Modern surgical management of rhegmatogenous retinal detachment wth superior breaks: current status from scleral buckling to vitrectomy

Rhegmatogenous retinal detachment (RRD) remains a leading cause of acute visual loss and requires timely surgical repair. Contemporary epidemiology shows rising RRD incidence worldwide among highly myopic patients [1–4]. First-line surgical management for RRD with superior breaks is debated. Pneumatic retinopexy (PR) offers minimally invasive repair with favorable functional outcomes in well-selected cases; the PIVOT randomized trial demonstrated better visual acuity and less vertical metamorphopsia versus pars plana vitrectomy (PPV), albeit with higher rates of new postoperative breaks and strong dependence on patient compliance with head positioning [6–8; 17–19]. Scleral buckling (SB) remains relevant, especially in phakic eyes due to lower cataract progression risk, while PPV is now the most commonly performed procedure, driven by improved visualization, control of proliferative vitreoretinopathy (PVR), and advances in technology (small-gauge systems, 3D heads-up viewing, intraoperative OCT) [5; 9–11; 20–22]. Choice of tamponade (air, SF6/C2F6/C3F8 gas, silicone oil) should account for break location, PVR grade, and patient positioning; air tamponade is increasingly discussed for uncomplicated superior breaks, whereas long-acting gas or silicone oil remains preferable for giant retinal tears and advanced PVR [13–16; 23–25]. This review synthesizes selection criteria and proposes a pragmatic decision algorithm considering lens status, number and extent of breaks, PVR severity, macular status, and positioning adherence.