Laser Retinopexy vs Retinal Cryopexy

Retinal tears and detachments are serious ophthalmologic conditions that can lead to permanent vision loss if left untreated. In a study of 1010 patients, 8.8% had symptomatic retinal tears and 0.8% experienced retinal detachments.

Laser retinopexy and retinal cryopexy also known as cryoretinopexy, are surgical procedures used to repair retinal tears, prevent detachment, or reattach the retina. Both techniques aim to create a firm scar around the retinal break to “spot weld” the retina to the underlying tissue, sealing the tear and preventing fluid ingress that could expand the detachment.

This article overviews laser retinopexy and retinal cryopexy, outlining procedural details, indications, efficacy rates, patient comfort and recovery, potential risks and complications, and relative accessibility and costs.

1. Description of the Procedure

Two key surgical interventions, laser retinopexy and retinal cryopexy, are utilized to manage vision conditions effectively. However, there are differences between these procedures.

Laser Retinopexy

Laser retinopexy uses a thermal laser that passes through the eye to create barricade scar tissues around a retinal tear. The scar tissue acts as a weld to prevent the expansion of the retinal tear and stop fluid from entering the tear, which can cause progressive retinal detachment.

The procedure is particularly effective when there is no significant retinal detachment, as indicated by the absence of subretinal fluid around the tear​​​​​​. The procedure utilizes a thermal laser and may involve a lens to focus the laser on the retina.

The thermal laser induces controlled burns in the retina, stimulating scar tissue formation. This scar tissue creates an adhesion between the retina and the underlying retinal pigment epithelium, effectively sealing the tear and preventing further detachment.

Retinal Cryopexy

Retinal cryopexy, or cryoretinopexy, uses intense cold to induce a retinal scar around a tear. A specially designed probe applies this cold therapy to the back wall of the eye, creating scar tissue that seals the retinal tear.

Like laser retinopexy, it prevents the expansion of the retinal tear and the ingress of fluid that could lead to retinal detachment. It is particularly suitable for larger retinal tears or those with associated detachment​​​​.

The procedure employs a cryoprobe, which is a device that delivers intense cold to the retina. The application of extreme cold causes localized freezing of the retinal tissue, leading to swelling and scar tissue formation. This scar tissue adheres the retina to the eye wall, effectively sealing the tear and preventing further damage.

2. Indications

Understanding when to use laser retinopexy and retinal cryopexy is crucial for optimal outcomes. Here’s an overview of the specific scenarios and conditions where each procedure is most beneficial:

Laser Retinopexy

This treatment is particularly important for certain types of retinal breaks and conditions, as outlined below.

• Rhegmatogenous Retinal Detachments: The primary indication for laser retinopexy is to prevent rhegmatogenous retinal detachments, the most common type of retinal detachment. These detachments occur due to full-thickness deficits in the neurosensory retina. Risk factors include axial myopia, cataract surgery complications, ocular trauma, and certain peripheral retinal degenerations like lattice degeneration​​.
• Asymptomatic Retinal Breaks: Asymptomatic retinal breaks, including operculated and atrophic round holes, are generally not treated with laser retinopexy as there is minimal risk of retinal detachment from these lesions. However, asymptomatic horseshoe retinal tears have a 5% risk of retinal detachment, warranting close follow-up​​.
• Symptomatic Retinal Breaks: Laser retinopexy is indicated for symptomatic retinal breaks, characterized by increased flashers or floaters due to vitreoretinal traction during an acute posterior vitreous detachment. These breaks have a higher risk of leading to retinal detachment, making intervention necessary​​.
• Lattice Degeneration: Patients with lattice degeneration, especially those with a history of retinal detachment in the fellow eye or the presence of atrophic holes with subretinal fluid, are candidates for laser retinopexy. This treatment aims to prevent progression to retinal detachment.

Retinal Cryopexy

Cryopexy is often chosen for specific scenarios, detailed below.

• Retinal Tears and Detachments: Cryopexy is used to repair retinal tears and prevent or treat retinal detachments. It is particularly effective when there is no significant retinal detachment (absence of subretinal fluid around the tear)​​​​.
• Larger Retinal Tears and Associated Detachment: Compared to laser retinopexy, cryopexy is better suited for treating larger retinal tears or those with associated detachment. This is due to the intense cold therapy applied to the retinal tissue, creating effective scar tissue around the tear​​.
• Leaking Blood Vessels and Neovascularization: Cryopexy can also be used to seal off leaking blood vessels or halt the growth of abnormal blood vessels in the eye, addressing conditions such as neovascularization.

3. Efficacy

A study comparing laser photocoagulation and cryotherapy for retinopexy in conventional retinal detachment surgery found that postoperative flare values were significantly higher in the cryotherapy group, indicating a greater breakdown of the blood-ocular barrier. Visual recovery was slower in patients receiving cryotherapy, although visual acuity after 10 weeks was not significantly different between groups.

For each of the procedure’s studies, here are the results:​

Laser Retinopexy

Laser retinopexy is a highly effective procedure for treating retinal tears and preventing retinal detachment. A study comparing outcomes between residents and specialists found no significant difference in the rate of progression to retinal detachment, indicating its overall efficacy. Progression to retinal detachment occurred in 6.9% of cases in the resident group and 5.5% in the specialist group​​.

In a large study involving 1157 patients, repeat retinopexy was required in 19.1% of patients on average 17 days after initial treatment, with some patients requiring up to four further sessions​​.

Retinal Cryopexy

A study of 85 patients undergoing pars plana vitrectomy and gas tamponade without perfluorocarbon liquids reported a primary anatomical success rate of 96% with cryopexy​​​​.

