Background: Rhegmatogenous retinal detachment (RRD) repair by pars plana vitrectomy (PPV) combined air tamponade has many advantages compared with PPV combined gas tamponade. However, there are controversial outcomes in RRD cases involving the lower quadrants. Objective: This study aimed to evaluate the efficacy and safety of PPV combined air tamponade in patients with RRD compared with PPV combined gas tamponade and whether it could be a safe alternative to PPV combined gas tamponade. Methods: The PubMed, Embase, and Cochrane Library databases published until September 2022 were comprehensively searched for studies that compared PPV combined with air tamponade and gas tamponade in patients with RRD. The rate of primary treatment success, best-corrected visual acuity (BCVA), and postoperative complications were extracted from the final eligible studies. Study quality was assessed using the Jadad scale and Newcastle-Ottawa scale (NOS). The mean difference (MD) and risk ratio (RR) were calculated for continuous and dichotomous variables, respectively, with 95% confidence intervals. The systematic review and meta-analysis were prospectively registered with PROSPERO (https://www.crd.york.ac.uk/PROSPERO/; registration number CRD42022353479). Results: A total of 8 studies with 668 eyes in the air tamponade group and 944 in the gas tamponade group were included. There was no significant difference in the rate of primary treatment success between the air tamponade group and the gas tamponade group (RR = 1.00, p = 0.79). In addition, the subgroup analysis suggested that whether retinal breaks were located above or below, there was no significant difference in either rate of primary treatment success (RR = 0.99, p = 0.89; RR = 1.02, p = 0.45). There was no significant difference in mean BCVA 3 months after surgery (MD = −0.02, p = 0.50). For postoperative complications, mean postoperative intraocular pressure was lower in the air tamponade group at 1 day (MD = −4.24, p < 0.001), and there was no significant difference between the two groups at 7 days (MD = −0.45, p = 0.71), 1 month (MD = −0.69, p = 0.33), and 3 months (MD = 0.69, p = 0.35) after surgery. The rate of epiretinal membrane development was lower in the air tamponade group (RR = 0.48, p = 0.04). Conclusions: For patients with uncomplicated RRD, PPV combined air tamponade is a feasible and safe alternative to PPV combined gas tamponade, regardless of the position of retinal breaks, with a similar primary treatment success rate, postoperative BCVA, and fewer postoperative complications.

Rhegmatogenous retinal detachment (RRD) is a severe retinal disease that can result in blindness. Current RRD treatments include scleral buckling, pneumatic retinopexy, and pars plana vitrectomy (PPV). Ophthalmologists have debated the best treatment technique. Since the introduction of tiny gauge vitrectomy, PPV has gained popularity and is now the most used method for treating primary RRD [1, 2].

Currently, PPV utilizes tamponade agents (mainly long-acting gases [LAGs] such as sulfur hexafluoride [SF6], C3F8, or silicone oil) to provide a sufficient surface tension that prevents the entry of fluid into the subretinal area and ensures the formation of chorioretinal adhesion. PPV combined gas tamponade is becoming an increasingly popular technique. However, because the gases remain in the eye for a long time, disadvantages of PPV combined gas tamponade for RRD include prolonged postoperative visual disturbance and limitation of daily activities [3, 4]. Additionally, these gases have been linked to some complications, including gas migration in the anterior chamber, increased intraocular pressure (IOP), and faster cataract formation [5, 6]. Compared to these gases, air tamponade has a shorter absorption time and is non-expanding [3], which may help reduce the disadvantages of the gas tamponade listed above. On the other hand, LAGs are not easy to obtain in some countries and are more expensive. Therefore, evaluating whether air tamponade can replace gas tamponade in treating RRD is necessary.

On this basis, some authors described PPV-combined air tamponade for RRD to evaluate the efficacy and safety of air tamponade. Several retrospective noncomparative studies have shown that air tamponade effectively achieved a high primary treatment success rate and lower postoperative complications whether retinal breaks were located above or below [7‒9]. In several other comparative studies, air tamponade was not significantly different from gas tamponade in the rate of primary treatment success, and there were fewer postoperative complications [10‒17]. However, in the subgroup analysis of one of the studies, the efficacy of gas tamponade was superior to air tamponade in RRD cases with the involvement of the lower quadrants [10].

