Retina Today - Macular Buckle for Retinal Detachment Related to Macular Hole in Highly Myopic Eyes (July/August 2013)

摘要

In this issue of Retina Today, Carlos Mateo, MD, details his surgical technique for macular buckling in highly myopic patients with retinal detachment due to macular hole. We extend an invitation to readers to submit pearls for publication in Retina Today. Please send submissions for consideration to Dean Eliott, MD (dean_eliott@meei.harvard.edu); or Ingrid U. Scott, MD, MPH (iscott@hmc.psu.edu). We look forward to hearing from you.a?? Dean Eliott, MD; and Ingrid U. Scott, MD, MPH High myopia is generally defined as an ocular axial length of at least 26 mm or a refractive error greater than -6.00 D. It has been shown that, in some highly myopic eyes, the centrifugal action of staphyloma formation is counteracted by the action of 3 main forces: (1) posterior vitreous traction, (2) internal limiting membrane (ILM), and (3) stretched retinal arteries. Retinal detachment (RD) secondary to macular hole is more frequent in myopic eyes and is more likely to develop in Asian patients. Several surgical techniques have been described for the treatment of these patients, including pars plana vitrectomy (PPV) with posterior hyaloid removal, ILM peeling, and macular buckling. Macular buckling is an old surgical technique, the goal of which is to counteract the pulling effect of the staphyloma. 1-3 Since 1982, PPV (with various additional procedures) has generally been considered the preferred surgical approach for the treatment of RD due to macular hole in highly myopic eyes.4 Although some surgeons continued performing and developing macular buckling surgery, it was commonly considered technically challenging probably because of the difficulties in achieving the correct placement of the macular buckle.5 However, in recent years there has been renewed interest in macular buckling surgery, and in the past 2 years several techniques have been described.6-11 BASIC TECHNIQUE Exposure of the Superotemporal Scleral Quadrant A 140?o superotemporal conjunctival peritomy is performed with separation of Tenon capsule (Figure 1A). The superotemporal quadrant is selected with the aim of avoiding the inferior oblique muscle, which runs posteriorly and laterally along the entire inferotemporal quadrant. The superior and temporal rectus tendon muscles are hooked with a 3-0 silk suture to help with the exposure of the superotemporal scleral quadrant (Figure 1B). After this step, we localize the insertion of the 2 oblique muscles, and between them a 5-0 nylon suture pointing toward the macular area is placed (Figures 1C and 1D). Although this suture can be positioned after vitrectomy, we prefer to do it before the eye has been opened. At this point, extra care must be taken to avoid the vortex veins near the tendon of the superior oblique muscle. SUPPLEMENTAL VIDEO Pars Plana Vitrectomy Although PPV is not absolutely necessary, we prefer to perform it to release the traction from the posterior hyaloid and the ILM. Any instrument diameter (20 gauge, 23 gauge, 25 gauge, or 27 gauge) can be used, but the instrument must have the necessary length to be able to reach the posterior pole of the eye. The posterior hyaloid can be removed with the assistance of triamcinolone. Due to the consistency of the posterior hyaloid in some cases, some surgeons prefer to use a Tano diamonddusted scraper to peel away the posterior hyaloid that remains adherent to the inner surface of the retina. Dyes Brilliant blue is a vital dye employed to stain the ILM. It is often used in Europe, but it is not available in the United States, where indocyanine green (ICG) at a low concentration is used instead. To prevent the dye from spilling into the subretinal space, there are 2 techniques that can be used: (1) injecting a small bubble of perfluorocarbon liquid to tamponade the macular hole or (2) mixing the dye with viscoelastic so that the viscosity will prevent the dye from passing into the subreti