Hospital of Wenzhou Medical University between March 19, 2025, and October 5, 2025, with primary RRD and who underwent mPnR were reviewed. Only eyes with a minimum postoperative follow-up interval of 3 months were included. Eligibility criteria for RRD were based on the Pneumatic Retinopexy versus Vitrectomy for the Management of Primary Rhegmatogenous Retinal Detachment (PIVOT) trial 11 and included the following: (1) one or more retinal breaks confined to a 30° sector (≤1 clock hour); and (2) all breaks located superior to the 8:00 and 4:00 meridians. Exclusion criteria were as follows: (1) clinically significant proliferative vitreoretinopathy; (2) a history of retinal detachment repair in the same eye, except for previous PnR; (3) inability to comply with postoperative positioning requirements (e.g., severe physical disability); and (4) inadequate visualization of the peripheral retina or inability to perform laser photocoagulation due to media opacity. The primary outcome measures were (1) the single-surgery anatomic success rate of mPnR and (2) best-corrected visual acuity (BCVA) at 3 months postoperatively. Patient medical records were reviewed to collect the following clinical data: age, sex, affected eye, axial length, history of hypertension, history of diabetes, duration of RRD symptoms, preoperative and postoperative BCVA, lens status, complications, follow-up duration, wide-field fundus photography (Optos, Marlborough, MA, USA), and spectral-domain optical coherence tomography (Heidelberg Spectralis OCT, Heidelberg, Germany). Symptom duration was defined as the interval between the onset of visual loss or visual field defects, as reported by the patient, and the date of surgery. Surgical Technique After adequate pupillary dilation, a preoperative fundus examination was performed. All retinal breaks and areas of lattice degeneration located in attached retina were surrounded with laser photocoagulation. Subconjunctival anesthesia was administered using 2% lidocaine hydrochloride (100 mg; Hunan Kelun Pharmaceutical Company, China; National Drug Approval Number: R25041403) over the quadrant corresponding to the retinal break(s). Transconjunctival fixation of the rectus muscles adjacent to the break(s) with traction sutures. A localized conjunctival incision (about 1 centimeter) was made to expose the sclera. Transscleral drainage of SRF was then performed using a needle (22 gauge) attached to a 5-mL syringe at the site of maximal retinal elevation adjacent to the retinal break(s). Beveled incision was recommended to enhance the self-sealing properties of the scleral wound. Gentle indentation with a sterile cotton swab was simultaneously applied to maintain normal intraocular pressure. A 30-gauge needle was subsequently inserted 4 mm posterior to the limbus, and filtered air was injected into the vitreous cavity. During air injection, the indentation was gradually released until intraocular pressure reached approximately Tn to T+1 (normal to slightly elevated) by digital palpation. The sequence of SRF drainage and air injection was repeated as necessary to maximize SRF evacuation while preserving the largest possible intravitreal air volume. For repeat SRF drainage, merely gentle scleral indentation immediately adjacent to the scleral incision with microforceps suffices, avoiding repeated needle entry. The conjunctival incision was closed by electrocoagulation or suturing (Video 1). Postoperatively, patients were instructed to maintain a position with the retinal break(s) uppermost for 3–5 days to ensure continuous air tamponade. Laser photocoagulation of the retinal break(s) was performed 12–24 hours after surgery, with additional treatment applied as required. Levofloxacin 0.5% ophthalmic solution was administered four times daily for 5 days postoperatively as infection prophylaxis. All surgical and laser procedures were performed by the same vitreoretinal surgeon (Q.T. Pan). Follow-up visits were scheduled at 1 day, 3–7 days, 1 month, 3 months, and 6 months postoperatively. Statistical Analysis Statistical analyses were performed using SPSS software, version 27.0. BCVA values were converted to the logarithm of the minimum angle of resolution (logMAR) before analysis. Continuous variables are presented as mean ± standard deviation, while non-normally distribute data are presented as median and interquartile range(IQR). Categorical variables are expressed as frequencies and percentages. Comparisons of continuous variables between groups were performed using the independent-samples t-test or the Mann–Whitney U test, as appropriate. For paired comparisons (e.g.,preoperative vs. postoperative BCVA), the paried t-test or the Wilcoxon signed-rank test was used based on data normality. Categorical variables were compared using the chi-square test. P-values < 0.05 were considered statistically significant. RESULTS The basic characteristics of the patients are summarized in Table 1.In total, 53 patients (53 eyes) were included in this study. The mean age was 43.13 ± 15.58 years (range,15-70); 28 patients (52.83%) were men and 25 (47.17%) were women. Systemic comorbidities included hypertension in eleven patients (20.75%) and type 2 diabetes mellitus in senven patients (13.21%). The mean axial length was 25.63 ± 1.98 mm (range,21.71-29.99). 52 eyes (98.11%) were phakic; among them, thirteen had mild lens opacity and eight had moderate lens opacity. Macula-off RRD was present in 20 eyes (37.74%) (Figure 1), whereas the remaining 33 eyes (62.26%) had macula-on RRD (Figure 2). The mean number of retinal breaks was 1.00 (IQR,1.00-2.00) (range,1.00-5.00), and the mean extent of retinal detachment was 2.00 ± 0.65 quadrants. The mean follow-up duration was 3.33 ± 0.84 months (range,3.00-6.37). The single-surgery anatomic success rate of mPnR at 3 months postoperatively was 96.23% (51/53). Mean BCVA significantly improved from 0.10 (IQR,0.00-0.60) logMAR preoperatively to 0.02 (IQR,0.00-0.20) logMAR at 3 months postoperatively (P＜0.001). No patient required cataract surgery during the 3-month postoperative period. Two eyes (3.77%) with macula-on RRD developed postoperative recurrent retinal detachment, which was identified at the 2-week follow-up visit. One eye (supplementary patient 1) subsequently underwent PPV, achieving successful retinal reattachment and BCVA recovery to 20/20 at 3 months postoperatively. The other eye (supplementary patient 2) eventually underwent PPV at another hospital, telephone follow-up at 3.5 months confirmed reattachment with BCVA 20/25, but further visits and records were declined. One patient (1.89%, supplementary patient 3) with macula-on RRD was diagnosed with a secondary epiretinal membrane at the 3-month follow-up; BCVA decreased from 20/32 to 20/100. The patient subsequently underwent combined PPV, phacoemulsification with intraocular lens implantation, epiretinal membrane peeling, and internal limiting membrane peeling. BCVA improved to 20/32 at 3 months after the combined procedure. Two eyes (supplementary patient 4 and 5) developed small, non–clinically significant subretinal hemorrhages adjacent to the drainage paracentesis site, which were detected on postoperative day 1. Forty-three procedures (81.13%) were performed in the outpatient operating suite, whereas the remaining 10 cases were performed in the inpatient operating room. Subgroup Analysis: Macula-off RRD The macula-off subgroup included 20 patients (20 eyes) with a mean age of 45.85 ± 15.35 years (range,19-67). Thirteen patients (65.00%) were male. The mean axial length was 25.65 ± 1.75 mm (range,23.24-29.06). All eyes were phakic, including five with mild lens opacity and six with moderate lens opacity. The mean number of retinal breaks was 1.00 (IQR,1.00-2.00) (range, 1.00-4.00), and the mean extent of retinal detachment was 2.30 ± 0.73 quadrants. In this subgroup, the single-surgery anatomic success rate at 3 months was 100% (20/20). Mean BCVA significantly improved from 0.75 (IQR,0.43-1.18) logMAR preoperatively to 0.20(IQR,0.04-0.30) logMAR postoperatively (P＜0.001). Two patients with macula-off RRD had undergone conventional PnR at another hospital 1 week earlier; however, retinal reattachment was not achieved. Both eyes subsequently achieved complete retinal reattachment after mPnR; BCVA improved to 20/20 in one eye (Figure 3) at 4 months postoperatively and to 20/50 in the other eye at 3 months postoperatively. TABLE 1. Basic Characteristics of Patients with Primary RRD Who Underwent mPnR Characteristic Over Cohort (n=53) Macula-Off Subgroup (n=20) Macula-On Subgroup (n=33) Age (years) 43.13±15.58 45.85±15.35 41.48±15.73 Gender (male/female) 28/25 13/7 15/18 Hypertension (yes/no) 11/42 6/14 5/28 Diabetes (yes/no) 7/46 2/18 5/28 Affected eye (right/left) 33/20 10/10 23/10 Axial length (mm) 25.63±1.98 25.65±1.75 25.62±2.13 Lens status Clear lens 31 9 22 Mild lens opacity 13 5 8 Moderate lens opacity 8 6 2 Pseudophakic 1 0 1 Retinal Detachment Feathers Number of breaks,media(IQR) 1.00(1.00-2.00) 