Therefore, whether air tamponade is an effective and safe enough alternative to gas tamponade for patients with RRD remains a debatable issue. To date, no systematic review and meta-analysis have been published. We performed a systematic review and meta-analysis to quantify the effect of these two treatments on the rate of primary treatment success, best-corrected visual acuity (BCVA), and postoperative complications in patients with RRD. Our study will help ophthalmologists choose the best treatment options for patients suffering from RRD.

This systematic review and meta-analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines (shown in online suppl. Table 1; for all online suppl. material, see https://doi.org/10.1159/000530690) and the methods described in the Cochrane Handbook [18, 19]. Its methods were prospectively registered in PROSPERO (https://www.crd.york.ac.uk/PROSPERO/; registration number CRD42022353479).

Search Strategy

The literature searches were performed on the papers and trials published up to September 2022 using the following databases: PubMed, Embase, and the Cochrane Library. The following key words were searched in these databases: (“Retinal detachment” or “Detachment, Retinal” or “Detachments, Retinal” or “Retinal Detachments” or “Retinal Pigment Epithelial Detachment”) and (“vitrectomy” or “vitrectomies”) and (“air” or “gas”) and (“tamponade”). PICO elements are shown in online supplementary Table 2. The last search was carried out on September 23, 2022. All relevant, potentially eligible studies published in peer-reviewed journals in English were considered, irrespective of publication status, publication date, or primary outcome. A manual search of reference lists of all included articles and consultation with experts in this field were also made. When clarifications were needed to assess the eligibility of the studies, we contacted the authors by email.

Inclusion and Exclusion Criteria

Studies were chosen for inclusion in our analyses using the following inclusion criteria: (1) patients with RRD; (2) the experimental group was PPV combined air tamponade, while the control group was PPV combined gas tamponade; (3) to provide at least one of the following: primary treatment success rate, BCVA, and postoperative complications; (4) the type of study included was prospective nonrandomized or randomized control trial (RCT) or retrospective case series; and (5) a 3-month or longer follow-up. Studies meeting any of the following exclusion criteria were excluded from our meta-analysis: (1) a history of vitreoretinal surgery or suffering from other visual impairing diseases apart from RRD; (2) noncomparative studies, single-arm studies, animal studies, case reports, meeting abstracts, or reviews; (3) duplicate publication; and (4) did not obtain sufficient information.

Data Extraction

All outcomes of interest were collected in an Excel sheet in piloted form, including the author, publication year, study design, participant characteristics (age, tamponade agent, area with retinal breaks, grading of proliferative vitreoretinopathy [PVR], follow-up, and defining the time of primary treatment success), rate of primary treatment success, BCVA, and postoperative complications. We used a unique statistical method for data transformation for studies that presented continuous data in median and range values [20]. A unique statistical formula was applied to calculate the change in mean BCVA and standard deviation [21].

Quality Assessment

The quality of RCTs and retrospective studies was evaluated by the Jadad scale and Newcastle-Ottawa scale (NOS), respectively [22, 23]. The total score of the Jadad scale ≥4 or the NOS ≥7 was considered high quality. Moreover, each study’s evidence level was assessed according to the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence [24]. Meanwhile, the risk of bias was independently assessed using the standard Cochrane Collaboration risk of bias tool for RCTs and the Risk of Bias in Non-Randomized Studies–of Interventions Tool (ROBINS-I) for nonrandomized controlled trials [25, 26].

The above steps (search strategy, inclusion and exclusion criteria, data extraction, and quality assessment) were completed independently by the two of us (A.M.Z. and J.N.W.). After the discussion, the disagreements were resolved by the senior author (W.T.).

Statistical Analysis

Statistical analyses were performed by using Review Manager software (version 5.4; Cochrane Collaboration) and Stata MP 17 software (StataCorp LLC). For continuous and dichotomous variables, the mean difference (MD) and risk ratio (RR) were applied, respectively, with their 95% confidence intervals (CIs). p < 0.05 was considered statistically significant on the test for overall effect. The heterogeneity between studies was assessed by using the χ2 and I-squared tests. A fixed-effect model was used if I2 was 50% or less, indicating low to moderate heterogeneity. A random-effects model was applied if I2 was higher than 50%, indicating high heterogeneity. A sensitivity analysis was performed to investigate the sources of heterogeneity. A regression-based Egger test was performed to assess the publication bias for the continuous and binary outcomes, with p < 0.05 considered significant.

