A new L-shaped design of macular buckle to support a posterior staphyloma in high myopia

Long-Term results of macular buckle for MTM stage 3-4 With maculoschisis and macular detachment without and With lamellar macular hole

PURPOSE

To report the long-term anatomical and functional results of macular buckle for Myopic Traction Maculopathy (MTM) in stages 3a, 3b, 4a, and 4b according to the MTM Staging System (MSS).

METHODS

Retrospective observational cohort study involving 55 consecutive patients with MTM in stages 3a, 3b, 4a, and 4b who underwent macular buckle (MB). Postoperative outcomes, including optical coherence tomography (OCT) scans to evaluate the MTM stage and its progression, were evaluated 1-month postoperatively (i.e., "intermediate follow-up") and at last follow-up ranging between 6 and 156 months postoperatively (i.e., "final follow-up").

RESULTS

Fifty-five eyes affected by MTM who underwent MB were enrolled. The mean preoperative and postoperative axial length was 31.13 ± 2.14 and 29.73 ± 2.16 mm, respectively (p < 0.01), with a mean axial shift of 1.32 ± 0.77 mm. The mean sample best corrected visual acuity (BCVA) at baseline, intermediate, and final follow-ups was 0.87 ± 0.36, 0.73 ± 0.31, 0.41 ± 0.32 logMar, respectively (p < 0.01). Foveal and retinal anatomical improvements were achieved in 50 (91%) and 53 (96.4%) eyes at intermediate follow-up, respectively. In the final follow-up, 54 (98.2%) and 55 (100%) eyes showed foveal and retinal anatomical improvements, respectively.

CONCLUSIONS

MB as a single procedure, when applied to MTM in stages 3a, 3b, 4a, and 4b, leads to significant anatomical and functional improvement. The MTM Staging System allows us to evaluate the best surgical technique and the surgical timing tailored to the different stages to increase the surgery's success and lower the complications of each technique.

Historical and practical aspects of macular buckle surgery in the treatment of myopic tractional maculopathy: case series and literature review

BACKGROUND

Uncorrected myopia is a leading cause of blindness globally, with a rising prevalence in recent decades. Pathological myopia, often seen in individuals with increased axial length (AXL), can result in severe structural changes in the posterior pole, including myopic tractional maculopathy (MTM). MTM arises from tractional forces at the vitreoretinal interface, leading to progressive macular retinoschisis, macular holes, and retinal detachment (RD). This study aims to outline preoperative evaluation and surgical indication criteria for MTM, based on the MTM staging system, and to share our Brazilian experience with three cases of macular buckle (MB) surgery, all with over a year of follow-up.

METHODS

We conducted a retrospective analysis of three cases of MTM-associated RD treated with MB surgery, with or without pars plana vitrectomy. Preoperative evaluations included optical coherence tomography (OCT) and ultrasonography (USG) to assess the extent of macular involvement and retinal detachment. Surgical indications were determined based on the MTM staging system. The MB was assembled using customizable and accessible materials. Surgical procedures varied according to the specific needs of each case. An informed consent form regarding the surgical procedure was appropriately obtained for each case. The study was conducted with the proper approval of the institution's ethics committee.

RESULTS

All three cases demonstrated successful retinal attachment during the mean follow-up of eighteen months. In the first case, combined phacoemulsification, vitrectomy, and MB were performed for MTM with macular hole and RD. The second case required MB and vitrectomy after two failed RD surgeries. In the third case, a macular detachment with an internal lamellar hole was treated with MB alone. These cases highlight the efficacy of MB surgery in managing MTM in highly myopic eyes.

CONCLUSIONS

MB surgery is an effective treatment option for MTM-associated RD in highly myopic eyes, providing long-term retinal attachment. Our experience demonstrates that with proper preoperative evaluation and surgical planning, MB can be successfully implemented using accessible materials, offering a viable solution in resource-limited settings. Further studies with larger sample sizes are warranted to validate these findings and refine surgical techniques.