1.00(1.00-2.00) 1.00(1.00-2.00) Extent of detachment (quadrants) 2.00±0.65 2.30±0.73 1.82±0.53 Visual Acuity (LogMAR) Preoperative BCVA,media(IQR) 0.10(0.00-0.60) 0.75(0.43-1.18) 0.00(0.00-0.10) 3-month postoperative BCVA ,media(IQR) 0.02(0.00-0.20) 0.20(0.04-0.30) 0.00(0.00-0.10) Final postoperative BCVA,media(IQR) 0.02(0.00-0.20) 0.20(0.04-0.30) 0.00(0.00-0.10) Surgical Outcomes Anatomical success at 3 months (yes/no) 51/2 20/0 31/2 Follow-up duration (months) 3.33±0.84 3.24±0.73 3.38±0.91 Data are presented as mean±standard deviation,unless otherwise specified. Abbreviations: RRD=rhegmatogenous retinal detachment; mPnR=modified pneumatic retinopexy; BCVA=best corrected visual acuity; LogMAR=logarithm of the minimum angle of resolution; IQR=interquartile range. DISCUSSION This study focused on an mPnR technique that combines transscleral drainage of SRF with intravitreal air injection, evaluating its efficacy in the treatment of primary RRD. The conceptual origins of this approach date to the early twentieth century. In 1911, Ohm described a method involving intravitreal air injection after SRF drainage through a paracentesis for the treatment of RRD. 15 However, this technique primarily relied on patient positioning to maximize contact between the air bubble and the detached retina; it lacked a clear understanding of the underlying pathophysiology of retinal detachment. Although the single reported case was successful, it is now believed to have involved a substantial element of chance. 16 Subsequently, Arruga combined intravitreal air injection with diathermy for the treatment of RRD. 17 In this approach, intraocular air was mainly used as a vitreous expander to maintain intraocular pressure and facilitate external drainage of SRF, rather than as a direct tamponade of retinal breaks. A major advance was reported by Rosengren in 1938, who introduced the concept of retinal break “tamponade.” 18 He applied diathermy strictly to the area corresponding to the retinal break and, after SRF drainage, injected an air bubble specifically to tamponade the break. This method achieved a reattachment rate of 77%; however, a substantial proportion of patients experienced redetachment. This outcome was likely related to premature absorption of the air bubble prior to formation of sufficiently strong chorioretinal adhesion around the break. Technical limitations of that era, including imprecise localization of retinal breaks and difficulty restricting diathermy application to the immediate surrounding area, may also have contributed. 19 Because of the subsequent development and widespread adoption of SB, PnR, and PPV, further evolution of RRD repair techniques combining air injection with SRF drainage largely stalled. In the modern era, however, high-resolution wide-field imaging enables precise localization of retinal breaks; contemporary laser photocoagulation permits accurate and rapid induction of chorioretinal adhesion. Consequently, most historical limitations that previously constrained the effectiveness of this approach have been largely resolved. The present study demonstrated a single-surgery retinal reattachment rate of 96.23% after mPnR for primary RRD. This outcome compares favorably with previously reported success rates of 93.2% for PPV and 82% for SB in similar RRD populations. 9,11 Furthermore, substantial functional improvement was observed, such that mean BCVA improved from 0.10 (IQR,0.00-0.60) logMAR preoperatively to 0.02 (IQR,0.00-0.20) logMAR at 3 months postoperatively (P＜ 0.001). Subgroup analysis of macula-off RRD cases showed even more pronounced visual recovery, whereby BCVA improved from 0.75 (IQR,0.43-1.18) logMAR to 0.20(IQR,0.04-0.30) logMAR (P＜0.001). Collectively, these findings support the anatomic and functional efficacy of the mPnR technique for the treatment of primary RRD. A critical determinant of PnR success is the rate of SRF resolution adjacent to the retinal break. However, the absorptive capacity of the retinal pigment epithelium substantially varies among individuals. 20,21,22 The “steam-roller” maneuver, which uses the buoyancy of an intravitreal gas bubble to displace SRF through the retinal break, can accelerate reattachment. Nevertheless, its efficacy is often limited in the presence of small retinal breaks or highly viscous SRF. Furthermore, the SRF clearance rate directly determines the duration of postoperative positioning. Conventional PnR typically requires maintained positioning for at least 5 days and up to 3 weeks, imposing a considerable burden on patient compliance and quality of life. In contrast, the mPnR technique incorporates deliberate SRF drainage through a paracentesis, accelerating retinal reattachment and creating additional intraocular space for the injection of a larger air volume. This increased air fill provides a more substantial tamponade and facilitates further evacuation of residual SRF through the paracentesis site, thereby promoting rapid reapposition of the neurosensory retina to the retinal pigment epithelium. The larger air bubble offers a more effective and sustained tamponade without requiring expansile gas. Concurrently, it reduces the stringency of postoperative positioning requirements because patients only need to maintain a position that allows the bubble to cover the retinal break. In our protocol, the required duration of postoperative positioning was reduced to 3–5 days, which is substantially shorter than the duration typically required after conventional PnR. This modification greatly reduces the burden of patient compliance and minimizes disruption of daily activities. These technical advantages of mPnR likely contributed to the higher single-surgery success rate observed in this study (96.23%) compared with success rates reported for conventional PnR in recent literature, which range from 81% to 90%. 11,23 Furthermore, procedures such as PPV and SB must be performed in an operating room under sedation or retrobulbar or peribulbar anesthesia; they require specialized surgical equipment and consumables. In contrast, mPnR—similar to conventional PnR—can be performed under subconjunctival anesthesia alone, without any need for sedation or regional blocks; this method reduces anesthesia-related risks. The brief, efficient procedure can be completed without reliance on an operating microscope or binocular indirect ophthalmoscope, which makes it suitable for an outpatient setting. Both mPnR and conventional PnR offer advantages of high efficiency, minimal invasiveness, and low health care cost; the principal difference is that mPnR replaces anterior chamber paracentesis with transscleral paracentesis for SRF drainage. Accordingly, mPnR may be regarded as an evolution of the PnR technique and can be considered a first-line treatment option for RRD cases that meet PIVOT trial criteria. The mPnR technique is particularly valuable in remote or resource-limited regions (where surgical resources are scarce and intraocular gas is often unavailable) because it provides a practical and timely option for RRD management. The paracentesis for SRF drainage should be placed at the site of maximal retinal elevation adjacent to the retinal break(s). An oblique incision is recommended to reduce the risk of an iatrogenic retinal break; if such a break occurs, its proximity to the primary break allows concurrent treatment during subsequent laser photocoagulation. In eyes with a large retinal break, an additional potential benefit may be achieved. A temporary fluid pathway may form between the vitreous cavity and paracentesis site through the retinal break, permitting egress of intravitreal fluid. This outflow may facilitate removal of dispersed retinal pigment epithelial cells and other potential mediators from the vitreous cavity, potentially contributing to the reduction of intraocular factors associated with proliferative vitreoretinopathy. 24 Some surgeons may express concern about the risk of subretinal hemorrhage associated with transscleral drainage paracentesis. 25 However, in the mPnR technique, continuous scleral indentation combined with immediate intraocular air injection maintains stable intraocular pressure throughout the procedure, thereby minimizing hemorrhage risk. In the present series, only two eyes (3.77%) developed small, clinically insignificant subretinal hemorrhages adjacent to the paracentesis site, supporting the safety of this approach. Additionally, whereas conventional PnR may require anterior chamber paracentesis, the mPnR technique eliminates this step and thus avoids the associated risk of iatrogenic angle-closure glaucoma due to anterior chamber shallowing. 