IRCCSFondazione G.B. Bietti

IRCCSFondazione G.B. Bietti

per lo Studio e la Ricerca in OftalmologiaRome - Italy

per lo Studio e la Ricerca in OftalmologiaRome - Italy

G. Ripandelli

4° Thessaloniki Vitreo-Retinal Summer School

June 16-21,2014

Posterior Buckling for Macular Hole

Retinal Detachment in High Myopic Eyes

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OCT scan of the macular region: differences of the vitreoretinalrelationship between moderate vs high myopia

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PATHOGENESIS ?

A shallow RD with or without MH, in most cases limited at the area of the staphyloma, appears mainly caused by the persistent adherence of the rigid epiretinal tissue to the inner retinal surface and by the retinal and choroidal defects of the area of the staphyloma.

Surgical managementBuckling techniqueTransvitreal approach• Special macular explant - 1980 Ando- 1982 Theodossiadis- 1990 Kuriyama- 2000 Sasoh- 2000 Stirpe-Ripandelli- 2005 Morin-Devin- 2006 Mateo- 2013 Parolini

• Pneumatic retinopexy - 1984-86 Miyake - 1987 Blankenship- 1990 Kuriyama

• PR + PPV - 1982 Gonvers, Machemer- 1984 Seike - 1990 Kuriyama

• Removal of ERM- 1990 Stirpe - 1997 Seike- 1998 Oshima

REASONS FOR UNSUCCESSFUL PPV SURGERY

• Incomplete removal of a thin and adherent epiretinal tissue

• RPE atrophy• Long-standing retinoschisis

• Incomplete removal of a thin and adherent epiretinal tissue

• RPE atrophy• Long-standing retinoschisis

POSTERIOR BUCKLING PROCEDURE

• Radial buckles, sylastic sponges fixed along the meridian 12-6 o’clock, “Ando” metal-silicon probe, rubber silicon segments articulated in catapult-shape with an elastic silicon band fixed at 12-6 o’clock’.….

Silicone rubber radial element, consisting of a “handle”designed for meridian positioning and a “terminal plate”intended to infold the macula.The handle is 2 x 2 x 10 mm with quadrangular section, the terminal plate is either quadrangular (4 x 4 mm) or circular (5 mm diameter).Two lateral “winglets” are placed at the opposite sides of the macular plate, to allow suture biting.

SURGICAL TECHNIQUE

After limbal 360 ° peritomy, superior, inferior and lateral recti (LR) muscles areisolated with 1-0 black silk bridle sutures. The LR muscle is disinserted and running double-armed 6-0 or 7-0 absorbable suture is preplaced for successive reinsertion. A 5-0 mersilene traction suture is placed at the insertion of the LR muscle to improveexposition of the posterior sclera.

A 5-0 mersilene suture is threaded through the winglets of the terminal plate, previous to its positioning.

The buckle is inserted in the exposed infero-temporal quadrant, just inferior to the LR muscle and superior to the inferior oblique muscle, like a regular radial exoplant.

The terminal plate is slide posterior to infold the most prominent part of the staphyloma under indirect ophthalmoscope visualization. Once positioning is accurate, the radial element is sutured to the sclera with a mattress 5-0 mersilene suture, just posterior to the equator. The buckle can be withdrawn or slide further posterior along the same meridian.

SURGICAL TECHNIQUE

To tension the macular element and indent the macula, the needles of the 5-0 mersilene suture of the terminal plate are passed underneath the superior and inferior rectus and bite the sclera anterior to the equator just nasal to the superior or the inferior rectus muscle.Macular buckling height and minimal lateral adjustment can at this point be regulated by tying the 2 5-0 mersilene sutures. Once macular buckling effect is judged adequate, the sutures are tied or bows can be left in place to allow further adjustment under local anesthesia in the immediate postoperative period, similarly to the adjustment of muscle sutures in strabismus surgery.

RD with MH

Posteriorepiscleral buckle

1. Deep posterior staphyloma and severe chorioretinal dysfunction

2. Epiretinal membrane strongly adherent to the inner retina

Indications for Posterior Buckle Procedure

Indications for Vitrectomy

1. Epiretinal membrane cleavable from the inner retina2. Moderate chorioretinal dystrophy and moderate posterior staphyloma

SURGERY

Conclusions

PEBP as first surgical option:

• extreme degrees of myopia (over - 19 D) • pronounced posterior staphyloma• presence of a PVS • OCT scans: disruption of neuroretinal layers(retinoschisis, “stretch schisis”)

Conclusions

PEBP for RD due to MH repair:

• technically challenging• potentially dangerous (thin sclera, largeposterior staphyloma)

CONCLUSIONS:

PPV is the primary procedure for most staphyloma-associated conditions. However, we believe that there is a role for macular buckles, mostly as a “salvage” procedure:when the staphylomatous contour prevents effective foveal tamponade contact, when RPE makes long-term reattachment more difficult, or “stretch schisis” stiffens the macula, preventing complete attachment despite vitreous traction relief.

The author has no potential conflict of interest

in this presentation