Macular Buckling Research Articles

Combined Surgical Approach for Repair of Refractory Macular Hole in Myopic Traction Maculopathy

Purpose: To present a combined surgical approach for repair of a persistent full-thickness macular hole (MH) in patients with myopic traction maculopathy. Methods: Two cases were evaluated. Results: Combining a macular buckle and pars plana vitrectomy with a controlled subretinal injection of a balanced salt solution resulted in MH closure and vision improvement in both cases. Case 1 also had significant recovery of macular sensitivity on microperimetry evaluation. Conclusions: Retinal redetachment was avoided by using the buckle indentation to provide external support of the posterior pole, resulting in successful closure of the MH and improvement in functional outcomes.

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

BackgroundUncorrected 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.MethodsWe 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.ResultsAll 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.ConclusionsMB 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.

VISION AND METAMORPHOPSIA OUTCOMES OF MACULAR BUCKLING FOR FOVEOSCHISIS-ASSOCIATED MACULAR DETACHMENT IN HIGHLY MYOPIC EYES.

To assess the functional outcomes in visual acuity, metamorphopsia, and vision-related quality of life (VR-QOL) and to evaluate prognostic factors after macular buckling (MB) surgery in eyes with high myopia and foveoschisis (FS)-associated macular detachment (MD). Thirty-nine eyes of 39 patients with FS-associated MD who underwent MB surgery were enrolled. Measured outcomes comprised best-corrected visual acuity (BCVA), metamorphopsia, VR-QOL, axial length (AL), macular reattachment, and resolution of foveoschisis. In addition, factors affecting final BCVA and metamorphopsia were analyzed. At 12 months postoperatively, 36 eyes (92.31%) achieved macular reattachment, 37 eyes (94.87%) achieved complete resolution of foveoschisis, and metamorphopsia diminished in 31 eyes (79.49%). LogMAR BCVAs at baseline and months 1, 3, 6, and 12 postoperatively were 0.62 ± 0.35 (20/83), 0.65 ± 0.3 (20/89), 0.59 ± 0.31 (20/77), 0.54 ± 0.31 (20/69), and 0.46 ± 0.27 (20/57) (P < 0.001), respectively. Metamorphopsia scores by M-CHARTS were 1.36° ± 0.51°, 1.04° ± 0.51°, 0.74° ± 0.47°, 0.59° ± 0.47°, and 0.13° ± 0.29° (P < 0.001). All Visual Function Questionnaire-25 subscales demonstrated significant improvement postoperatively, with the exception of "general health" (P = 0.08) and "driving" (P = 0.111). Preoperative BCVA was an independent risk factor for postoperative BCVA at month 12 (r = 0.638, P < 0.001), and the preoperative M-score was an independent risk factor for postoperative M-score at month 12 (r = 0.187, P = 0.045). MB surgery significantly improved BCVA, metamorphopsia, and VR-QOL in patients with FS-associated MD. Preoperative BCVA and metamorphopsia score were prognostic factors for postoperative BCVA and metamorphopsia score at month 12.

Advancements in Myopic Macular Foveoschisis Research.

Presently, the global prevalence of myopia and high myopia reaches approximately 1.95 billion and 277 million individuals, respectively. Projections suggest that by 2050, the number of people with myopia may rise to 4.758 billion and those with high myopia to 938 million. In highly myopic eyes, the occurrence of MF is reported to be as high as 8-33%. This review comprehensively addresses the classification, pathogenesis, natural progression, concomitant pathologies, and therapeutic strategies for macular foveoschisis in highly myopic patients. In recent years, macular foveoschisis has emerged as a prevalent complication in individuals with high myopia, primarily resulting from the combination of inward traction by vitreoretinal adhesions and outward traction exerted by posterior scleral staphyloma on the retina. While some maintain partial visual stability over an extended period, others may progress to macular holes or even retinal detachment. For highly myopic patients with macular foveoschisis, the mainstay procedures are vitrectomy, macular buckle, and posterior scleral reinforcement. However, there is controversy about whether to perform inner limiting membrane peeling and gas filling.

