Primary Retinal Detachment

Conclusion 169
vitrectomy and search for the retinal break at the operating table,
where the wage rate is 37% higher (Medicare fees from New York,
New Jersey, Connecticut). If one does not find the break, a surgeon
might be inclined to do a peripheral laser barricade augmented
by an encircling band. The barrier operation, which was disappearing
near the end of the twentieth century, is returning as a
prophylactic supplement to primary vitrectomy and pneumatic
retinopexy [54].
Peer Review
A third factor operating against the buckle operation for primary
detachment, beyond the lack of training and the limit of reimbursement
for the time spent, is the absence of peer review. Preoperative
surgical rounds, where the surgical plan for retinal detachment
was open for review, suggestion, criticism, and even censure,
have disappeared; with 1-day surgery, there is not time for it. The
surgeon admits his patient on the day of the operation with as
much preparation as his schedule allowed, and, when the patient
leaves the hospital later in the day with the eye filled with gas, there
is no opportunity to evaluate the effort by his or her peers.
Conclusion
The proponents of primary vitrectomy claim that the final attachment
rate after multiple procedures is 99%. In the series that we
examined, it was 97%, equal to that of buckling. This is reassuring.
They dismiss the morbidity of multiple operations and regard the
frequent provocation of cataract as acceptable.
We do not think it is possible to counteract the change in the
treatment of retinal detachment. Perhaps market forces will relax,
and peer review will return, or maybe new and less morbid methods
to attach the retina will be invented. Admittedly, the incidence of