A New Model of a Macular Buckle and a Refined Surgical Technique for the Treatment of Myopic Traction Maculopathy

Myopic traction maculopathy (MTM) affects 20% of eyes with pathologic myopia (PM). The MTM Staging System (MSS), published in 2020, describes the nomenclature of MTM as well as a proposal of pathogenesis, natural evolution, and prognosis. A study of customized treatment for each stage of MTM has been published previously and suggested to treat maculoschisis and detachment by placing a macular buckle (MB) behind the macula to push the sclera towards the retina, selecting pars plana vitrectomy (PPV) only in cases where a macular hole is associated with MTM. We hereby describe a new model of a macular buckle, known as NPB, and an NPB loading device, with the aim to standardize the surgical technique and render it more user friendly, efficient, and safe. Macular buckle is an effective and safe procedure to treat maculoschisis and macular detachment in MTM. We recommend using it as a unique and first-line treatment.

A TITANIUM MACULAR BUCKLE IMPLANT DESIGNED FOR AN EASY PLACEMENT IN MYOPIC MACULAR HOLES

PURPOSE

A new easy-to-place titanium macular buckle implant and the surgical technique for placing it in myopic macular holes are presented. A 60-year-old patient with pathologic myopia presented with macular holes in both eyes. The hole in the right eye was recurrent and long-standing since the initial diagnosis, which was over 5 years ago. He refused surgery for the better seeing left eye. The vision of the right eye was 20/200. The patient only wanted macular hole repair in the right eye if a macular buckle could be incorporated in the surgery.

METHODS

Because there was no commercially available macular buckle in the United States, a custom-made titanium buckle was designed and manufactured for this patient. In addition to the standard pars plana vitrectomy, internal limiting membrane peel, and gas tamponade, the titanium macular buckle was placed externally to provide indentation over the macula.

RESULTS

The titanium macular buckle provided approximately 1 mm of indentation, shortening the axial length from 28.88 mm to 27.94 mm. The macular hole was closed postoperatively. Postoperative best-corrected visual acuity was 20/200 at 1 month with no complications from the titanium macular buckle implant or the surgical technique. There was no improvement in the final visual acuity, which was attributed to foveal atrophy because of the long-standing nature of the macular hole.

CONCLUSION

This titanium macular buckle implant designed for an easy placement could be an invaluable addition for surgical success in myopic macular pathologies, including myopic macular holes.

The Role of the Intraoperative Optical Coherence Tomography for Vitreoretinal Surgery in a Real-Life Setting

BACKGROUND

To descriptively report the advantages and the feasibility of microscope-integrated intraoperative optical coherence tomography (i-OCT) in managing different vitreoretinal diseases in a real-life setting.

METHODS

We conducted an observational retrospective study involving 265 eyes that underwent elective retinal surgery and intraoperative OCT between 1 September 2018 and 1 October 2022 at Eyecare Clinic (Brescia, Italy).

RESULTS

52 epiretinal membranes, 30 retinal detachments, 60 high myopic eyes, 30 choroidal transplants, 40 macular holes, and 32 vitreo-proliferative retinopathies underwent vitreoretinal surgery and intraoperative OCT scans. The i-OCT was a useful diagnostic exam for all cases and significantly influenced our surgical management.

CONCLUSIONS

i-OCT is a helpful surgical tool in ophthalmic surgery as it provides real-time feedback of tissue anatomy to surgeons, thereby guiding decision-making. Moreover, it provides additional information on the microarchitectural changes after instrument-tissue interactions, further guiding procedures when necessary and possibly reducing unessential surgical maneuvers.

Posterior scleral reinforcement for the treatment of myopic traction maculopathy

Background

This study aimed to investigate the clinical effectiveness of posterior scleral reinforcement(PSR) for the treatment of myopic traction maculopathy (MTM).

Methods

This was a prospective study of 32 eyes from 20 patients with MTM treated with PSR using genipin-cross-linked donor sclera. The length of the scleral strip used for the surgery was designed to be 1.5-times the axial length of the eye, whereas its width was 0.4-times the axial length of the eye. The optical coherence tomography images, spherical equivalent of refractive error, axial length, best corrected visual acuity, electroretinogram findings, and intraocular pressure of the patients were assessed postoperatively.