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.

Outcomes of different surgical procedures for optic disc pit: a meta-analysis

Objective To assess the surgical outcomes of pars plana vitrectomy (PPV) in conjunction with various adjuvant procedures for optic disc pit maculopathy (ODPM). Methods We conducted a literature search to identify clinical studies and case series of surgically treated OPM patients. (1) greater than two patients, (2) surgical treatment and (3) reporting of pre and postoperative visual acuity data were inclusion criteria. We excluded review articles and studies unavailable in the English language. One-way analysis of variance, Pearson’s chi-squared test and straightforward linear regression were used to analyze the results. Results A total of 838 studies were initially identified as potentially relevant studies. After removing duplicates and screening titles and abstracts, the eligibility of 86 full-text articles was evaluated. There were 50 studies included in the meta-analysis. We identified the following commonly reported techniques: juxtapapillary laser alone, PPV alone or with juxtapapillary laser (PPV/JPL), internal limiting membrane peeling (PPV/ILMP), both ILMP and JPL (PPV/ILMP/JPL), inner retinal fenestration (PPV/IRF), autologous platelet concentrate (PPV/APC), macular buckling alone or with PPV, PPV with ocriplasmin (PPV/OCR) and PPV with autologous scleral flap. All groups showed an improvement in best-corrected visual acuity compared with baseline, with no significant differences between groups. The average OPM resolution rate for all groups was 70% (range: 56–100%), and the average resolution duration was 9.1 months. Central macular thickness was diminished in the PPV, PPV/JPL, and PPV/ILMP groups, but there were no significant differences between groups. There was no effect on the outcomes. Analyses of linear regression revealed significant correlations between preoperative best-corrected visual acuity and the aforementioned outcome measures. The rate of complete anatomic success and visual improvement following PPV is ∼85%. Anatomic and visual success rates for PPV alone are 89% and 100%, respectively, according to subgroup analysis. Gas tamponade, laser and ILMP during vitrectomy are less promising, whereas PPV with ILM flap stuffing may yield better results than cases without it. Conclusion We did not find a significant difference in functional outcomes between the various surgical procedures used to treat OPM. Based on the available evidence, PPV is effective for ODPM, while gas tamponade, laser and ILMP should be used with caution. This study is limited by its reliance on retrospective studies and publication bias towards positive outcomes.

Introducing a customized low-cost macular buckle.

To demonstrate a novel surgical technique that is a low-cost alternative to commercial implants for macular buckling in high myopia. A silicon encircling band serves as the anchor. A second silicon circling band is employed, with a 10mm silicon strip to widen the posterior scleral indentation. This band is inserted posteriorly the lateral and inferior rectus muscles and pushed behind the globe, orienting it in a superior-temporal to inferio-nasal position with the silicone strip directly under the macula. For better visualization, the placement of the macular buckle is done under the microscope. The placement of the macular buckle led to reattachment of the central retina in treated patients during long-term follow-up. This technique eliminates the need for detaching a rectus muscle. Visual acuity remained stable throughout the follow-up period. This customized macular buckle technique can improve the anatomical outcome in patients with central retinal detachment due to high myopia.

Emphasizing the timing and procedure selection for vitrectomy in pathological myopic traction maculopathy

Myopic maculopathy is the primary cause of irreversible visual impairment in patients with pathologic myopia, and myopic traction maculopathy often requires vitrectomy for treatment. Myopic traction maculopathy encompasses epiretinal membrane, foveoschisis, macular hole, and macular hole-related retinal detachment. It is recommended to perform vitrectomy combined with inner limiting membrane peeling for Type II epiretinal membrane, foveal-sparing inner limiting membrane peeling for foveoschisis, inverted inner limiting membrane flap technique for macular hole, and vitrectomy combined with macular buckle for refractory macular hole-related retinal detachment. Myopic traction maculopathy is a chronically progressive condition, and surgeons need to accurately determine the timing of surgery and choose appropriate procedures to maximize the benefits for patients.