26 In most mPnR cases, the retina surrounding the break is already reattached at the conclusion of surgery. However, because patients are often stressed and frequently exhibit corneal epithelial edema on the day of surgery, it is advisable to defer laser photocoagulation until 12–24 hours postoperatively. The presence of an intraocular air bubble can complicate laser application. Depending on the location of the retinal break and size of the air bubble, two approaches may be used: rotating the patient’s head to expose the retinal break for laser treatment, or, if the bubble is sufficiently large, positioning the break at the center of the bubble to allow laser application through the bubble. Cryotherapy applied to the retinal break area before air injection may represent a viable alternative. Algvere et al. previously reported a similar technique combining cryotherapy, drainage of SRF, and air injection; however, their primary retinal reattachment rate (86%) was notably inferior to the results achieved in the present study. 27 This disparity is likely attributable to chorioretinal adhesion typically develops more slowly after cryotherapy than after laser photocoagulation. 28,29 Because the mPnR technique uses air, which is absorbed relatively quickly, the more rapid adhesion achieved with laser photocoagulation may be more appropriate in this setting. In this series, two eyes with macula-off RRD showed persistent detachment after initial PnR. Their retina subsequently achieved complete reattachment after mPnR. This outcome suggests that mPnR can be considered a treatment option for selected cases of failed initial PnR, provided that clinical features remain suitable for the mPnR approach. Another illustrative case (Figure 1) demonstrated an unexpected sequence of events: after successful reattachment of a superior retinal break following mPnR, residual SRF shifted inferiorly, leading to the reopening of a pre-existing retinal break at the 5:00 position and causing secondary inferior RRD. Management consisted of immediate laser photocoagulation of the superior break, along with maintenance of an uppermost position. After 24 hours, patient positioning was changed to a head-low, prone posture to allow the air–fluid interface to cover the inferior break. Complete retinal reattachment was ultimately achieved. On the basis of this experience, we put forward the bold hypothesize that mPnR may be extended to RRDs with breaks in the inferior quadrant (4:00 to 8:00), provided that appropriate postoperative positioning is maintained. Undoubtedly, the validity of this hypothesis awaits verification in future prospective studies. This study has several limitations. First, its retrospective design and relatively small sample size limit the generalizability of the findings. Second, the minimum follow-up duration was only 3 months. Although the PIVOT trial showed a low likelihood of redetachment beyond 3 months post-PnR, longer follow-up is necessary to fully assess subjective visual outcomes, long-term complications such as epiretinal membrane formation, and the incidence of late redetachment. Additionally, this study did not include a direct comparison of mPnR with other retinal detachment repair techniques, including conventional PnR, PPV, or SB. Prospective controlled studies are needed to address these limitations. CONCLUSION The mPnR technique is a safe and effective approach for the management of primary RRD. By actively draining SRF, it accelerates retinal reattachment, shortens the required duration of postoperative positioning, and achieves a single-operation anatomic success rate of 96.23%. The procedure is efficient and minimally invasive, does not require expansile gas, and can be performed in an outpatient setting, thus supporting its broad potential for widespread adoption. Abbreviations mPnR modified pneumatic retinopexy RRD rhegmatogenous retinal detachment BCVA best corrected visual acuity LogMAR logarithm of the minimum angle of resolution IQR interquartile range PPV pars plana vitrectomy SB scleral buckling PnR pneumatic retinopexy SRF subretinal fluid PIVOT pneumatic retinopexy versus vitrectomy for the management of primary rhegmatogenous retinal detachment Declarations Ethics approval and consent to participate This single-center retrospective cohort study was approved by the Ethics Committee of the Eye Hospital of Wenzhou Medical University (Approval No. 2025-043-X-02-01). All procedures adhered to the tenets of the Declaration of Helsinki. The requirement for informed consent was waived due to the retrospective nature of the study. Consent for publication Not applicable. This manuscript does not contain any individual person’s data in any form (including individual details, images, or videos). Availability of data and materials The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors' contributions Q.T.P. contributed to study conception and design, performed the surgeries, and drafted the manuscript. R.W.L contributed to data collection, analysis, and interpretation. H.R.P., M.Q.L., J.Y.W., S.F.Z., X.T.H., and Z.L.Z. contributed to data acquisition, analysis, and assisted in the literature review. W.C. and Z.D.Z. supervised the study, provided critical revisions for important intellectual content, and gave final approval for the version to be published. All authors read and approved the final manuscript. 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Taiwan J Ophthalmol. 2016;6:161–9. 10.1016/j.tjo.2016.04.006 . Chignell AH, Talbot J. Absorption of subretinal fluid after nondrainage retinal detachment surgery. Arch Ophthalmol. 1978;96:635–7. 10.1001/archopht.1978.03910050331007 . Ricker LJ, Noordzij LJ, Goezinne F, et al. Persistent subfoveal fluid and increased preoperative foveal thickness impair visual outcome after macula-off retinal detachment repair. Retina. 2011;31:1505–12. 10.1097/IAE.0b013e31820a6910 . Chen YY, Tian B, He L, et al. [Influencing factors of visual prognosis in patients with persistent submacular fluid after successful scleral buckle surgery for macula-off retinal detachment]. Zhonghua Yan Ke Za Zhi. 2023;59:899–905. 10.3760/cma.j.cn112142-20230809-00030 . Zhu T, Xiang Z, Huang Q, Li G, Guo S, Li E. Pneumatic retinopexy involving the use of intravitreal air injection and laser photocoagulation for rhegmatogenous retinal detachment in phakic eyes. J Pers Med. 2023;13:328. 10.3390/jpm13020328 . Pastor JC, Rojas J, Pastor-Idoate S, Di Lauro S, Gonzalez-Buendia L, Delgado-Tirado S. Proliferative vitreoretinopathy: a new concept of disease pathogenesis and practical consequences. Prog Retin Eye Res. 2016;51:125–55. 10.1016/j.preteyeres.2015.07.005 . Burton RL, Cairns JD, Campbell WG, Heriot WJ, Heinze JB. Needle drainage of subretinal fluid. A randomized clinical trial. Retina. 1993;13:13–6. 10.1097/00006982-199313010-00004 . Choo CH, Pisitpayat P, Yan D, et al. Practice patterns, diagnostic utility, and safety of anterior chamber paracentesis. Am J Ophthalmol. 2025;277:260–8. 10.1016/j.ajo.2025.05.017 . Algvere PV, Gjötterberg M, Olivestedt G, Fituri S. Results of pneumatic retinopexy with air. Acta Ophthalmol (Copenh). 1992;70:632–6. 10.1111/j.1755-3768.1992.tb02144.x . Yoon YH, Marmor MF. Rapid enhancement of retinal adhesion by laser photocoagulation. Ophthalmology. 1988;95:1385–8. 10.1016/s0161-6420(88)33000-9 . Kita M, Negi A, Kawano S, Honda Y. Photothermal, cryogenic, and diathermic effects of retinal adhesive force in vivo. Retina. 1991;11:441–4. 10.1097/00006982-199111040-00015 . Additional Declarations No competing interests reported. Supplementary Files Supplementarymaterial26.pdf Video1.mp4 Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 08 May, 2026 Reviews received at journal 22 Apr, 2026 Reviews received at journal 20 Apr, 2026 Reviews received at journal 08 Apr, 2026 Reviewers agreed at journal 06 Apr, 2026 Reviews received at journal 05 Apr, 2026 Reviewers agreed at journal 01 Apr, 2026 Reviewers agreed at journal 01 Apr, 2026 Reviewers agreed at journal 29 Mar, 2026 Reviewers agreed at journal 29 Mar, 2026 Reviewers agreed at journal 21 Mar, 2026 Reviewers agreed at journal 18 Mar, 2026 Reviews received at journal 18 Mar, 2026 Reviews received at journal 16 Mar, 2026 Reviewers agreed at journal 16 Mar, 2026 Reviewers agreed at journal 03 Mar, 2026 Reviewers invited by journal 01 Mar, 2026 Editor assigned by journal 24 Feb, 2026 Submission checks completed at journal 24 Feb, 2026 First submitted to journal 23 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8947548","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":600565315,"identity":"1548e5b1-6cf2-42ac-99cf-94444f2e08b1","order_by":0,"name":"QinTuo Pan","email":"","orcid":"","institution":"Affiliated Eye Hospital of Wenzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"QinTuo","middleName":"","lastName":"Pan","suffix":""},{"id":600565316,"identity":"80b90de8-c82f-4bf2-a89e-0defa49f1cc4","order_by":1,"name":"RenWan Liu","email":"","orcid":"","institution":"Affiliated Eye Hospital of Wenzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"RenWan","middleName":"","lastName":"Liu","suffix":""},{"id":600565317,"identity":"39caf8f3-edac-40cd-a00f-33d6e464e8f1","order_by":2,"name":"HuiRong Pan","email":"","orcid":"","institution":"Affiliated Eye Hospital of Wenzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"HuiRong","middleName":"","lastName":"Pan","suffix":""},{"id":600565318,"identity":"a661e087-02b2-47fc-9994-ff99d4dbdad7","order_by":3,"name":"MeiQi Liu","email":"","orcid":"","institution":"Affiliated Eye Hospital of Wenzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"MeiQi","middleName":"","lastName":"Liu","suffix":""},{"id":600565319,"identity":"8d16ed65-0087-4323-8aef-fcba7783a4a5","order_by":4,"name":"JiaYi Wei","email":"","orcid":"","institution":"Affiliated Eye Hospital of Wenzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"JiaYi","middleName":"","lastName":"Wei","suffix":""},{"id":600565320,"identity":"3a0b832c-7089-43b4-9988-3dd7edf904f6","order_by":5,"name":"SaiFei Zhang","email":"","orcid":"","institution":"Affiliated Eye Hospital of Wenzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"SaiFei","middleName":"","lastName":"Zhang","suffix":""},{"id":600565321,"identity":"b93352b2-6b74-4820-b5a7-1cf0ea802364","order_by":6,"name":"XuTing Hu","email":"","orcid":"","institution":"Affiliated Eye Hospital of Wenzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"XuTing","middleName":"","lastName":"Hu","suffix":""},{"id":600565322,"identity":"fdb9f9ef-653f-4ca8-88b3-4c7e05f6870b","order_by":7,"name":"ZhaoLiang Zhang","email":"","orcid":"","institution":"Affiliated Eye Hospital of Wenzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"ZhaoLiang","middleName":"","lastName":"Zhang","suffix":""},{"id":600565323,"identity":"2808d176-af3a-4530-b5e4-0ebaca41bc65","order_by":8,"name":"Wei Chen","email":"","orcid":"","institution":"Affiliated Eye Hospital of Wenzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Chen","suffix":""},{"id":600565324,"identity":"25c0baca-e545-4598-9d58-2762a3256968","order_by":9,"name":"ZongDuan Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvElEQVRIiWNgGAWjYHACAyC2AWIe0rSkwbQYEK3lMAla5PsPb5P4ueN8Yj/72QPMBRV/CGthbDhWJtl75nbizJ68BOYZZ4iwhZmxx0yCt+124oYDOQbMvG1EaGFj5jGT/Nt2LnH/+TdALf+I0MLDxmMmzdt2IHGDBMiWBiK0SPCwFVvLtiUbz7jxxuAwzzFjwlqAIbbx5ts2O9n+/hzDxzw1coS1wIBjA5A4QLx6ILAnSfUoGAWjYBSMLAAA8eg0j/mwNjEAAAAASUVORK5CYII=","orcid":"","institution":"Affiliated Eye Hospital of Wenzhou Medical University","correspondingAuthor":true,"prefix":"","firstName":"ZongDuan","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2026-02-23 13:23:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8947548/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8947548/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104181051,"identity":"685ddc4e-6a21-4723-a6d5-f49898b44cac","added_by":"auto","created_at":"2026-03-08 17:24:38","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":3349917,"visible":true,"origin":"","legend":"\u003cp\u003eA 67-year-old phakic man with rhegmatogenous retinal detachment involving the macula in the left eye. (A) Preoperatively, best-corrected visual acuity (BCVA) was 20/250. Retinal detachment extended from 10:00 to 12:00 to 3:30; peripheral retinal breaks were identified at 12:00 and 5:00. (B) Preoperatively, laser retinopexy had been applied around the inferior retinal break. (C) On postoperative day 1, the superior retina was flat and the superior break was closed. Subretinal fluid had shifted inferiorly, resulting in inferior retinal detachment and reopening of the inferior break. Laser retinopexy was applied to the superior break, and the patient was maintained in a position with the superior break uppermost for 24 hours. After 24 hours, patient positioning was changed to elevate the inferior retinal break (prone position). (D) On postoperative day 4, the inferior retina was fully attached, without visible subretinal fluid. Supplemental laser retinopexy was applied around the inferior retinal break. (E) At 3 months postoperatively, BCVA was 20/25. The retina was fully attached and no new retinal breaks were detected.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-8947548/v1/4ff237eebbf9285443b4fe2f.png"},{"id":104181055,"identity":"d52cc191-fd13-4f1e-a12e-6e88a85321f0","added_by":"auto","created_at":"2026-03-08 17:24:39","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":3212794,"visible":true,"origin":"","legend":"\u003cp\u003eA 60-year-old phakic woman with rhegmatogenous retinal detachment in the right eye not involving the macular fovea. (A) Preoperatively, BCVA was 20/25. Retinal detachment extended from 3:30 to 12:00 to 1:00; a peripheral retinal break was identified at 11:00. (B) On postoperative day 1, the superior retina and posterior pole were fully attached, with a small amount of residual subretinal fluid in the inferior retina. (C) On postoperative day 1, laser retinopexy was applied around the retinal break. (D) At 3 months postoperatively, BCVA was 20/25. The retina was fully attached and no new retinal breaks were detected.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8947548/v1/20174dc14abc55a592a36753.png"},{"id":104181056,"identity":"be6dcdd3-dcd1-45e6-a4a8-9c967b2538ab","added_by":"auto","created_at":"2026-03-08 17:24:39","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":3394938,"visible":true,"origin":"","legend":"\u003cp\u003eA 50-year-old phakic man with rhegmatogenous retinal detachment involving the macula in the left eye who had undergone pneumatic retinopexy at another hospital 1 week earlier but reattachment was not achieved. (A) Preoperatively, BCVA was 20/50. Retinal detachment extended from 0:30 to 3:30; retinal breaks were identified at the edge of a degenerative band at 1:30 and 6:00. (B) On postoperative day 1, no subretinal fluid was observed, and the retina was fully attached. Laser retinopexy was applied around the retinal breaks and the degenerative band. (C) On postoperative day 2, the retina remained fully attached; laser retinopexy was completed around the breaks and degenerative band. (D) At 4 months postoperatively, BCVA was 20/20. The retina was fully attached and no new retinal breaks were detected.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-8947548/v1/8796faa35eebd9224fc3e360.png"},{"id":104181133,"identity":"62045b06-37e8-411b-9faa-52c4cc64442b","added_by":"auto","created_at":"2026-03-08 17:24:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":9664463,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8947548/v1/f742f40c-d8d3-45d9-94fc-e9a013a15705.pdf"},{"id":104181054,"identity":"a11a4582-cc25-47fd-a466-da772dd79595","added_by":"auto","created_at":"2026-03-08 17:24:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":754729,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterial26.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8947548/v1/18df367526a25270e743197b.pdf"},{"id":104181052,"identity":"b9f2d236-db77-405f-a5d2-4ebef16b2e0c","added_by":"auto","created_at":"2026-03-08 17:24:38","extension":"mp4","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":19649731,"visible":true,"origin":"","legend":"","description":"","filename":"Video1.mp4","url":"https://assets-eu.researchsquare.com/files/rs-8947548/v1/ae59e3099b384cbc20b32490.mp4"}],"financialInterests":"No competing interests reported.","formattedTitle":"Outcomes of modified pneumatic retinopexy with transscleral subretinal fluid drainage for primary rhegmatogenous retinal detachment","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRhegmatogenous retinal detachment (RRD), the most common form of retinal detachment, occurs when liquefied vitreous passes through a full-thickness retinal break, resulting in separation of the neurosensory retina from the underlying retinal pigment epithelium.\u003csup\u003e1\u003c/sup\u003e Risk factors for RRD include posterior vitreous detachment, cataract surgery, myopia, degenerative retinoschisis, lattice degeneration, and ocular trauma.\u003csup\u003e2\u003c/sup\u003e The incidence of RRD ranges from 6.3 to 17.9 cases per 100,000 population, and incidence increases with age.\u003csup\u003e3\u003c/sup\u003e Current primary surgical treatments for RRD include pars plana vitrectomy (PPV), scleral buckling (SB), and pneumatic retinopexy (PnR); however, the optimal intervention remains a subject of ongoing debate.\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eOver the past several decades, PPV and SB have been the preferred surgical approaches for RRD, demonstrating favorable single-surgery anatomic success rates.\u003csup\u003e4,5,6\u003c/sup\u003e PnR, first described by Domínguez as an outpatient procedure for RRD repair without conjunctival incision, was later popularized by Hilton and Grizzard.\u003csup\u003e7,8\u003c/sup\u003e A prospective, multicenter, randomized controlled trial comparing PnR with SB demonstrated no significant difference in single-surgery reattachment rates, whereas the PnR group achieved better visual acuity at 6 months and 2 years postoperatively.\u003csup\u003e9,10\u003c/sup\u003e More recent studies have shown that, in selected RRD cases, PnR provides superior functional and anatomic outcomes relative to PPV, with equivalent primary reattachment rates.