We agree that pneumatic retinopexy (PnR) is important in the management of rhegmatogenous retinal detachment (RRD) [1]. Longitudinal data regarding post-operative ellipsoid zone recovery suggests that reducing time to reattachment in fovea-involving RRD is beneficial [2]. PnR is readily accessible, without requirement for an operating theatre, specialist equipment or support staff. The PIVOT randomised trial compared PnR versus pars plana vitrectomy (PPV) in patients with retinal break/s in detached retina within one clock hour above the 8- and 4-o’clock meridians, with any number of retinal breaks or lattice degeneration in attached retina. Patients received PnR a median 2.0 h after presentation and required on average one visit more than patients undergoing PPV [3]. PnR also offers superior functional and structural retinal recovery compared to PPV in appropriately selected patients [3, 4]. The authors refer to the reattachment rates and visual acuity outcomes from a non-controlled retrospective study of patients not meeting PIVOT criteria. Patients had gas injection, some received partial laser retinopexy, and all underwent planned PPV 1–2 weeks later [5]. The study did not assess risk of discontinuity of the ellipsoid zone and external limiting membrane, outer retinal folds, retinal displacement, cataract and functional outcomes such as aniseikonia, vertical metamorphopsia and subjective visual function, all of which have been shown to be worse with PPV compared to PnR.

Up to 50% of presenting RRDs meet PIVOT criteria, and real-life data suggests that the primary anatomic reattachment rate for the PnR arm (80.8%) may be achieved in daily clinical practice [6, 7]. It is thus apparent that a large proportion of patients being subjected to the proposed ‘temporising pneumatic’ (TP) could go on to achieve excellent (perhaps better) results without the need for a subsequent PPV.

We propose that the TP should be avoided in patients meeting PIVOT criteria, with PPV reserved only for those who have failed or incompletely responded to PnR. In patients who fulfil PIVOT criteria, a ‘definitive pneumatic’ is warranted. PnR should be undertaken with the resolute intention to fully reattach the retina and avoid PPV. The extra effort and visit would be well worth the opportunity to achieve superior long-term outcomes and almost certainly represent a more judicious use of healthcare resources.