The same study observed proliferative vitreoretinopathy (PVR) in 4.7% of cases and ocular hypertension in 8.2% of patients​​.

4. Patient Comfort and Recovery

Post-operative recovery and patient comfort are significant concerns in eye surgeries. Below are the insights into what patients can expect following laser retinopexy and retinal cryopexy, highlighting recovery times and comfort levels.

Laser Retinopexy

Post-procedure, patients can generally resume their normal daily activities with no restrictions on activities such as watching television or reading. They are advised to avoid strenuous activities and contact sports until the eye has completely healed, which varies from person to person.

Travel is not recommended until all gas bubbles used during surgery have dissipated, as changes in altitude can cause the bubbles to expand. A follow-up visit is usually scheduled a week after the procedure

Retinal Cryopexy

The increased breakdown of the blood-ocular barrier suggests that there might be more inflammation following cryopexy, which could result in more discomfort and a slower recovery process immediately following the procedure.

However, visual acuity after 10 weeks post-procedure is typically not significantly different between cryopexy and laser photocoagulation groups​

5. Complications and Risks

While highly effective, these procedures carry certain risks. Here are the potential complications associated with laser retinopexy and retinal cryopexy

Laser Retinopexy

The common complications from laser retinopexy include transient blurriness, light sensitivity, and pain or discomfort. A small grey spot noticeable in the peripheral vision may also occur​​. Rare complications can involve retinal bleeding and epiretinal membrane formation. There is also a very rare risk of accidental laser burns to the center of the retina.

For the effect on Macular Morphology, a study using OCT to study microstructural changes following laser retinopexy found no significant changes in central macular thickness and peripapillary global retinal nerve fiber layer thickness at 6 months follow-up. The incidence of epiretinal membrane (ERM), vitreomacular traction (VMT), and cystoid macular edema (CME) was 0% at 6 months follow-up​​.

Another study found that extensive photocoagulation is linked to an increased risk of ERM formation. However, the incidence of ERM formation after laser retinopexy was found to be low in several studies, ranging from 0 to 2.3%.​

Retinal Cryopexy

The most common adverse effects from retinal cryopexy include:

• Redness
• Swelling
• Bruising
• Tearing
• Pain after the procedure

Cryopexy does not prevent retinal detachment, and more surgery may be needed. The white of the eye may appear red for a week or two, and over-the-counter pain medications often help improve comfort​​.

Severe complications are rare but include infection:

• Bleeding
• Scarring
• Deformity
• Blindness
• Loss of the eye​​

6. Cost and Accessibility

The financial aspect of medical care cannot be overlooked. Here’s an overview of the costs associated with laser retinopexy and retinal cryopexy, including factors influencing the overall expenses.

Laser Retinopexy

The cost of laser retinopexy in the US varies depending on whether or not you are covered by insurance. The average price for the procedure can range from $2,000 to $9,000 per eye without insurance coverage. This price typically includes both hospital and professional fees​​.

The cost can be influenced by the severity of the retinal tear, the specific method used for repair, the surgeon's expertise, the facility where the surgery is performed, and geographic location. Other expenses such as laboratory tests, anesthesia, and follow-up care can increase the total cost​​.

Most insurance companies are likely to cover laser retinopexy as long as it is medically necessary, potentially reducing the out-of-pocket cost for patients to as low as $100

Retinal Cryopexy

The costs of this procedure can vary and are generally not as well documented or available as for laser retinopexy. However, for retinal detachment surgery, which may include cryopexy, costs can range as follows:

• Retinal Detachment Surgery (Scleral Buckle): $5,000 – $10,000
• Retinal Detachment Surgery (Pneumatic Retinopexy): $3,000 – $8,000
• Retinal Detachment Surgery (Vitrectomy): $8,000 – $20,000
• Intraocular Gas or Silicone Oil Injection: $1,500 – $5,000
• Anesthesia: $500 – $1,500
• Pre-operative testing and imaging: $300 – $800
• Follow-up care and medications: $200 – $600

Similar to laser retinopexy, costs can increase due to anesthesia, additional treatments, pre-operative and post-operative care, and potential complications that require further medical attention.

Wrap Up

Both laser retinopexy and retinal cryopexy are highly effective surgical techniques that create scar tissue around retinal tears to prevent detachment. Laser retinopexy is best for small tears without significant detachment, while cryopexy works better for larger tears or those with some degree of associated detachment.

Although laser retinopexy offers faster patient recovery and comfort, visual outcomes after 10 weeks are similar between the procedures. Common complications like blurriness and light sensitivity are temporary. Laser retinopexy is also more affordable, costing $2,000-$9,000 per eye, compared to retinal cryopexy, which is part of more complex $5,000-$20,000 retinal detachment surgery. Overall, these two techniques play critical roles in managing retinal conditions.

What are the key differences in the applications of Laser Retinopexy and Cryopexy?

Laser Retinopexy uses light to create burns, while Cryopexy uses cold to freeze the tear. Laser Retinopexy is often preferred due to its lower risk of complications and faster healing. However, Cryopexy is more effective for larger tears or those with associated detachment.

Is anesthesia required for Laser Retinopexy and Retinal Cryopexy?

Both Laser Retinopexy and Cryopexy are typically performed under local anesthesia and do not require a hospital stay.

Can Laser Retinopexy and Retinal Cryopexy be performed in a doctor's office setting?

Yes, both Laser Retinopexy and Retinal Cryopexy can usually be performed in a doctor's office or an outpatient surgery center.

How does one decide between Laser Retinopexy and Retinal Cryopexy?

The choice between Laser Retinopexy and Retinal Cryopexy depends on the specific characteristics of the retinal tear or detachment, as well as the patient's overall eye health. An ophthalmologist will recommend the most appropriate treatment based on these factors.