Literature Search

After a literature search, 810 studies were identified. Of these studies, 288 records were screened after the removal of duplicates. By reading the titles and abstracts, 666 studies were excluded. Then 21 studies were screened for the full-text review, and 13 articles were excluded: 5 of them related to different surgical technique, while 4 were studies with patients who were not relevant, and the rest 4 were studies with incomplete data. Ultimately, 8 studies were included in this meta-analysis [10‒17]. The flow diagram is shown in Figure 1.

Fig. 1.

Flow diagram.

Characteristics of Included Studies and Risk of Bias Assessment

The characteristics of the included studies and their quality scores are shown in Table 1. One RCT, one prospective nonrandomized study, and 6 retrospective studies were incorporated. There were 688 eyes in the PPV combined air tamponade group and 944 in the PPV combined gas tamponade. The follow-up time of one study was 3 months, 3 studies were at least 3 months, one study was 6 months, one was at least 6 months, one was at least 12 months, and one was 13.09 ± 1.90 months. Regarding the grading of PVR, there was no PVR in 2 studies, the PVR grading of 4 studies was less than grade C, the PVR of one study was less than or equal to C1, and the other two studies did not state. In terms of defining the time of primary treatment success, 5 studies explained it as 3 months, one study described it as 6 months, and 2 studies did not specify. A moderate risk of bias was recorded for the seven non-RCTs [10, 12‒17], while a high risk of bias was recorded for the remaining one RCT (shown in Fig. 2) [11].

Table 1.

Characteristics and quality assessment of included studies

Author, yearStudy designTamponadeArea with retinal breaksPVRPatients, nAge, yearsFollow-upDefining the time of primary successQualitydLevel of evidencee
Amara et al. [13], 2021 Air versus SF6/C2F6/C3F8 Superior breaks No 48/214 62.2±8.9/64.3±11a At least 6 months 3 months 2b 
Moussa et al. [15], 2022 Air versus C2F6/SF6/C3F8 NA NA 22/24 60 (55–66)/59 (51–72)b 3 months 3 months 2b 
Nakamura et al. [16], 2022 Air versus SF6 Superior breaks/inferior breaks <Grade C 156/138 61.31±8.11/63.64±9.79a 6 months 6 months 2b 
Singh et al. [14], 2021 Air versus SF6 Superior breaks/inferior breaks/multiple breaks <Grade C 165/71 60.3±10.9a At least 3 months 3 months 2b 
Tan et al. [10], 2013 Air versus SF6 Superior breaks <Grade C 158/366 60.3±7.3/60.9±8.1a At least 3 months 3 months 2b 
Tetsumoto et al. [12], 2020 Air versus SF6 Superior breaks/inferior breaks No 35/35 59.2±7.9/56.8±10.1a 12 months NA 2b 
Uemura et al. [17], 2022 Air versus SF6 Inferior breaks <Grade C 52/64 56.7±8.6/53.9±8.9a At least 3 months 3 months 2b 
Zhou et al. [11], 2015 RCT Air versus C3F8 Inferior breaks ≤Grade C1 32/32 57.19/53.91c 13.09±1.90a months NA 1b 
Author, yearStudy designTamponadeArea with retinal breaksPVRPatients, nAge, yearsFollow-upDefining the time of primary successQualitydLevel of evidencee
Amara et al. [13], 2021 Air versus SF6/C2F6/C3F8 Superior breaks No 48/214 62.2±8.9/64.3±11a At least 6 months 3 months 2b 
Moussa et al. [15], 2022 Air versus C2F6/SF6/C3F8 NA NA 22/24 60 (55–66)/59 (51–72)b 3 months 3 months 2b 
Nakamura et al. [16], 2022 Air versus SF6 Superior breaks/inferior breaks <Grade C 156/138 61.31±8.11/63.64±9.79a 6 months 6 months 2b 
Singh et al. [14], 2021 Air versus SF6 Superior breaks/inferior breaks/multiple breaks <Grade C 165/71 60.3±10.9a At least 3 months 3 months 2b 
Tan et al. [10], 2013 Air versus SF6 Superior breaks <Grade C 158/366 60.3±7.3/60.9±8.1a At least 3 months 3 months 2b 
Tetsumoto et al. [12], 2020 Air versus SF6 Superior breaks/inferior breaks No 35/35 59.2±7.9/56.8±10.1a 12 months NA 2b 
Uemura et al. [17], 2022 Air versus SF6 Inferior breaks <Grade C 52/64 56.7±8.6/53.9±8.9a At least 3 months 3 months 2b 
Zhou et al. [11], 2015 RCT Air versus C3F8 Inferior breaks ≤Grade C1 32/32 57.19/53.91c 13.09±1.90a months NA 1b 