\u003csup\u003e11,12,13\u003c/sup\u003e Although PnR offers advantages such as procedural efficiency, minimal invasiveness, and reduced resource utilization compared with PPV or SB—which typically require an operating room—its conventional approach requires strict and prolonged postoperative positioning (at least 5 days and up to 3 weeks) to allow subretinal fluid (SRF) resorption.\u003csup\u003e6\u003c/sup\u003e Furthermore, the intravitreal gas bubble can cause sustained visual impairment for several weeks, a period that may be further extended if supplemental gas injections are required.\u003csup\u003e14\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAccordingly, we modified the conventional PnR technique by incorporating transscleral drainage of SRF. This modification facilitates rapid postoperative retinal reattachment, eliminates the need for intraocular expansile gas, and preserves the inherent advantages of PnR. The present study was designed to evaluate the primary anatomic success rate and visual outcomes of this modified pneumatic retinopexy (mPnR) approach in patients with primary RRD.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThis single-center retrospective cohort study was approved by the Ethics Committee of the Eye Hospital of Wenzhou Medical University (Approval No. 2025-043-X-02-01). All procedures adhered to the tenets of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eThe medical records of consecutive patients who presented to the Eye Hospital of Wenzhou Medical University between March 19, 2025, and October 5, 2025, with primary RRD and who underwent mPnR were reviewed. Only eyes with a minimum postoperative follow-up interval of 3 months were included.\u003c/p\u003e\n\u003cp\u003eEligibility criteria for RRD were based on the Pneumatic Retinopexy versus Vitrectomy for the Management of Primary Rhegmatogenous Retinal Detachment (PIVOT) trial\u003csup\u003e11\u003c/sup\u003e and included the following: (1) one or more retinal breaks confined to a 30° sector (≤1 clock hour); and (2) all breaks located superior to the 8:00 and 4:00 meridians. Exclusion criteria were as follows: (1) clinically significant proliferative vitreoretinopathy; (2) a history of retinal detachment repair in the same eye, except for previous PnR; (3) inability to comply with postoperative positioning requirements (e.g., severe physical disability); and (4) inadequate visualization of the peripheral retina or inability to perform laser photocoagulation due to media opacity. The primary outcome measures were (1) the single-surgery anatomic success rate of mPnR and (2) best-corrected visual acuity (BCVA) at 3 months postoperatively.\u003c/p\u003e\n\u003cp\u003ePatient medical records were reviewed to collect the following clinical data: age, sex, affected eye, axial length, history of hypertension, history of diabetes, duration of RRD symptoms, preoperative and postoperative BCVA, lens status, complications, follow-up duration, wide-field fundus photography (Optos, Marlborough, MA, USA), and spectral-domain optical coherence tomography (Heidelberg Spectralis OCT, Heidelberg, Germany). Symptom duration was defined as the interval between the onset of visual loss or visual field defects, as reported by the patient, and the date of surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Technique\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter adequate pupillary dilation, a preoperative fundus examination was performed. All retinal breaks and areas of lattice degeneration located in attached retina were surrounded with laser photocoagulation.\u003c/p\u003e\n\u003cp\u003eSubconjunctival anesthesia was administered using 2% lidocaine hydrochloride (100 mg; Hunan Kelun Pharmaceutical Company, China; National Drug Approval Number: R25041403) over the quadrant corresponding to the retinal break(s). Transconjunctival fixation of the rectus muscles adjacent to the break(s) with traction sutures. A localized conjunctival incision (about 1 centimeter) was made to expose the sclera. Transscleral drainage of SRF was then performed using a needle (22 gauge) attached to a 5-mL syringe at the site of maximal retinal elevation adjacent to the retinal break(s). Beveled incision was recommended to enhance the self-sealing properties of the scleral wound. Gentle indentation with a sterile cotton swab was simultaneously applied to maintain normal intraocular pressure. A 30-gauge needle was subsequently inserted 4 mm posterior to the limbus, and filtered air was injected into the vitreous cavity. During air injection, the indentation was gradually released until intraocular pressure reached approximately Tn to T+1 (normal to slightly elevated) by digital palpation. The sequence of SRF drainage and air injection was repeated as necessary to maximize SRF evacuation while preserving the largest possible intravitreal air volume. For repeat SRF drainage, merely gentle scleral indentation immediately adjacent to the scleral incision with microforceps suffices, avoiding repeated needle entry. The conjunctival incision was closed by electrocoagulation or suturing (Video 1).\u003c/p\u003e\n\u003cp\u003ePostoperatively, patients were instructed to maintain a position with the retinal break(s) uppermost for 3–5 days to ensure continuous air tamponade. Laser photocoagulation of the retinal break(s) was performed 12–24 hours after surgery, with additional treatment applied as required.\u003c/p\u003e\n\u003cp\u003eLevofloxacin 0.5% ophthalmic solution was administered four times daily for 5 days postoperatively as infection prophylaxis. All surgical and laser procedures were performed by the same vitreoretinal surgeon (Q.T. Pan). Follow-up visits were scheduled at 1 day, 3–7 days, 1 month, 3 months, and 6 months postoperatively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analyses were performed using SPSS software, version 27.0. BCVA values were converted to the logarithm of the minimum angle of resolution (logMAR) before analysis. Continuous variables are presented as mean ± standard deviation, while non-normally distribute data are presented as median and interquartile range(IQR). Categorical variables are expressed as frequencies and percentages. Comparisons of continuous variables between groups were performed using the independent-samples t-test or the Mann–Whitney U test, as appropriate. For paired comparisons (e.g.,preoperative vs. postoperative BCVA), the paried t-test or the Wilcoxon signed-rank test was used based on data normality. Categorical variables were compared using the chi-square test. P-values \u0026lt; 0.05 were considered statistically significant.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe basic characteristics of the patients are summarized in Table 1.In total, 53 patients (53 eyes) were included in this study. The mean age was 43.13 \u0026plusmn; 15.58 years (range,15-70); 28 patients (52.83%) were men and 25 (47.17%) were women. Systemic comorbidities included hypertension in eleven patients (20.75%) and type 2 diabetes mellitus in senven patients (13.21%). The mean axial length was 25.63 \u0026plusmn; 1.98 mm (range,21.71-29.99). 52 eyes (98.11%) were phakic; among them, thirteen had mild lens opacity and eight had moderate lens opacity. Macula-off RRD was present in 20 eyes (37.74%) (Figure 1), whereas the remaining 33 eyes (62.26%) had macula-on RRD (Figure 2). \u0026nbsp;The mean number of retinal breaks was 1.00 (IQR,1.00-2.00) (range,1.00-5.00), and the mean extent of retinal detachment was 2.00 \u0026plusmn; 0.65 quadrants. The mean follow-up duration was 3.33 \u0026plusmn; 0.84 months (range,3.00-6.37).\u003c/p\u003e\n\u003cp\u003eThe single-surgery anatomic success rate of mPnR at 3 months postoperatively was 96.23% (51/53). Mean BCVA significantly improved from 0.10 (IQR,0.00-0.60) logMAR preoperatively to 0.02 (IQR,0.00-0.20) logMAR at 3 months postoperatively (P＜0.001). No patient required cataract surgery during the 3-month postoperative period.\u003c/p\u003e\n\u003cp\u003eTwo eyes (3.77%) with macula-on RRD developed postoperative recurrent retinal detachment, which was identified at the 2-week follow-up visit. One eye (supplementary patient 1) subsequently underwent PPV, achieving successful retinal reattachment and BCVA recovery to 20/20 at 3 months postoperatively. The other eye (supplementary patient 2) eventually underwent PPV at another hospital, telephone follow-up at 3.5 months confirmed reattachment with BCVA 20/25, but further visits and records were declined. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOne patient (1.89%, supplementary patient 3) with macula-on RRD was diagnosed with a secondary epiretinal membrane at the 3-month follow-up; BCVA decreased from 20/32 to 20/100. The patient subsequently underwent combined PPV, phacoemulsification with intraocular lens implantation, epiretinal membrane peeling, and internal limiting membrane peeling. BCVA improved to 20/32 at 3 months after the combined procedure. Two eyes (supplementary patient 4 and 5) developed small, non\u0026ndash;clinically significant subretinal hemorrhages adjacent to the drainage paracentesis site, which were detected on postoperative day 1. Forty-three procedures (81.13%) were performed in the outpatient operating suite, whereas the remaining 10 cases were performed in the inpatient operating room.