Results

The mean duration of follow-up was 17.80 ± 8.74 months. The differences between the spherical equivalent of refractive error, best corrected visual acuity, axial length, and electroretinogram findings recorded preoperatively and those measured postoperatively were statistically significant (p < 0.05). The final reduction in axial length was 1.64 ± 0.85 mm. At the end of the follow-up, optical coherence tomography showed essential foveal reattachment in 30 eyes (93.75%), partial reattachment in two eyes (6.25%), and closure of macular holes in seven eyes (77.78%). No retinal detachment, vitreous haemorrhage, or other serious complications occurred following the surgery.

Conclusions

Posterior scleral reinforcement with genipin-cross-linked sclera showed safe and effective outcomes for the treatment of MTM during a follow-up period of at least one year.

Trial registration

11\12\2018, ChiCTR1800020012.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-022-02497-6.

CHARACTERISTICS AND MANAGEMENT OF MYOPIC TRACTION MACULOPATHY IN MYOPIC EYES WITH AXIAL LENGTH LESS THAN 26.5 mm

To explore the characteristics and underlying mechanisms of myopic traction maculopathy (MTM) with axial length less than 26.5 mm and to assess the effectiveness of macular buckling for the treatment of MTM.

The Role of the Outer Lamellar Macular Hole in the Surgical Management of Myopic Traction Maculopathy

PURPOSE

To evaluate the anatomical and functional surgical outcomes of eyes affected by myopic traction maculopathy (MTM) with and without an outer lamellar macular hole (O-LMH).

METHODS

Forty-eight eyes affected by MTM were included: a study group of 24 eyes with an O-LMH and a control group of 24 eyes without an O-LMH. All patients underwent spectral-domain optical coherence tomography (SD-OCT) and were staged according to the MTM staging system. The surgical techniques applied were pars plana vitrectomy (PPV), macular buckle (MB), or combined surgery. The follow-up visit was 12 months after the latest intervention.

RESULTS

Best-corrected visual acuity (BCVA) improved significantly in both groups after surgery (p < 0.05). A successful surgical result was obtained in both groups at the final follow-up. In the study group, 3 eyes underwent PPV, 14 eyes underwent MB, and 7 underwent a combined surgery. Six patients developed an iatrogenic full-thickness macular hole (FTMH). In the control group, 5 eyes underwent PPV, 16 underwent MB, and 3 had combined surgery. Four patients developed a FTMH. In both groups, all the eyes with an iatrogenic FTMH received PPV as first surgery (alone or combined). A topographical correspondence between the interruption of the ellipsoid zone (EZ) and the backscattering phenomenon was found on OCT.

CONCLUSION

The O-LMH is an OCT sign that may occur in eyes affected by MTM. Its presence is correlated with a higher risk of developing an iatrogenic FTMH after PPV (alone or combined) probably due to the thinner residual retinal tissue. Postoperative BCVA is not limited in eyes with an O-LMH and this may be explained by the restoration of the EZ after surgery.

Myopic Traction Maculopathy: A New Perspective on Classification and Management

ABSTRACT

Myopic traction maculopathy (MTM) is a complex disease affecting approximately 30% of eyes with pathologic myopia. A review of the history of treatment of MTM with success rates and limitations of different surgical techniques are reported.The pathogenesis, the definition and the management were clarified in a recent study(cit). The MTM Staging System (MSS) table summarizes all the stages of MTM offering insights on the pathogenesis and natural evolution of the disease.Guidelines of management of MTM were therefore proposed, but customized for each stage.Initial stages 1a and 2a, which define maculoschisis in the inner or inner-outer or only outer layers of the retina, should be observed. Stages 3a and 4a, defining macular detachment with and without associated schisis, should be treated with a macular buckle (MB).Stage 1b, which is a lamellar macular hole in a myopic eye, should be treated with pars plana vitrectomy (PPV) only in symptomatic cases. Stages 2b, 3b, and 4b should be treated with a MB and PPV should be added in a second step only if the presence of a lamellar macular hole requires intervention to improve visual function.Stage 1c, which is a full thickness macular hole in a myopic eye, should be treated with PPV. Stages 2c, 3c and 4c should be treated with a combination of simultaneous MB + PPV to treat both the retinal pattern of schisis or detachment and the full thickness macular hole.