R, retrospective; P, prospective; RCT, randomized controlled trial; PVR, proliferative vitreoretinopathy; superior breaks: retinal break(s) between 3 and 9 o’clock; inferior breaks: retinal break(s) between 4 and 8 o’clock; NA, not available.

aMean ± SD.

bMedian (range).

cMean.

dUsing the Jadad scale or NOS.

eAccording to the Oxford Centre for Evidence-Based Medicine 2011 levels of evidence.

Fig. 2.

The risk of bias for the included studies according to ROBINS-I.

Fig. 2.

The risk of bias for the included studies according to ROBINS-I.

Close modal

Rate of Primary Treatment Success

Pooled analysis of cohorts from all 8 studies was conducted for primary treatment success. Overall, 605 out of 668 (90.6%) eyes had primary treatment success after surgery in the air tamponade group and 849 out of 944 (89.9%) in the gas tamponade group. Results from our meta-analysis comparing the rate of primary treatment success in the two groups are shown in Figure 3. The pooled analysis revealed no significant difference in the rate of primary treatment success between the air tamponade group and the gas tamponade group in the total analysis (RR = 1.00, CI: 0.85–1.37, p = 0.79). Low heterogeneity was found between the two groups (I2 = 16%, p = 0.30).

Fig. 3.

A forest plot shows the rate of primary treatment success and the associated 95% CI, comparing air tamponade with gas tamponade after vitrectomy.

Fig. 3.

A forest plot shows the rate of primary treatment success and the associated 95% CI, comparing air tamponade with gas tamponade after vitrectomy.

Close modal

The subgroup analysis of the location of retinal breaks revealed that whether retinal breaks were located above or below, there was no significant difference in either rate of primary treatment success (RR = 0.99, CI: 0.92–1.08, p = 0.89, Fig. 4a; RR = 1.02, CI: 0.96–1.09, p = 0.45, Fig. 4b). There was a high heterogeneity between the two groups for superior breaks (I2 = 76%, p = 0.02). No statistical heterogeneity was found between the studies for inferior breaks (I2 = 0%, p = 0.81).

Fig. 4.

A forest plot shows the subgroup analysis of the location of retinal breaks: the primary treatment success rate of superior (a) and inferior breaks (b).

Fig. 4.

A forest plot shows the subgroup analysis of the location of retinal breaks: the primary treatment success rate of superior (a) and inferior breaks (b).

Close modal

Best-Corrected Visual Acuity

Pooled data for investigating BCVA were obtained from 4 studies [12, 13, 15, 17]. Results from our meta-analysis comparing the mean BCVA at baseline and mean postoperative BCVA at 3 months, as well as the mean change in BCVA between the air tamponade and gas tamponade groups (shown in Fig. 5). The pooled analysis illustrated no significant difference in the mean BCVA at baseline, mean postoperative BCVA at 3 months, and mean change in BCVA between the two groups (MD = −0.01, CI = −0.08 to 0.05, p = 0.67, Fig. 5a; MD = −0.02, CI = −0.09 to 0.04, p = 0.50, Fig. 5b; MD = −0.03, CI = −0.18 to 0.12, p = 0.66, Fig. 5c), with moderate heterogeneity (I2 = 44%, p = 0.15), high heterogeneity (I2 = 73%, p = 0.01), and high heterogeneity (I2 = 53%, p = 0.09).