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubgroup Analysis: Macula-off RRD\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe macula-off subgroup included 20 patients (20 eyes) with a mean age of 45.85 \u0026plusmn; 15.35 years (range,19-67). Thirteen patients (65.00%) were male. The mean axial length was 25.65 \u0026plusmn; 1.75 mm (range,23.24-29.06). All eyes were phakic, including five with mild lens opacity and six with moderate lens opacity. The mean number of retinal breaks was 1.00 (IQR,1.00-2.00) (range, 1.00-4.00), and the mean extent of retinal detachment was 2.30 \u0026plusmn; 0.73 quadrants. In this subgroup, the single-surgery anatomic success rate at 3 months was 100% (20/20). Mean BCVA significantly improved from 0.75 (IQR,0.43-1.18) logMAR preoperatively to 0.20(IQR,0.04-0.30) logMAR postoperatively (P＜0.001). Two patients with macula-off RRD had undergone conventional PnR at another hospital 1 week earlier; however, retinal reattachment was not achieved. Both eyes subsequently achieved complete retinal reattachment after mPnR; BCVA improved to 20/20 in one eye (Figure 3) at 4 months postoperatively and to 20/50 in the other eye at 3 months postoperatively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTABLE 1.\u0026nbsp;\u003c/strong\u003eBasic Characteristics of Patients with Primary RRD Who Underwent mPnR\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"567\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eOver Cohort (n=53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eMacula-Off Subgroup (n=20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eMacula-On Subgroup (n=33)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e43.13\u0026plusmn;15.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e45.85\u0026plusmn;15.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e41.48\u0026plusmn;15.73\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eGender (male/female)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e28/25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e13/7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e15/18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eHypertension (yes/no)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e11/42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e6/14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5/28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eDiabetes (yes/no)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e7/46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2/18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5/28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eAffected eye (right/left)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e33/20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e10/10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e23/10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eAxial length (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e25.63\u0026plusmn;1.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e25.65\u0026plusmn;1.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e25.62\u0026plusmn;2.13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eLens status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eClear lens\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eMild lens opacity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eModerate lens opacity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003ePseudophakic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eRetinal Detachment Feathers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eNumber of breaks,media(IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1.00(1.00-2.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1.00(1.00-2.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1.00(1.00-2.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eExtent of detachment (quadrants)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2.00\u0026plusmn;0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2.30\u0026plusmn;0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1.82\u0026plusmn;0.53\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eVisual Acuity (LogMAR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003ePreoperative BCVA,media(IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.10(0.00-0.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.75(0.43-1.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.00(0.00-0.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e3-month postoperative BCVA ,media(IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.02(0.00-0.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.20(0.04-0.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.00(0.00-0.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Final postoperative BCVA,media(IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.02(0.00-0.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.20(0.04-0.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.00(0.00-0.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eSurgical Outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Anatomical success at 3 months (yes/no)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e51/2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e20/0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 31/2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Follow-up duration (months)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3.33\u0026plusmn;0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3.24\u0026plusmn;0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3.38\u0026plusmn;0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are presented as mean\u0026plusmn;standard deviation,unless otherwise specified.\u003c/p\u003e\n\u003cp\u003eAbbreviations: RRD=rhegmatogenous retinal detachment; mPnR=modified pneumatic retinopexy; BCVA=best corrected visual acuity; LogMAR=logarithm of the minimum angle of resolution; IQR=interquartile range.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study focused on an mPnR technique that combines transscleral drainage of SRF with intravitreal air injection, evaluating its efficacy in the treatment of primary RRD. The conceptual origins of this approach date to the early twentieth century. In 1911, Ohm described a method involving intravitreal air injection after SRF drainage through a paracentesis for the treatment of RRD.\u003csup\u003e15\u003c/sup\u003e However, this technique primarily relied on patient positioning to maximize contact between the air bubble and the detached retina; it lacked a clear understanding of the underlying pathophysiology of retinal detachment. Although the single reported case was successful, it is now believed to have involved a substantial element of chance.\u003csup\u003e16\u003c/sup\u003e Subsequently, Arruga combined intravitreal air injection with diathermy for the treatment of RRD.\u003csup\u003e17\u003c/sup\u003e In this approach, intraocular air was mainly used as a vitreous expander to maintain intraocular pressure and facilitate external drainage of SRF, rather than as a direct tamponade of retinal breaks. A major advance was reported by Rosengren in 1938, who introduced the concept of retinal break “tamponade.”\u003csup\u003e18\u003c/sup\u003e He applied diathermy strictly to the area corresponding to the retinal break and, after SRF drainage, injected an air bubble specifically to tamponade the break. This method achieved a reattachment rate of 77%; however, a substantial proportion of patients experienced redetachment. This outcome was likely related to premature absorption of the air bubble prior to formation of sufficiently strong chorioretinal adhesion around the break. Technical limitations of that era, including imprecise localization of retinal breaks and difficulty restricting diathermy application to the immediate surrounding area, may also have contributed.\u003csup\u003e19\u003c/sup\u003e Because of the subsequent development and widespread adoption of SB, PnR, and PPV, further evolution of RRD repair techniques combining air injection with SRF drainage largely stalled. In the modern era, however, high-resolution wide-field imaging enables precise localization of retinal breaks; contemporary laser photocoagulation permits accurate and rapid induction of chorioretinal adhesion. Consequently, most historical limitations that previously constrained the effectiveness of this approach have been largely resolved.\u003c/p\u003e\n\u003cp\u003eThe present study demonstrated a single-surgery retinal reattachment rate of 96.23% after mPnR for primary RRD. This outcome compares favorably with previously reported success rates of 93.2% for PPV and 82% for SB in similar RRD populations.