Retina Today - Macular Buckling for Retinal Detachment in Highly Myopic Eyes With Macular Hole (July/August 2015)

摘要

At a Glance • Macular buckling is an effective approach to treating myopic macular hole retinal detachment with posterior staphyloma. • Modifying a macular buckling device by illuminating the macular plate with an optical fiber allowed visualization of the macular area and improved the accuracy of positioning. High myopia is a relatively frequent condition affecting approximately 2.5% to 9.6% of the elderly world population.1,2 The highest rates occur among Asians, with roughly 50% to 80% of the adult population myopic.3–5 Macular schisis and macular detachment, with or without macular hole, are severe complications that can occur in highly myopic eyes and result in significantly reduced visual acuity. Posterior staphyloma, in combination with anteroposterior traction caused by vitreous cortex and tangential forces due to epiretinal membranes or internal limiting membrane (ILM), plays a significant role in the pathogenesis of myopic maculopathy.6 To address these issues, two approaches to myopic maculopathy treatment have been developed: the transvitreal approach and the macular buckling procedure.7,8 In recent years, macular detachments have most frequently been treated using pars plana vitrectomy (PPV) with or without ILM peeling, but the use of macular buckling is having a resurgence. Recent designs of macular buckles have been shown to be safe and effective.3,4 In this article, we describe a modification to the adjustable macular buckling (AMB) device that we have used with success—the AMB model BMM4 (Micromed). In our modification, we illuminated the device’s terminal plate using an optical fiber in order to facilitate the location of the fovea and to guide correct positioning of the macular buckle, reducing the risk of procedure failure. In parallel, other researchers have proposed similar modifications of the macular buckle.6,9 This article describes our modification of the device and our results in two patients. USE OF THE MODIFIED AMB DEVICE Two patients affected by myopia and macular detachment with macular hole were referred to our department, where they were operated on with a modified AMB device. They were informed about all treatment details, and each gave consent prior to the operation. Preoperative and postoperative visual acuity and optical coherence tomography (OCT) scans were evaluated, and postoperative orbital computed tomography (CT) was performed to assess the implant’s position. Case No. 1 An 83-year-old woman with retinal detachment in a highly myopic eye with macular hole had BCVA of finger counting at 60 cm. She was pseudophakic and had no history of retinal detachment. We performed a macular buckling procedure, which resulted in complete retinal reattachment and closure of the macular hole as observed on OCT. Case No. 2 A monocular, 70-year-old woman with retinal detachment in a highly myopic eye with macular hole had a BCVA of 1/50. She had previously undergone three vitreoretinal operations: phacovitrectomy with posterior intraocular lens (IOL) implantation and gas tamponade, PPV with silicone oil tamponade, and subsequent PPV with silicone oil tamponade. Figure 1. A double-armed 5-0 polyester suture threaded through the terminal plate of the macular buckle (A). The tip of the optical fiber being thrust into the terminal plate of the AMB (B). A canal is formed in the device’s handle and terminal plate using a 25-gauge needle (C). The optical fiber is inserted into the canal (D). We first performed a complete PPV with revision of her peripheral retina, ILM peeling, and heavy silicone oil tamponade. One week after this intervention, the retina was attached and the macular hole was completely closed. Unfortunately, 3 weeks later, we observed macular redetachment and a macular hole. Episcleral macular buckling in combination with PPV, silicone oil removal, and SF6 gas tamponade were then performed. The procedure resulted i