16.5 Myopic Traction Maculopathy – Macular Buckling

Myopic foveoschisis (MF) affects 8–34% of eyes with high myopia[1,2] and is characterized by intraretinal splitting in the macular region, representing a major cause of visual loss in highly myopic eyes. The term myopic foveal retinoschisis was initially described in 1958 by Calbert Phillips, who proposed that localized posterior retinal macular detachment (MD) over the posterior staphyloma may occur without a detectable macular hole (MH).[3,4]

The management of MF has inspired much debate. Elimination of epiretinal traction by means of vitrectomy with or without internal limiting membrane (ILM) peeling seems a reasonable approach and has proven to be effective in MF[5,6] despite not exempt from complications such as MH formation, extrafoveal retinal hole formation[7] or physiologic changes in the macular area.[8] Moreover, some reports suggest that vitrectomy, with or without ILM peeling, only causes a transient release of the traction[9] without addressing the major risk factor associated with the development of the MF, which is the posterior staphyloma.[10]

Reshaping and providing support to the posterior scleral wall by means of macular buckling (MB) has the advantage of releasing both the anteroposterior traction caused by the posterior staphyloma and the tangential traction caused by the vitreous cortex.[11,12,13]

Several buckles designs and techniques have been developed to treat these myopic sequelae.[14,15,16,17,18]

Our preferred approach is outlined below:

Wu PC, Chen YJ, Chen YH, et al. Factors associated with foveoschisis and foveal detachment without macular hole in high myopia. Eye. 2009. doi:10.1038/sj.eye.6703038

Baba T, Ohno-Matsui K, Futagami S, et al. Prevalence and characteristics of foveal retinal detachment without macular hole in high myopia. Am J Ophthalmol. 2003;135(3):338-342. doi:10.1016/S0002-9394(02)01937-2

Phillips CI, Dobbie JG. Posterior staphyloma and retinal detachment. Am J Ophthalmol. 1963;55(2):332-335. doi:10.1016/0002-9394(63)92692-8

Phillips CI. Retinal detachment at the posterior pole. Br J Ophthalmol. 1958;42(12):749-753. doi:10.1136/bjo.42.12.749

Kanda S, Uemura A, Sakamoto Y, Kita H. Vitrectomy with internal limiting membrane peeling for macular retinoschisis and retinal detachment without macular hole in highly myopic eyes. Am J Ophthalmol. 2003. doi:10.1016/S0002-9394(03)00243-5

Ikuno Y, Sayanagi K, Ohji M, et al. Vitrectomy and internal limiting membrane peeling for myopic foveoschisis. Am J Ophthalmol. 2004. doi:10.1016/j.ajo.2003.10.019

Steven P, Laqua H, Wong D, Hoerauf H. Secondary paracentral retinal holes following internal limiting membrane removal. Br J Ophthalmol. 2006. doi:10.1136/bjo.2005.078188

Wolf S, Schnurbusch U, Wiedemann P, Grosche J, Reichenbach A, Wolburg H. Peeling of the basal membrane in the human retina: Ultrastructural effects. Ophthalmology. 2004. doi:10.1016/j.ophtha.2003.05.022

Gaucher D, Haouchine B, Tadayoni R, et al. Long-term Follow-up of High Myopic Foveoschisis: Natural Course and Surgical Outcome. Am J Ophthalmol. 2007. doi:10.1016/j.ajo.2006.10.053

Theodossiadis GP, Theodossiadis PG. The macular buckling procedure in the treatment of retinal detachment in highly myopic eyes with macular hole and posterior staphyloma: Mean follow-up of 15 years. Retina. 2005;25(3):285-289. doi:10.1097/00006982-200504000-00006

Sasoh M, Yoshida S, Ito Y, Matsui K, Osawa S, Uji Y. Macular buckling for retinal detachment due to macular hole in highly myopic eyes with posterior staphyloma. Retina. 2000;20(5):445-9. doi: 10.1097/00006982-200009000-00003.

