THE MANAGEMENT OF MYOPIC MACULAR HOLE RETINAL DETACHMENT The Indications and Technique of Macular Buckling - A New Approach

2. 1. Paracentesis  air or gas tamponade +/-
macular laser
2. Drainage of SRF  air or gas tamponade +/-
macular laser
3. Volume reduction, drainage, air injection, +/-
macular Laser.
4. PP Vitrectomy:
 Gas or silicone oil tamponade.
 ± ILM peeling.
 ± Photocoagulation at the macular hole edges.
5. Macular buckling without physical
treatment

5.  In our cases: Up to 40 %.
 Li et al; 25 – 40% recurrence rate (Ophthalmology.
2009 Jun;116(6):1182-87.e1. Epub 2009 Apr 17).
 Lam et al: 37 % recurrence rate. Am J Ophthalmol.
2006 Dec;142(6):938-44. Epub 2006 Sep 1.
 Cho et al: 21% recurrence. Korean J Ophthalmol. 2004
Dec;18(2):141-7.
 Uemoto et al: up to 50% recurrence rate. Retina. 2004
Aug;24(4):560-6.
 Ichibe et al: 30% failure and recurrence. Am J
Ophthalmol. 2003 Aug;136(2):277-84.
 Kwok et al: 25% failure. Ophthalmic Surg Lasers. 2002
Mar-Apr;33(2):155-7.

6. And does not need physical treatment

7.  Our thesis: 26 cases 100% success rate.
 Schepens et al: AMA Arch Ophthalmol. 1957 Dec; 58(6):797-
811.
 Rosengreen B: Bibl Opthalmol 1966;70:253-6, 1966.
 Paufique & Bonnet: Ann Ocul (Paris). Mar;201(3):290-302,
1968 [Article in French].
 Haut et al: Arch Ophtalmol Rev Gen Ophtalmol. Aug-Sep;
32(8):541-8, 1972.
 Siam A-L:Brit. J. Ophthalmol. 57; 351, 1973.
 Kapuschinski W.J:, 1972
 Harris G.S:Ophthalmol. Vol. 12, P. 337, Karger, Basel, 1974.
 Theodossiadis:Mod. Frob. Ophthalmol. Basel, Karger, 12, 322,
1974.
 Theodossiadis & Theodossiadiss. Retina, Apr-May; 25(3):285-9,
2005.
 Ando F: Afr Asian J Ophthalmol, 11. 48, 1983.

8.  Failed & recurrent cases after PP
vitrectomy including cases with silicone oil
tamponade.
 Very atrophic background ; white holes.
 Very high myopia with posterior
staphyloma.
INDICATION FOR MACULAR
BUCKLING

9. Still ret. det. after PPV & S.O tamp. plus mac. PC
Reopening of the hole with re-detachment

10. A new approach has been
discovered only after finding
clear-cut and constant
anatomical landmarks , to be
able to perform exact macular
buckling

11. ONS
ON
OD

12. • The macular area is approached between
the superior and lateral rectus muscles.
• Hook the 4 recti with silk sutures.
• The superior oblique muscle is severed which
allows hooking and pulling on the inferior oblique
(IO) muscle belly & to hold its insertion
• This exposes the intra-scleral course of the TLPCA
and the space between the point of intra-scleral
entry of this vessel and the optic nerve sheath
(ONS)
HOW TO EXPOSE THE POSTERIOR POLE
DURING SUGERY

13. ONS
Press on the softened eye beyond the nasal end of IO insertion to take sutures
on either side of TLPCA
TLPCA
IO

14.  Sever the SO insertion.
 Hook the IO inbetween SR & LR.
 Soften the eye (paracentesis).
 Remove the speculum.
 Retract the lateral canthus with
a retractor.
 Flatten the sclera by gentle
pressure with a non toothed
forceps.
 Take the suture bites at equal
distances from the TLPSA.
 Use fine round needles.
 No need to pull much on the
sutures.

15. Orbital Fat
IOM
NO SPECULUM
RETRACTOR
1
‫ز‬
5
‫ةة‬
‫ز‬

17. The macular hole has closed ; disappeared !
?

19. The macular hole has closed ; disappeared
?

20. Macular buckling offers the highest
success rate and the best visual result

21. At least to deal with failed and recurrent cases
after PPV with various types of internal tamponade
and to avoid physical injury to the fovea
CONCLUSION