Fig. 5.

A forest plot shows the mean BCVA and the associated 95% CI, comparing air tamponade with gas tamponade at baseline (a), 3 months after vitrectomy (b), and mean change in BCVA (c).

Fig. 5.

A forest plot shows the mean BCVA and the associated 95% CI, comparing air tamponade with gas tamponade at baseline (a), 3 months after vitrectomy (b), and mean change in BCVA (c).

Close modal

Postoperative IOP

Pooled data for investigating the postoperative IOP were obtained from 4 studies [12, 13, 15, 17]. Results from our meta-analysis comparing postoperative IOP in the two groups are shown in Figure 6. The pooled analysis showed a lower postoperative IOP at 1 day (MD = −4.24, CI = −6.66 to −1.82, p < 0.001, Fig. 6a) was associated with air tamponade group and moderate heterogeneity (I2 = 49%; p = 0.14). There was no significant difference in the postoperative IOP at 7 days between the two groups (MD = −0.94, CI = −1.36–0.45, p = 0.71, Fig. 6b) and high heterogeneity (I2 = 95%; p < 0.001). There was no significant difference in the postoperative IOP at 1 month between the two groups (MD = −0.45, CI = −1.36–0.46, p = 0.33, Fig. 6c) and no statistical heterogeneity (I2 = 0%; p = 0.85). Similarly, there was no significant difference between the two groups for the postoperative IOP at 3 months (MD = 0.69, CI = −0.75–2.13, p = 0.35, Fig. 6d) and no statistical heterogeneity between studies (I2 = 0%; p = 0.98).

Fig. 6.

A forest plot shows the mean IOP and the associated 95% CI, comparing air tamponade with gas tamponade at 1 day (a), 7 days (b), 1 month (c), and 3 months (d) after vitrectomy.

Fig. 6.

A forest plot shows the mean IOP and the associated 95% CI, comparing air tamponade with gas tamponade at 1 day (a), 7 days (b), 1 month (c), and 3 months (d) after vitrectomy.

Close modal

Rate of Epiretinal Membrane Development

Pooled data for investigating the postoperative epiretinal membrane (ERM) formation were obtained from 3 studies [12, 13, 17]. In air and gas tamponade groups, ERM developed in 10 out of 135 (7.4%) and 49 out of 313 (15.7%) eyes. Results from our meta-analysis are shown in Figure 7. The pooled analysis indicated a significantly lower rate of postoperative ERM formation in the air tamponade group than that in the gas tamponade group (RR = 0.48; CI: 0.23–0.98; p = 0.04), and low heterogeneity was found between the two groups (I2 = 23%; p = 0.27).

Fig. 7.

A forest plot shows the rate of ERM development and the associated 95% CI, comparing air tamponade with gas tamponade after vitrectomy.

Fig. 7.

A forest plot shows the rate of ERM development and the associated 95% CI, comparing air tamponade with gas tamponade after vitrectomy.

Close modal

Cataracts

Amara et al. [13] and Moussa et al. [15] reported fewer occurrences of cataracts in the air group than those in the gas group. Still, the two groups had no statistical difference. Data merging analysis was not performed due to a need for more sufficient data.

Publication Bias

The Egger test revealed no evidence of publication bias for the total rate of primary treatment success (p = 0.846), rate of primary treatment success for superior retinal breaks (p = 0.337), rate of primary treatment success for inferior retinal breaks (p = 0.965), rate of ERM development (p = 0.798), mean BCVA at baseline (p = 0.063), mean postoperative BCVA at 3 months (p = 0.883), mean change in BCVA (p = 0.148), and mean postoperative IOP at 1 day (p = 0.450).

Sensitivity Analysis

In the sensitivity analysis, the heterogeneity was decreased by removing Tan’s study [10] for the primary treatment success rate of superior retinal breaks (I2 = 0%, p = 0.46). After removing the study, there was no change in the significance of the primary treatment success rate of superior retinal breaks (RR = 1.03, CI = 0.99–1.07, p = 0.17). In addition, the heterogeneity decreased by removing Amara’s study [13] for the mean postoperative BCVA at 3 months (I2 = 37%, p = 0.21) and mean change in BCVA (I2 = 0%, p = 0.96). After removing the study, there was no change in the significance of the mean postoperative BCVA at 3 months and mean change in BCVA (MD = 0.01, CI = −0.04–0.06, p = 0.74; MD = 0.03, CI = −0.04–0.09, p = 0.42). Therefore, the results of the primary treatment success rate of superior retinal breaks, the mean postoperative BCVA at 3 months, and the mean change in BCVA were stable.