Stirpe M, Ripandelli G, Rossi T, Cacciamani A, Orciuolo M. A New Adjustable Macular Buckle Designed for. Retina. 2012;32(7):1424-1427.

Ando F, Ohba N, Touura K, Hirose H. Anatomical and visual outcomes after episcleral macular buckling compared with those after pars plana vitrectomy for retinal detachment caused by macular hole in highly myopic eyes. Retina. 2007. doi:10.1097/01.iae.0000256660.48993.9e

Mateo C, Medeiros MD, Alkabes M, Burés-Jelstrup A, Postorino M, Corcóstegui B. Illuminated ando plombe for optimal positioning in highly myopic eyes with vitreoretinal diseases secondary to posterior staphyloma. JAMA Ophthalmol. 2013;131(10):1359-1362. doi:10.1001/jamaophthalmol.2013.4558

Mateo C, Burés-Jelstrup A, Navarro R, Corcóstegui B. Macular buckling for eyes with myopic foveoschisis secondary to posterior staphyloma. Retina. 2012;32(6):1121-1128. doi:10.1097/IAE.0b013e31822e5c32

Parolini B, Frisina R, Pinackatt S, Mete M. A New L-shaped design of macular buckle to support a posterior staphyloma in high myopia. Retina. 2013;33(7):1466-1470. doi:10.1097/IAE.0b013e31828e69ea

Devin F, Tsui I, Morin B, Duprat JP, Hubschman JP. T-shaped scleral buckle for macular detachments in high myopes. Retina. 2011;31(1):177-180. doi:10.1097/IAE.0b013e3181fc7e73

Surgical Technique

The previously described technique[18] for MB has been modified by Mura et al:[19]

  • After 360° conjunctival peritomy, the 4 recti muscles and the inferior oblique muscle are isolated with 3-0 silk suture in the standard fashion for scleral buckling procedures
  • The sub-Tenon’s space is exposed, and the sclera is inspected for thinning and to locate relevant vortex veins. The vortex veins, although variable in location and quantity, are typically located in the mid-quadrant between the recti muscles. They are carefully bluntly dissected away from the globe with dressing forceps and a Q-tip
  • A 2-mm solid silicone band (FCI, Paris, France) is first passed under the lateral rectus muscle, then posteriorly under the inferior oblique muscle and finally beneath the inferotemporal inferior vortex vein.
  • The band is fixed to the sclera along the nasal aspect of the inferior rectus insertion using 5-0 Mersilene suture (Ethicon Inc,Somerville, NJ)
  • The solid silicone macular plate (FCI, Paris, France) is threaded on the free extremity of the 2-mm band in the superotemporal quadrant
  • To avoid vortex vein compression, the other end of the 2-mm band is passed posterior to the superotemporal vortex vein, which is then positioned to the nasal aspect of the superior rectus muscle insertion
  • A chandelier light with wide-angle viewing system is used to check the posterior indentation of the macular plate, the height of the buckle and to ensure that the nasal edge of the macular plate is adjacent to but not touching the optic nerve
  • The height of the macular buckle is adjusted by lengthening or shortening the 2-mm band (by stretching or relaxing the 2-mm band positioned next to the superior rectus)
  • The optic nerve and retina are carefully examined to ensure perfusion
  • When the position of the macular plate is as desired to reoppose the posterior retina, the superior end of the 2-mm band is trimmed and sutured to the nasal aspect of the superior rectus tendon and the anterior end of the macular plate is trimmed and sutured underneath the lateral rectus muscle
  • To close, Tenon’s and conjunctiva are pulled over the globe and the conjunctiva is sutured This procedure can be combined at the discretion of the surgeon and depending on the clinical aspects with vitrectomy, subretinal fluid drainage, and endotamponade (gas or silicone oil). (Figure 16.5.1 to Figure 16.5.4) show different views of the T-shaped macular buckle and its position on the eye.

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