Macular buckling versus vitrectomy on macular hole associated macular detachment in eyes with high myopia: a randomised trial

Aim

To compare the efficacy of macular buckling (MB) and pars plana vitrectomy (PPV) for full-thickness macular holes (FTMH) and associated macular detachment (MD) in highly myopic eyes.

Methods

Prospective interventional case series of eyes undergoing PPV or MB for FTMH and MD.

Main outcome measures

Best-corrected visual acuity (BCVA) at postoperative month 24. Other measured outcomes include the initial surgical success rate, macular hole closure rate and the progression of myopic maculopathy.

Results

A total of 53 eyes from 53 participants were included in this study (26 participants receiving MB and 27 participants receiving PPV), and finally 49 eyes from 49 participants (25 participants in the MB group and 24 participants in the PPV group) were analysed. At postoperative month 24, the BCVA had improved significantly in those that underwent either MB (p<0.001) or PPV (p=0.04). The difference between the groups was not significant (p=0.653). The surgical failure rate after the primary treatment was significantly higher in the PPV group than the MB group (25.00% vs 4.00%, respectively; p=0.04). The macular closure rate was higher in the MB group compared with the PPV group, but the difference was not statistically significant (64.00% vs 58.33%, respectively; p=0.45). Myopic maculopathy development may be more severe following PPV than following MB surgery.

Conclusion

Patients with high myopia obtained anatomical and functional improvements from either MB or PPV. However, MB achieved a significantly higher success rate in retinal reattachment compared with PPV.

Trial registration number

NCT03433547.

Proposal for the management of myopic traction maculopathy based on the new MTM staging system

PURPOSE

To propose the Myopic Traction Maculopathy (MTM) management Table, based on the MTM Staging System (MSS).

METHODS

A retrospective review of 157 eyes affected by MTM, operated with pars plana vitrectomy (PPV), or macular buckle (MB) or combined surgery (MB + PPV). Each case was classified according to the MSS. Anatomical results were evaluated with OCT at an intermediate follow-up (3-6 months) and at a final follow-up (2-8 years), considering changes both in the foveal and in the retinal pattern. The number and type of operations needed were noted. The surgical complications were reported.

RESULTS

Primary surgery was MB for 83 eyes (52%), PPV for 36 (23%) and MB + PPV for 38 (24%). At intermediate follow-up, the retinal pattern was restored in 55.41% and foveal in 42.68%.Further surgery was indicated as PPV in 25.48%, MB in 14.65%. At the final follow-up, the retinal pattern was restored in 96.16% and the foveal pattern in 87.90%.BCVA improved at the final follow-up (p < 0.05). The complications of MB were not sight-threatening. The complications of PPV were FTMH in 67% cases in stages 2, 3, and 4. Cataract developed in 60% of phakic eyes. The complications of combined MB+PPV were cataract (56%) and PVR (5%).

CONCLUSIONS

Both PPV and MB may be used to treat MTM. PPV addresses the changes in the foveal pattern while MB addresses the changes in the retinal pattern. The MTM management table offers a proposal for the choice of type and timing of treatment customized per each stage of MTM.

Myopic Traction Maculopathy: Diagnostic and Management Strategies

Pathologic myopia (PM) is an ocular disorder characterized by a spherical equivalent (SE) of more than - 6.0 diopters (D) or by an axial length (AL) of more than 26.5 millimeters (mm). PM is associated with myopic maculopathy (MM). The ATN classification describes all the aspects of MM which regroups atrophic, tractional and neovascular consequences to the sclera, choroid and retina of highly myopic eyes. The advent of OCT allowed to define the ultrastructural characteristics of the tractional changes in MM, described by the term myopic traction maculopathy (MTM). They include foveoschisis/maculoschisis/retinoschisis (FS/MS/RS), retinal/foveal detachment (RD/FD), lamellar macular holes (LMH) and full-thickness macular holes (FTMH) with or without RD (MHRD). The MTM staging system (MSS) describes all foveal and retinal changes related to MTM and their natural history interpreting them as different stages of a single progressive disorder. The management of MTM can be just observation for the earliest cases with good vision or surgery for the severe stages with vision loss. There are two possible surgical approaches: ab externo, that acts on the alteration of the scleral shape and includes posterior scleral reinforcement and macular buckle. Ab interno, that targets the alteration of the foveal profile and consists in pars plana vitrectomy with removal of all the epiretinal tractions, maneuvers on the internal limiting membrane, and the use of intravitreal tamponade and laser. As they target two different sides of the same pathology, the two techniques have to be selected on the base of the MTM stage, single or combined.