This study analyzed the rate of primary treatment success, visual change, and postoperative complications to assess the efficacy and safety of PPV combined air tamponade for RRD. Regarding the primary treatment success rate, our meta-analysis revealed no significant difference in efficacy between the air tamponade and gas tamponade groups across all 8 studies, with air tamponade achieving 90.6% success and gas tamponade achieving 89.9% success.

It is generally believed that the choice of tamponade agent is related to the location of the retinal break in vitrectomy; LAGs, including SF6/C3F8 and silicone oil, are generally selected for tamponade selection for the inferior retinal breaks [27]. The low use of air tamponade is multifactorial [28]: because it is non-expanding, there is less safety for patients who do not have complete subretinal effusion drainage. Additionally, strict posture may be considerably more critical in air tamponade. However, in recent years, due to the many advantages of air tamponade, attempts have been made to select air tamponade for repositioning the retina with the inferior breaks. In our meta-analysis, a subgroup analysis of the position of the retinal breaks revealed that there was no significant difference in the primary treatment success rate between the air tamponade and gas tamponade groups, regardless of whether the retinal breaks were placed above or below the retina. In the subgroup with superior breaks, the result was highly heterogeneous, which may be attributable to differences in baseline parameters, such as the status of the macula, the status of the lens, and the involvement of the inferior quadrants, between the two research groups in Tan et al.’s [10] study. Due to the limited studies, we could not do a subgroup analysis to assess the potential source of heterogeneity, but we conducted a sensitivity analysis, and the result was stable.

The following reasons are possible to support the effectiveness of air tamponade: first, it has been reported that the adhesive strength between the retina and retinal pigment epithelium was equivalent to that of the normal retina 24 h after photocoagulation. Once established, a tamponade is no longer required [29, 30]. The half-life of air in the eye is 1.6 days [3], which can meet the time requirement for retinal reattachment. Second, patients who underwent surgery did not have complicated RRD and had a PVR less than C1 in 7 studies [10‒14, 16, 17]. Third, Martínez-Castillo et al. [31, 32] reported that RRD with inferior breaks could be successfully treated when applying air tamponade or no tamponade at all, as long as adequate subretinal effusion draining was carried out, and a laser could be used to seal the retinal break instantly. In those cases, lying face down was not even necessary. Based on those earlier findings and the results of this investigation, we deduce that for uncomplicated RRD, even brief tamponades may sufficiently lower the risk of recurrent detachment if the subretinal fluid does not approach the original wound.

BCVA is one of the most significant functional measuring tools for assessing therapy effectiveness. Our meta-analysis showed no significant difference in mean postoperative BCVA at 3 months and mean change in BCVA between eyes receiving air tamponade and gas tamponade in vitrectomy, with high heterogeneity. Regarding heterogeneity, we found that in the study by Amara et al. [13], the BCVA at baseline was worse than that in the other three studies, which may account for heterogeneity. In addition, difficulty in adjusting for possible variables that could affect vision is also a potential contributing factor (e.g., the status of the macula at the time of diagnosis, the duration of macular detachment, and the duration of surgery). Due to a limited number of studies, we could not do a subgroup analysis to assess the potential source of heterogeneity. However, we could conduct a sensitivity analysis, and the result was stable. It is worth noting that, as the observation period is 3 months postoperatively, a longer follow-up period may yield different results.

Moreover, in the study by Amara et al. [13], the visual acuity of the air tamponade group was significantly better than that of the gas tamponade group 7 days after surgery. This result may be due to the shorter half-life of air in the eye than that of gas [3]. No data merging was performed because of a lack of sufficient data. Our results show that air and gas tamponades have similar outcomes and that postoperative visual recovery is faster in the air tamponade group.