\u003csup\u003e9,11\u003c/sup\u003e Furthermore, substantial functional improvement was observed, such that mean BCVA improved from 0.10 (IQR,0.00-0.60) logMAR preoperatively to 0.02 (IQR,0.00-0.20) logMAR at 3 months postoperatively (P＜\u0026nbsp;0.001). Subgroup analysis of macula-off RRD cases showed even more pronounced visual recovery, whereby BCVA improved from 0.75 (IQR,0.43-1.18) logMAR to 0.20(IQR,0.04-0.30) logMAR (P＜0.001). Collectively, these findings support the anatomic and functional efficacy of the mPnR technique for the treatment of primary RRD.\u003c/p\u003e\n\u003cp\u003eA critical determinant of PnR success is the rate of SRF resolution adjacent to the retinal break. However, the absorptive capacity of the retinal pigment epithelium substantially varies among individuals.\u003csup\u003e20,21,22\u003c/sup\u003e The “steam-roller” maneuver, which uses the buoyancy of an intravitreal gas bubble to displace SRF through the retinal break, can accelerate reattachment. Nevertheless, its efficacy is often limited in the presence of small retinal breaks or highly viscous SRF. Furthermore, the SRF clearance rate directly determines the duration of postoperative positioning. Conventional PnR typically requires maintained positioning for at least 5 days and up to 3 weeks, imposing a considerable burden on patient compliance and quality of life.\u003c/p\u003e\n\u003cp\u003eIn contrast, the mPnR technique incorporates deliberate SRF drainage through a paracentesis, accelerating retinal reattachment and creating additional intraocular space for the injection of a larger air volume. This increased air fill provides a more substantial tamponade and facilitates further evacuation of residual SRF through the paracentesis site, thereby promoting rapid reapposition of the neurosensory retina to the retinal pigment epithelium. The larger air bubble offers a more effective and sustained tamponade without requiring expansile gas. Concurrently, it reduces the stringency of postoperative positioning requirements because patients only need to maintain a position that allows the bubble to cover the retinal break. In our protocol, the required duration of postoperative positioning was reduced to 3–5 days, which is substantially shorter than the duration typically required after conventional PnR. This modification greatly reduces the burden of patient compliance and minimizes disruption of daily activities. These technical advantages of mPnR likely contributed to the higher single-surgery success rate observed in this study (96.23%) compared with success rates reported for conventional PnR in recent literature, which range from 81% to 90%.\u003csup\u003e11,23\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eFurthermore, procedures such as PPV and SB must be performed in an operating room under sedation or retrobulbar or peribulbar anesthesia; they require specialized surgical equipment and consumables. In contrast, mPnR—similar to conventional PnR—can be performed under subconjunctival anesthesia alone, without any need for sedation or regional blocks; this method reduces anesthesia-related risks. The brief, efficient procedure can be completed without reliance on an operating microscope or binocular indirect ophthalmoscope, which makes it suitable for an outpatient setting. Both mPnR and conventional PnR offer advantages of high efficiency, minimal invasiveness, and low health care cost; the principal difference is that mPnR replaces anterior chamber paracentesis with transscleral paracentesis for SRF drainage. Accordingly, mPnR may be regarded as an evolution of the PnR technique and can be considered a first-line treatment option for RRD cases that meet PIVOT trial criteria. The mPnR technique is particularly valuable in remote or resource-limited regions (where surgical resources are scarce and intraocular gas is often unavailable) because it provides a practical and timely option for RRD management.\u003c/p\u003e\n\u003cp\u003eThe paracentesis for SRF drainage should be placed at the site of maximal retinal elevation adjacent to the retinal break(s). An oblique incision is recommended to reduce the risk of an iatrogenic retinal break; if such a break occurs, its proximity to the primary break allows concurrent treatment during subsequent laser photocoagulation. In eyes with a large retinal break, an additional potential benefit may be achieved. A temporary fluid pathway may form between the vitreous cavity and paracentesis site through the retinal break, permitting egress of intravitreal fluid. This outflow may facilitate removal of dispersed retinal pigment epithelial cells and other potential mediators from the vitreous cavity, potentially contributing to the reduction of intraocular factors associated with proliferative vitreoretinopathy.\u003csup\u003e24\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eSome surgeons may express concern about the risk of subretinal hemorrhage associated with transscleral drainage paracentesis.\u003csup\u003e25\u003c/sup\u003e However, in the mPnR technique, continuous scleral indentation combined with immediate intraocular air injection maintains stable intraocular pressure throughout the procedure, thereby minimizing hemorrhage risk. In the present series, only two eyes (3.77%) developed small, clinically insignificant subretinal hemorrhages adjacent to the paracentesis site, supporting the safety of this approach. Additionally, whereas conventional PnR may require anterior chamber paracentesis, the mPnR technique eliminates this step and thus avoids the associated risk of iatrogenic angle-closure glaucoma due to anterior chamber shallowing.\u003csup\u003e26\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eIn most mPnR cases, the retina surrounding the break is already reattached at the conclusion of surgery. However, because patients are often stressed and frequently exhibit corneal epithelial edema on the day of surgery, it is advisable to defer laser photocoagulation until 12–24 hours postoperatively. The presence of an intraocular air bubble can complicate laser application. Depending on the location of the retinal break and size of the air bubble, two approaches may be used: rotating the patient’s head to expose the retinal break for laser treatment, or, if the bubble is sufficiently large, positioning the break at the center of the bubble to allow laser application through the bubble. Cryotherapy applied to the retinal break area before air injection may represent a viable alternative. Algvere et al. previously reported a similar technique combining cryotherapy, drainage of SRF, and air injection; however, their primary retinal reattachment rate (86%) was notably inferior to the results achieved in the present study.\u003csup\u003e27\u003c/sup\u003e This disparity is likely attributable to chorioretinal adhesion typically develops more slowly after cryotherapy than after laser photocoagulation.\u003csup\u003e28,29\u0026nbsp;\u003c/sup\u003eBecause the mPnR technique uses air, which is absorbed relatively quickly, the more rapid adhesion achieved with laser photocoagulation may be more appropriate in this setting.\u003c/p\u003e\n\u003cp\u003eIn this series, two eyes with macula-off RRD showed persistent detachment after initial PnR. Their retina subsequently achieved complete reattachment after mPnR. This outcome suggests that mPnR can be considered a treatment option for selected cases of failed initial PnR, provided that clinical features remain suitable for the mPnR approach. Another illustrative case (Figure 1) demonstrated an unexpected sequence of events: after successful reattachment of a superior retinal break following mPnR, residual SRF shifted inferiorly, leading to the reopening of a pre-existing retinal break at the 5:00 position and causing secondary inferior RRD. Management consisted of immediate laser photocoagulation of the superior break, along with maintenance of an uppermost position. After 24 hours, patient positioning was changed to a head-low, prone posture to allow the air–fluid interface to cover the inferior break. Complete retinal reattachment was ultimately achieved. On the basis of this experience, we put forward the bold hypothesize that mPnR may be extended to RRDs with breaks in the inferior quadrant (4:00 to 8:00), provided that appropriate postoperative positioning is maintained. Undoubtedly, the validity of this hypothesis awaits verification in future prospective studies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study has several limitations. First, its retrospective design and relatively small sample size limit the generalizability of the findings. Second, the minimum follow-up duration was only 3 months. Although the PIVOT trial showed a low likelihood of redetachment beyond 3 months post-PnR, longer follow-up is necessary to fully assess subjective visual outcomes, long-term complications such as epiretinal membrane formation, and the incidence of late redetachment. Additionally, this study did not include a direct comparison of mPnR with other retinal detachment repair techniques, including conventional PnR, PPV, or SB. Prospective controlled studies are needed to address these limitations.