Comparison of macular buckling and vitrectomy for the treatment of macular schisis and associated macular detachment in high myopia: a randomized clinical trial

OBJECTIVE

To compare the efficacy and safety of macular buckling and vitrectomy for myopic traction maculopathy showing macular schisis (MS) and associated macular detachment (MD) but without full-thickness macular hole (FTMH).

DESIGN

Prospective, randomized, parallel, open-label study.

METHODS

Patients were randomly assigned to either buckling or vitrectomy group. Macular buckling and intravitreal C3F8 gas injection were performed in the buckling group. Small gauge vitrectomy, internal limiting membrane peeling (ILMP) and C3F8 gas tamponade were performed in the vitrectomy group. The patients were followed for 12 months.

MAIN OUTCOME MEASURES

Best-corrected visual acuity (BCVA) at 12 months.

RESULTS

A total of 85 patients were randomized, 80 eyes were included (41 receiving buckling, 39 received vitrectomy), and 78 patients completed the study. There were less eyes determined as surgical failure and required a second surgery in the buckling group than vitrectomy the group (2.4% versus 18.4%, p = 0.021). After surgery, macular buckling achieved more improvement in BCVA (+21.7 versus +4.5 Early Treatment Diabetic Retinopathy Study (ETDRS) letters, p = 0.002). FTMH development was observed in only 1 (2.4%) eye, after removing of the implant due to recurrent conjunctival erosion, in the buckling group and 10 (26.3%) eyes (seven with-, three without MD) in the vitrectomy group (p < 0.001). More eyes developed cataracts in the vitrectomy group than did in the buckling group (28.9% versus 7.5%, p = 0.014). Macular buckling-associated strabismus (esotropia), binocular diplopia and implant exposure were observed in limited cases.

CONCLUSIONS AND RELEVANCE

Macular buckling is superior to vitrectomy with ILM peeling plus gas injection for surgical treatment of MS and associated MD in high myopia.

Combined Vitrectomy With Macular Buckling In High Myopic Eyes With Macular Hole Retinal Detachment: A Pilot Study Of A Novel Snail-Tipped Exoplant

Purpose

To evaluate the efficacy of a novel snail-tipped exoplant for macular buckling combined with vitrectomy in high myopic eyes with macular hole retinal detachment.

Patient and methods

A novel exoplant was simply prepared with a 5 × 3 mm silicone sponge strengthened in the center with a malleable titanium plate. One end was bent to make a rolled tip like a snail shell to be placed under the macula. Combined vitrectomy with macular buckling using this exoplant was performed in eight consecutive cases. The long arm of the exoplant was manipulated manually to fit the curvature of the eyeball and the length was trimmed appropriately after scleral suturing of the exoplant.

Results

Retinal reattachment was achieved in all cases (100%) and macular hole closure was confirmed in 6 eyes (75%). The mean best-corrected visual acuity improved from 1.53 ± 0.73 LogMAR preoperatively to 1.14 ± 0.59 LogMAR to postoperatively (p = 0.063). The mean pre- and postoperative AL was 28.44 ± 1.86 mm and 27.60 ± 1.83 mm, respectively (p = 0.016). The mean follow-up period was 15.4 months and no buckle-related complications such as diplopia, infection or exposure of the exoplant were noticed during the period.

Conclusion

This exoplant could easily be prepared with readily available materials in the operating room and it was well tolerated with favorable anatomic results in high myopic eyes. Further studies of increased number of patients with long-term follow-up will be necessary.

Microscope-Assisted ab externo Surgery for the Treatment of Primary Rhegmatogenous Retinal Detachment - New Tech Meets Old Art

AIM

To report the outcomes of ab externo surgery using a surgical microscope, wide-angle viewing system, and chandelier endoilluminator (microscope-assisted ab externo surgery) for rhegmatogenous retinal detachment (RRD).

