Commentary: Sealing breaks comfortably— A novel approach to retinopexy without positioning

The treatment of retinal detachment underwent a radical change in the 1920s when Jules Gonin identified that retinal breaks were actually the cause of retinal detachment (RD) and not the result of it, as it was then thought. He went on to treat retinal breaks by ignipuncture, where he cauterized the retina through the sclera by a hot, pointed instrument, thereby single handedly changing the outcome of the eyes affected by retinal detachment.[1] To this day, the primary method of treating retinal breaks, especially rhegmatogenous retinal detachment, is by creating a chorioretinal adhesion (CRA) around through retinopexy.

Management of RD has since come a long way. Today, we use laser and cryotherapy to achieve retinopexy.[2] Lasers are the main modality, but require relatively clear media and do not work in the presence of subretinal fluid. In such cases, cryotherapy is used which has certain disadvantages such as potential to cause increased inflammation and increased risk of epiretinal membrane formation or proliferative vitreoretinopathy (PVR).[3]

Though these methods achieve satisfactory CRA, the time taken for the same is around 3–4 weeks. This necessitates the use of an internal tamponading agent like silicone oil or gases to maintain the apposition between retina and choroid, till the formation of a strong CRA. Each of these agents come with their own set of pros and cons. Although the gases provide excellent tamponade due to greater surface tension, they are not suitable in patients with one eye, those who travel by air, and those with inferior break. Silicone oil requires a second procedure for removal and carries the risk of pupillary block, corneal decompensation, emulsification, and secondary glaucoma. Above all, these internal tamponading agents require prolonged face-down positioning by the patient. This is often difficult to maintain, especially for the elderly or the very young patients and those with spinal problems. In addition, it is highly difficult to identify whether the position is properly maintained by the patient.

The problem unique to RD with inferior retinal breaks is that none of the tamponading agents are effective inferiorly because of their physical properties. An effective tamponade may require additional external segmental buckles for large inferior breaks or maintaining face-down with head-low position, which is very physically taxing.[4] This paved way to heavy tamponading agents[5,6] including heavy molecular weight silicone oils—densiron, oxane HD, and semi-fluorinated alkenes and alkanes. These agents are expensive and it is very difficult to remove them from the eyes.

Tissue adhesives are a novel modality of sealing a break till CRA forms. The main advantage is that of immediately sealing of the break and thereby eliminating the need of internal tamponade as well as postoperative positioning. The proof-of-concept of the pilot study “Glue Assisted Retinopexy for Rhegmatogenous Retinal Detachments (GuARD): A Novel Surgical Technique for Closing Retinal Breaks”[7] opens a new avenue with immense potential for bringing about a paradigm change in the way RD surgeries are performed. A larger randomized blinded trial is needed to answer questions regarding its effectiveness in cases with multiple breaks, in giant retinal tears, and in the presence of PVR need to be addressed. We also need to understand the reactions of these eyes if there is a recurrence of RD, mainly factors that may predict a recurrence as well as the potential complications of a resurgery. The early recovery period of this procedure could be beneficial to the patients in terms of less resting time and less loss of income. A cost–benefit analysis taking into consideration the cost of consumables like gas or oil versus fibrin glue as well as loss of working hours would also be of interest.