Anatomical and visual outcomes of pneumatic retinopexy in primary rhegmatogenous retinal detachment

• Pneumatic retinopexy achieved a 67% single-operation success rate in primary rhegmatogenous retinal detachment. • Final anatomical success increased to 98% after selective secondary interventions. • Pseudophakia, high myopia, delayed presentation, new or missed retinal breaks and proliferative vitreoretinopathy were independent factors of both anatomical and visual failure. • Visual acuity improved significantly postoperatively, with the greatest recovery during the first month. To evaluate pneumatic retinopexy (PnR) outcomes for primary rhegmatogenous retinal detachment (RRD) in a real-world North African cohort and identify factors associated with surgical failure. Retrospective observational case series. A total of 112 eyes from 112 patients treated for primary RRD with PnR (January 2023–March 2025) were reviewed. Patient selection followed PIVOT trial criteria, including single retinal break or clustered breaks ≤1 clock hour, located within superior 8 clock hours (between 8 and 4 o'clock), with documented postoperative compliance. Preoperative demographics, ocular characteristics, and postoperative complications were systematically recorded. The primary anatomical outcome was defined as complete retinal reattachment without additional surgery at 6 months. Anatomical failure was defined as subretinal fluid persistence exceeding 4 weeks requiring secondary intervention. The primary visual outcome was best-corrected visual acuity (BCVA) at 6 months and its change over time. Logistic regression was used to identify factors associated with anatomical and visual failure. Single-operation anatomical success was 67% (75/112 eyes); secondary procedures achieved 98% final reattachment (110/112). Mean final BCVA was 0.12 logMAR, with 80% of visual improvement occurring within the first postoperative month (0.62 logMAR gain; p<0.001). Pseudophakia (OR=3.49, p<0.001), high myopia (OR=1.82, p=0.02), and prolonged symptom duration (OR=1.12 per day, p=0.002) were independent factors associated with anatomical failure. New or missed retinal breaks (OR=2.16, p=0.03) and proliferative vitreoretinopathy (PVR) (OR=1.96, p=0.02) were independent postoperative factors of failure. For visual outcomes, pseudophakia (OR=3.2, p=0.001), high myopia (OR=2.49, p=0.004), worse preoperative BCVA (OR = 2.23, p = 0.002), and prolonged symptom duration (OR=1.35 per day, p=0.002) were independent factors associated with poor outcomes. Postoperative complications (missed breaks OR=2.8; PVR OR=1.8) also independently contributed to poor visual recovery. PnR achieves competitive anatomical and visual outcomes in real-world practice when rigorous patient selection and meticulous surgical technique are applied. Success depends equally on preoperative patient selection and surgical execution. Optimization through timely intervention, comprehensive preoperative examination, enhanced visualization, and rigorous surveillance may increase real-world success rates toward trial-level performance while maintaining procedural simplicity and cost-effectiveness in resource-limited settings.