Key messages

• Scleral buckling might be better than pneumatic retinopexy in achieving reattachment of the retina, and might have a lower risk of recurrence, but the certainty of the evidence is low.
• Pneumatic retinopexy might have less adverse ocular events, but the certainty of the evidence is low.
• It is not clear whether pneumatic retinopexy improves visual success because the certainty of the evidence is very low.

What is the evidence.
See evidence matrix  in Epistemonikos later

We found three systematic reviews [1],[2],[3], including six primary studies reported in nine references [4],[5],[6],[7],[8],[9],[10],[11],[12], of which three corresponded to randomized trials reported in five references [4],[5],[6],[7],[8]  because one of these studies was reported in several publications [4],[5],[6]. 

This table and the summary in general are based on the randomized trials since the observational studies did not increase the certainty of the existing evidence or provide additional relevant information.

What types of patients were included*

All trials included participants with phakic and non phakic eyes (aphakic and pseudophakic), with or without macular detachment.

All participants were good candidates to pneumatic retinopexy (uncomplicated retinal detachments, with single or multiple retinal tears, less or equal to one clock hour size, located in the superior half of the retina).

What types of interventions were included*

All trials compared scleral buckling versus pneumatic retinopexy. Also, one of them [2] analized retinopexy options for scleral buckling and other surgical techniques such as vitrectomy.

What types of outcomes
were measured

All trials reported reattachment of the retina with single intervention and the need of a second procedure to achieve it.

Other reported outcomes were recurrence of retinal detachment at 6 months of follow-up, visual success, ocular adverse events and occurrence of proliferative vitreoretinopathy.

Follow-up was for at least 6 months (6-90 months) in two trials [4],[7], and of 4.3 months in the other trial [8]. 

To whom this evidence does and does not apply

• The presented evidence applies to rhegmatogenous retinal detachments in both phakic and non phakic eyes (aphakic and pseudophakic), with or without macular detachment, that are good candidates for pneumatic retinopexy (uncomplicated retinal detachments, with single or multiple retinal tears less or equal to one clock hour size, located in the superior half of the retina). 
• We could not identify if effects were different when comparing subgroups of patients (phakic and non phakic eyes, with macula on or macula off), because the existing evidence is very limited and systematic reviews did not report this analysis.

• The outcomes presented in the summary of findings table are those considered critical for decision-making, according to the opinion of the authors of this summary. In general, they coincide with the outcomes reported by the systematic reviews identified. One exception was the need of a second procedure to achieve retinal reattachment,  outcome reported by all systematic reviews but not by the authors of this summary.
• It is important to note that visual outcome is determined by the presence of macular detachment and the time of evolution of this finding (less than 14 days). This analysis was not performed in the identified systematic reviews.

• Even though the certainty of the existing evidence is low; scleral buckling appears to be better in terms of reattachment of the retina with a lower risk of recurrence of the retinal detachment, but pneumatic retinopexy has less ocular adverse events, which could be related to the characteristics of this technique (minimally invasive).
• It is not possible to make an adequate balance between benefits and risks because of the existing uncertainty. 

• None of the systematics reviews considered an economic analysis within its outcomes, but in general, scleral buckling is more expensive than pneumatic retinopexy.
• Even though there may be some benefits, it was not possible to make a balance between benefits and economic cost, because of the uncertainty of the evidence available.

• Faced with the evidence presented in this summary, the decisions made by clinicians might not change because of the uncertainty of the information available.
• Even though clinicians usually prefer scleral buckling over pneumatic retinopexy, this second technique is less expensive and carries a lower risk, so there may be a renovated interest in this procedure.

Differences between this summary and other sources

• The conclusions of this summary agree with those presented by the different systematic reviews identified in relation to reattachment of the retina and visual outcome. As only one systematic review [1] reported the other outcomes, our results coincide with the ones presented in that review.
• We did not identify international guidelines about retinal detachment, but some evidence-based reviews [13] include scleral buckling or classic surgery, pneumatic retinopexy and vitrectomy as first line treatment options for rhegmatogenous retinal detachment.

• The probability that future research changes the conclusions of this summary is high, due to the uncertainty of the existing evidence.
• We did not identify ongoing randomized trials comparing both interventions in the International Clinical Trials Registry Platform of the World Health Organization, or ongoing systematic reviews in PROSPERO database.