Regarding the postoperative complications, the meta-analysis of postoperative IOP shows that a lower IOP at 1 day was associated with air tamponade after surgery, and there was no significant difference in the postoperative IOP at 7 days, 1 month, and 3 months between the two groups. These results may still be related to the half-life of air in the eye [3]. In the four included studies, different types of gas tamponade agents were present: one was 20% SF6, one was C3F8, and the other two had SF6, C2F6, and C3F8 [11‒13, 15]. 20% SF6 is a non-expanding gas with a short duration in the vitreous cavity, whereas C2F6 and C3F8 are expansive and stay longer in the vitreous cavity. This concept explains why postoperative IOP at 1 day in two studies was no significant difference between the two groups and the high heterogeneity of postoperative IOP at 7 days. Due to insufficient data, the subgroup analysis of air versus SF6 and air versus C2F6/C3F8 was performed poorly.

For the ERM, our meta-analysis found that the air tamponade group had a significantly lower rate of postoperative ERM development than the gas tamponade group. Different risk factors for the incidence of ERM after PPV for RRD have been postulated, including the number and size of retinal breaks, the macula-off status, the use of cryopexy, and the existence of PVR and/or vitreous hemorrhage at baseline [33‒35]. Amara et al. [13] hypothesized that the compartmentalization effect created by intraocular gas bubbles might be responsible for the greater incidence of ERM in the gas group. More longitudinal investigations are needed to understand further the causal connections between intraocular tamponades and the development of ERM.

For cataracts, a previous report revealed that the severity of cataract development after vitreoretinal procedures with gas tamponade was related to how long the intraocular tamponade stayed in the vitreous cavity [5]. One explanation is that intravitreal tamponade may cause the posterior layers of the lens to become dehydrated, accelerating the formation of cataracts [5]. As a result, compared to gas tamponade, the shortened persistence duration of air may lead to a lower incidence of cataracts. Further studies with larger sample sizes and longer follow-ups will clarify this problem.

The results of our meta-analysis show that PPV-combined air tamponade is better than PPV-combined gas tamponade. Air tamponade has benefits like faster vision recovery and a lower risk of postoperative high IOP and ERM development. However, there are several unavoidable limitations to our meta-analysis. First, just one RCT was included, whereas the majority of the studies were retrospective. Second, the differences in patients’ characteristics and surgeries in each study might represent a significant source of bias. Third, PVR in RRD patients did not exceed grade C in any of the studies, except for two studies that did not specify the PVR grading of RRD patients. Therefore, our meta-analysis’s findings cannot explain how air and gas tamponades affect patients with complicated RRD. Finally, computer-based literature searches might not contain all relevant research. Gray literature was likewise ineligible for inclusion.

In conclusion, this meta-analysis reveals that for patients with uncomplicated RRD, PPV combined air tamponade is a feasible and safe alternative to PPV combined gas tamponade regardless of the position of retinal breaks, with a similar primary treatment success rate, postoperative BCVA, and fewer postoperative complications. However, due to the low quality of the evidence, the findings should be used with caution in the clinic. Further quality studies, particularly in complicated RRD, are required to compare the effectiveness and safety of air tamponade versus gas tamponade.

The World Medical Association Declaration of Helsinki was followed in the ethical conduct of the study. This paper provides a summary analysis of already published data, as our research did not involve an original review of clinical studies. As a result, ethical approval was not necessary.

The study was carried out without any financial or commercial ties that may be viewed as a possible conflict of interest, according to the authors.

This work was supported by the National Natural Science Foundation of China (No. 82160200), R and D Program of the First People’s Hospital of Zunyi [No. (2020) 4], the Science and Technology Fund Project of Guizhou Provincial Health Commission in 2020 (gzwjk2020-1-155), and the Science and Technology Planning Project of Zunyi [No. HZ (2022) 58]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

A.M.Z. designed this study. A.M.Z. and J.N.W. collected and double checked the data. J.N.W. and Y.Y. analyzed the data. A.M.Z. wrote the manuscript. L.Z., X.C.W., and W.T. provided critical revision to the article. All authors participated in revision and approved the final version for submission. All authors read and approved the final manuscript.

All data generated or analyzed during this study are included in this article and its online supplementary material files. Further inquiries can be directed to the corresponding author.

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