METHODS

This was a retrospective study. Consecutive charts of patients with RRD who underwent microscope-assisted ab externo surgery were analyzed. The following demographic parameters were analyzed: age (years), gender (male/female), and eye (right/left). Clinical parameters were axial length (AL) measured in millimeters (mm), preoperative best-corrected visual acuity (BCVA) measured in logarithm of minimum angle of resolution (logMAR), intraocular pressure (IOP), and lens status (phakic/pseudophakic). The parameters of RRD were number and type of retinal breaks, location of retinal breaks, extent of retinal detachment (RD) (number of detached quadrants), and macular detachment (MD), as well as retinal breaks not detected preoperatively. Use of cryopexy, circumferential or segmental scleral buckle, drainage of subretinal fluid, injection of air or gas, and duration of surgery were recorded. The postoperative parameters analyzed were BCVA, IOP and recurrence of RD and postoperative complications. Follow-up was established at 3 months.

RESULTS

A total of 213 eyes (97 right, 116 left) of 205 patients (114 males, 91 females) affected by primary RRD were included. Fifty-two eyes (24.4%) were affected by high myopia (AL >26.5 mm), and 160 patients (75.1%) were affected by RRD caused by a single retinal break and involving only one quadrant. The superior quadrant was the most frequently involved (49.3%). Forty-two eyes (19.7%) were affected by MD. In 13 eyes (11.3%), retinal breaks were not detected preoperatively. The duration of surgery was 75.5 ± 42 min. No significant BCVA changes were observed in the whole group, whereas a significant improvement of BCVA from the baseline (2.83 ± 0.87 logMAR) to each time point of follow-up was observed in the subgroup of patients affected by MD. Six eyes (2.8%) developed a recurrent RD, secondary to proliferative vitreoretinopathy (3 eyes) and secondary to a new retinal break (3 eyes). Two eyes developed a persistent vitreous hemorrhage, and one eye developed a macular hole after 1 week. PPV was performed for both.

CONCLUSION

Microscope-assisted ab externo surgery is effective and safe, it reduces discomfort, it allows the surgeon to work with both hands free, and provides an adequate visualization of each step being performed.

Macular buckle without vitrectomy for myopic macular schisis: a Canadian case series

OBJECTIVE

To determine the effectiveness of a macular buckle procedure without vitrectomy for the treatment of symptomatic myopic macular schisis.

DESIGN

Retrospective case series.

PARTICIPANTS AND METHODS

All patients who underwent surgery with placement of an NPB macular buckle (AJL Ophthalmic, Miñano, Álava, Spain) without vitrectomy for symptomatic myopic macular schisis were included. Visual acuity and anatomical outcomes based on optical coherence tomography (OCT) were reviewed.

RESULTS

Eight consecutive eyes from 7 patients were included. Six of the 7 patients were female and the mean age was 59 ± 6 years (range, 49-66 years). The mean follow-up duration was 11 ± 7 months (range, 3-23 months). Mean preoperative axial length was 29.54 ± 1.28 mm (range, 27.88-31.96 mm). Mean preoperative best-corrected visual acuity (BCVA) was 0.71 ± 0.29 logMAR (Snellen equivalent 20/103); mean postoperative BCVA was 0.46 ± 0.44 (Snellen equivalent 20/58; p = 0.19) and 87.5% of patients maintained or improved vision. Pre- and postoperative OCT images are included and discussed within. Preoperative ellipsoid zone status and postoperative central macular buckle indentation appear to be important in visual outcomes. Two patients required a buckle repositioning for persistent schisis. One patient developed a macular hole postoperatively that resolved with subsequent vitrectomy. There were no other complications.

CONCLUSIONS

The macular buckle is an effective and promising therapeutic option for myopic macular schisis.