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe mPnR technique is a safe and effective approach for the management of primary RRD. By actively draining SRF, it accelerates retinal reattachment, shortens the required duration of postoperative positioning, and achieves a single-operation anatomic success rate of 96.23%. The procedure is efficient and minimally invasive, does not require expansile gas, and can be performed in an outpatient setting, thus supporting its broad potential for widespread adoption.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003emPnR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;modified pneumatic retinopexy\u003c/p\u003e\n\u003cp\u003eRRD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;rhegmatogenous retinal detachment\u003c/p\u003e\n\u003cp\u003eBCVA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;best corrected visual acuity\u003c/p\u003e\n\u003cp\u003eLogMAR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;logarithm of the minimum angle of resolution\u003c/p\u003e\n\u003cp\u003eIQR interquartile range\u003c/p\u003e\n\u003cp\u003ePPV\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;pars plana vitrectomy\u003c/p\u003e\n\u003cp\u003eSB\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;scleral buckling\u003c/p\u003e\n\u003cp\u003ePnR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;pneumatic retinopexy\u003c/p\u003e\n\u003cp\u003eSRF\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;subretinal fluid\u003c/p\u003e\n\u003cp\u003ePIVOT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;pneumatic retinopexy versus vitrectomy for the management of\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eprimary rhegmatogenous retinal detachment\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis single-center retrospective cohort study was approved by the Ethics Committee of the Eye Hospital of Wenzhou Medical University (Approval No. 2025-043-X-02-01). All procedures adhered to the tenets of the Declaration of Helsinki. The requirement for informed consent was waived due to the retrospective nature of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. This manuscript does not contain any individual person’s data in any form (including individual details, images, or videos).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQ.T.P. contributed to study conception and design, performed the surgeries, and drafted the manuscript. R.W.L contributed to data collection, analysis, and interpretation. H.R.P., M.Q.L., J.Y.W., S.F.Z., X.T.H., and Z.L.Z. contributed to data acquisition, analysis, and assisted in the literature review. W.C. and Z.D.Z. supervised the study, provided critical revisions for important intellectual content, and gave final approval for the version to be published. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank Ryan Chastain-Gross,Ph.D.,from Liwen Bianji (Edanz) (www.liwenbianji.cn) for editing the English text of a draft of this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePollreisz A, Sacu S, Eibenberger K, et al. Extent of detached retina and lens status influence intravitreal protein expression in rhegmatogenous retinal detachment. 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Retina. 1991;11:441\u0026ndash;4. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/00006982-199111040-00015\u003c/span\u003e\u003cspan address=\"10.1097/00006982-199111040-00015\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":false,"email":"","identity":"eye-and-vision","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"","title":"Eye and Vision","twitterHandle":"","acdcEnabled":false,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"VoR Journals","inReviewEnabled":false,"inReviewRevisionsEnabled":false},"keywords":"Modified pneumatic retinopexy, rhegmatogenous retinal detachment, transscleral subretinal fluid drainage, air, laser photocoagulation","lastPublishedDoi":"10.21203/rs.3.rs-8947548/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8947548/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTo evaluate the anatomic and visual outcomes of a modified pneumatic retinopexy (mPnR) technique incorporating transscleral drainage of subretinal fluid for the treatment of primary rhegmatogenous retinal detachment (RRD).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis retrospective, single-centre case series included 53 consecutive eyes of 53 patients with primary RRD meeting the Pneumatic Retinopexy versus Vitrectomy trial criteria. All patients underwent mPnR, which consisted of transscleral subretinal fluid drainage, intravitreal air injection, and postoperative laser photocoagulation of retinal breaks. The main outcome measures were single-surgery anatomical success rate and best-corrected visual acuity (BCVA) at 3 months postoperatively.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe single-surgery anatomic success rate was 96.23% (51/53). Mean BCVA significantly improved from 0.10 (interquartile range [IQR],0.00-0.60) logarithm of the minimum angle of resolution (logMAR) preoperatively to 0.02 (IQR,0.00-0.20) logMAR at 3 months postoperatively (P\u0026lt;0.001). In the macula-off subgroup (n\u0026thinsp;=\u0026thinsp;20), the anatomic success rate was 100%; BCVA improved from 0.75 (IQR,0.43\u0026ndash;1.18) logMAR to 0.20(IQR,0.04\u0026ndash;0.30) logMAR (P\u0026lt;0.001). Two eyes (3.77%) with recurrent detachment and one eye (1.89%) with a secondary macular epiretinal membrane required subsequent pars plana vitrectomy.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe mPnR technique is an effective and safe treatment for primary RRD. The procedure is efficient and minimally invasive, does not require expansile gas, and can be performed in an outpatient setting, supporting its potential for widespread adoption.\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e","manuscriptTitle":"Outcomes of modified pneumatic retinopexy with transscleral subretinal fluid drainage for primary rhegmatogenous retinal detachment","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-08 17:24:19","doi":"10.21203/rs.3.rs-8947548/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-08T08:01:04+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-22T17:51:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-21T01:13:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-08T08:15:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"184015657411436181450414770206784753641","date":"2026-04-06T04:43:09+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-05T14:24:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"963524548272508229861102989783584973","date":"2026-04-01T15:24:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"46528080846999247411386797204777096483","date":"2026-04-01T11:59:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"95091791246950485424458334236622516766","date":"2026-03-30T02:24:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"256195691224023215717683180968706781132","date":"2026-03-30T01:58:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"147352935458341522481432908253590863597","date":"2026-03-21T09:54:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"254035089198689880420432210104591707298","date":"2026-03-18T10:51:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-18T07:02:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-16T19:53:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"97171636786876472154712602398490142364","date":"2026-03-16T19:18:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"261668299105216350295380156456943674239","date":"2026-03-04T04:28:25+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-02T02:31:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-24T13:32:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-24T13:28:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"Eye and Vision","date":"2026-02-23T13:07:06+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":false,"email":"","identity":"eye-and-vision","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"","title":"Eye and Vision","twitterHandle":"","acdcEnabled":false,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"VoR Journals","inReviewEnabled":false,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"4d8777ca-7367-4f84-bf87-97e0efa5394d","owner":[],"postedDate":"March 8th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-08T08:01:04+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-08T08:11:12+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-08 17:24:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8947548","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8947548","identity":"rs-8947548","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}