Morphological analysis and quantitative evaluation of myopic maculopathy by three-dimensional magnetic resonance imaging

PurposeTo study the characteristic morphology and quantitatively evaluate the eye shape in different types of myopic maculopathy.MethodsA total of 103 eyes from 65 patients with high myopic maculopathy were examined by spectral-domain optical coherence tomography (SD-OCT) and three-dimensional magnetic resonance imaging (3D MRI). The participants were classified into two groups, namely myopic traction maculopathy (MTM) eyes and non-MTM eyes, with SD-OCT imaging. Volume renderings and morphology analysis of the 3D MRI of the eyeball were obtained. Quantitative analysis was achieved in the calculation of vitreous volume and the three-dimensional diameters of the eyeball in three cardinal axes. The eye shape distribution and the diameters of the eyeball were compared between the two groups. Eye shape distribution, vitreous volume, and eyeball diameter were compared between MTM and non-MTM eyes.ResultsThe MTM and non-MTM groups had a total of 68 and 35 eyes, respectively. A significant difference was found in the eye shape distribution (P<0.0001) between MTM and non-MTM eyes. Most of the MTM eyes had undergone a non-uniform expansion of the eyeball, whereas the non-MTM eyes had expanded uniformly. There was no significant difference (P>0.05) in either vitreous volume or other diameters between the two groups.ConclusionsNon-uniform globe expansion and staphyloma formation might play an important role in the pathogenesis of MTM.

Vitrectomy with a modified temporal inverted limiting membrane flap to reconstruct the foveolar architecture for macular hole retinal detachment in highly myopic eyes

PURPOSE

We investigated the surgical results of macular hole retinal detachment (MHRD) with a modified C-shaped temporal inverted internal limiting membrane (ILM) flap to reconstruct the foveolar architecture in highly myopic eyes.

METHODS

Eighteen highly myopic eyes with MHRD in 17 patients who underwent a vitrectomy with a modified C-shaped temporal inverted ILM flap were followed for 12 months. Anatomic outcomes were evaluated by fundus examinations and optical coherence tomography. The preoperative and postoperative best-corrected visual acuities (BCVAs) were compared as functional outcomes.

RESULTS

Women accounted for 88% of the MHRD patients. The mean age was 60.2 ± 8.2 years. The mean axial length was 29.25 ± 2.10 mm. Type 1 and type 2 MHRD was present in four eyes and 14 eyes, respectively. After a single surgery, the hole was closed in 18 eyes (100%). Retinal attachment was achieved in 95%. Persistent shallow subretinal fluid (SRF) was noted in one case, which was resolved at follow-up. The surgery significantly improved BCVAs (from 1.7 ± 0.6 to 0.72 ± 0.4 logarithm of the minimum angle of resolution units [p < 0.001]) at the last visit. In total, 94.4% of the eyes had restored foveolar architecture. Ellipsoid zone recovery within the foveola was found in 77.8% of the eyes.

CONCLUSION

A vitrectomy and modified C-shaped inverted temporal ILM flap is effective for closing MHs, reattaching the retina, restoring the foveolar architecture and significantly improving the postoperative BCVA in MHRD patients. This technique is feasible, and we propose 'presumed' Müller cell cone repair in MHRD surgery.

Effectiveness of combined macular buckle under direct vision and vitrectomy with ILM peeling in refractory macular hole retinal detachment with extreme high axial myopia: a 24-month comparative study

Purpose

To evaluate the efficacy of a combined macular buckle under direct vision and 23-gauge pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling in refractory macular hole retinal detachment (MHRD) with extreme high axial myopia.

Design

Prospective, randomised controlled study.

Participants

The study included 98 eyes of 98 patients of MHRD with extreme high axial (>30 mm) myopia.

Intervention

Patients were randomly assigned to undergo PPV with ILM peeling (group 1, n=52) or PPV with ILM peeling combined with macular buckle under direct vision (group 2, n=46).

Main outcome measures

Complete ocular examination included best-corrected visual acuity (BCVA) (LogMAR), applanation tonometry, optical biometry, slit-lamp biomicroscopy, colour fundus photography, ultrasound examination and optical coherence tomography at baseline and every follow-up visit.

Results

Initial retinal reattachment rate was significantly higher in group 2 than in group 1 at 12-month postoperatively (χ² test, p=0.020). Macular hole closure rate in group 2 was significantly higher than that in group 1 at 3, 12, 18 and 24 months postoperatively (Fisher's exact test, p<0.05). In initial retinal reattachment cases, the mean BCVA decreased significantly in group 2 than in group 1 at 3 months postoperatively (Wilcoxon matched pairs signed rank test, p=0.036), and had increased significantly in group 2 than in group 1 since 6 months postoperatively (Wilcoxon matched pairs signed rank test, p<0.05). Mean axial lengths in group 2 were significantly shorter than that of group 1 at each follow-up time point (Wilcoxon matched pairs signed rank test, p<0.05).

Conclusions

Combined macular buckle under direct vision and PPV with ILM peeling is more effective in treatment of MHRD with extreme high axial (>30 mm) myopia.

INDICATIONS AND RESULTS OF A NEW L-SHAPED MACULAR BUCKLE TO SUPPORT A POSTERIOR STAPHYLOMA IN HIGH MYOPIA

BACKGROUND

The efficacy of a macular buckle in treating myopic traction maculopathy was studied.

METHODS

Fifty eyes with myopic traction maculopathy, in the form of macular detachment with macular hole (MHMD), or without macular hole (MD) and macular foveoschisis (MF), were treated with vitrectomy combined with macular buckle or with a macular buckle without vitrectomy.

RESULTS

Combined group: The combined group comprised 10 eyes with MHMD, 6 eyes with MD, and 4 eyes with MF. The retina was attached in 100% of MD and MHMD and the MF was improved in 100% of cases. The hole was closed in 60% of MHMD. The mean initial and final Snellen best-corrected visual acuity was 20/500 and 20/100 for MHMD, 20/200 and 20/60 for MD, and 20/200 and 20/50 for MF. The mean surgical time was 80 ± 35 minutes. Fundus angiography or indocyanine green revealed no alteration of the chorioretinal blood flow. Buckle shortening was required in 6/20 (30% of cases) patients for lateral extrusion of the sponge through the conjunctiva with the first sponge model. This complication was overcome by changing the arm of the buckle. Buckle group: The buckle group comprised 5 eyes with MHMD, 11 with MD, and 14 with MF. The retina was attached in 100% of MHMD, MD, and MF. The macular hole was closed in 60%. The mean initial and final Snellen best-corrected visual acuity was 20/800 and 20/60 for MHMD, 20/125 and 20/50 for MD, and 20/200 and 20/63 for MF. The mean postoperative decrement in axial length was 1.21 mm. The mean surgical time was 35 ± 15 minutes. Fundus angiography or indocyanine green revealed no alteration of the chorioretinal blood flow. Complications included conjunctiva erosion (15%), diplopia (7.7%), and pain (3.8%). Magnetic resonance imaging showed flattening of the posterior staphyloma.

CONCLUSION

Considering the possible complications and technical difficulties of vitrectomy, we suggest that the macular buckle alone should be the first treatment of myopic traction maculopathy. Vitrectomy should be reserved only for cases of tangential tractions.

Inverted Internal Limiting Membrane Insertion for Macular Hole-Associated Retinal Detachment in High Myopia

PURPOSE

To investigate the surgical outcomes of inverted internal limiting membrane (ILM) insertion in macular hole (MH)-associated retinal detachment (RD) in high myopia.

DESIGN

Retrospective, interventional, consecutive case series.

METHODS

This study was conducted at 2 medical centers. Consecutive cases of highly myopic eyes with MH-associated RD were included. Forty eyes were divided into 2 groups: Group 1 (20 eyes) received vitrectomy, ILM peeling within the arcade area, and air-fluid exchange, and Group 2 (20 eyes) received vitrectomy, inverted ILM inserted into the macular hole, and air-fluid exchange. Optical coherence tomography was used to observe the closure of the macular hole. Corrected visual acuity (VA) was also recorded. Two-sample t test and Mann-Whitney U test were used for statistical analysis to compare differences between the 2 groups.

RESULTS

MH was closed in 35% of the eyes in Group 1 and in all eyes in Group 2 (P < .001). Significant improvement in VA in logarithm of minimal angle of resolution (logMAR) was achieved in both groups. There was no difference in the initial, final, or improvement of logMAR VA in the 2 groups.

CONCLUSION

Inverted ILM insertion into a macular hole effectively helps close the macular hole in MH-associated RD in high myopia. This may prevent the possible re-detachment from the MH. A prospective study with a larger number of cases and longer follow-up may help validate our findings.