EVALUATION OF MACULAR ATROPHY IN PATIENTS TREATED WITH MACULAR BUCKLE FOR MYOPIC TRACTION MACULOPATHY: Mid- and Long-Term Follow-Up.

To evaluate the incidence, rate, and pattern of progression of myopic maculopathy in eyes operated with macular buckle (MB) for myopic traction maculopathy versus a control group without surgery to find out whether the progression varies due to the MB's indentation and to evaluate possible MB-related pigmentary changes or atrophy. Eyes operated with MB with two good quality fundus images: one preoperative or early postoperative image and a second image at least 12 months apart; the control group comprised the contralateral eyes. Demographics, axial length, follow-up, stage of myopic traction maculopathy, and myopic maculopathy were reported. Progression results of groups and subgroups (mid- and long-term follow-up) were reported and compared. Overall, 116 eyes of 66 patients were included. Progression was found in 29 eyes (41.4%) and 23 eyes (50%) in the MB group and control group, respectively. The progression rate was 73 per 1,000 eye-years and 88.9 per 1,000 eye-years in the MB group and the control group, respectively. Axial length was found to predict progression (odds ratio [OR], 2.59; P = 0.02). Progression of myopic maculopathy was similar in both groups and was mildly greater in the control group. No MB-related pigmentary changes or atrophy was detected.

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

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). 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"). 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. 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.

Lamellar macular hole in highly myopic eyes and insights into its development, evolution, and treatment: a mini-review.

Lamellar macular holes (LMHs) are a manifestation of myopic tractional maculopathy (MTM). Owing to the complex and multidirectional traction force in the elongated eyeball, the clinical features, development, evolution, and treatment algorithms of LMH in highly myopic eyes may differ from those of idiopathic LMH or MTM in general. This review aimed to specifically explore the LMHs in highly myopic eyes. Several developmental processes of LMH and their association with macular retinoschisis have been demonstrated, with the tractional component identified in all processes. Epiretinal proliferation was more prevalent and more extensive in LMHs in highly myopic eyes than in idiopathic LMHs. LMHs in highly myopic eyes may remain stable or progress to foveal detachment and full-thickness macular hole with or without retinal detachment. The predictive factors associated with disease progression were summarized to facilitate monitoring and guide surgical intervention. The treatment of LMHs in highly myopic eyes was based on an algorithm for treating myopic tractional maculopathy, including gas tamponade, pars plana vitrectomy, macular buckling, and a combination of vitrectomy and macular buckling. New internal limiting membrane (ILM) manipulation techniques such as fovea-sparing ILM peeling or fovea-sparing ILM peeling combined with ILM flap insertion could reduce the risk of developing iatrogenic full-thickness macular holes postoperatively. Further research should focus on the treatment of LMH in highly myopic eyes.

Visualized analysis of research on myopic traction maculopathy based on CiteSpace.

To analyze the global scientific output concerning myopic traction maculopathy (MTM) and to summarize the research frontiers and hot topics of MTM related researches. Data were collected for bibliometric and visualization analyses from Web of Science (WOS) Core Collection. Exported records were analyzed for titles, publication years, research institutions, journal names, authors, keywords, and abstracts using CiteSpace software version 6.1. A total of 839 related studies were analyzed, the publication volume increased annually, with Asia the most active region of MTM research. Optical coherence tomography angiography, optical coherence tomography, macular hole, high myopia, macular buckling were identified as the focus of the current research. Progression, association, classification and shape were identified as the major research frontiers. MTM is a major cause of visual loss in pathological myopic eyes. During the preceding 17y, the number of annual publications in MTM research increased gradually. Studies on the progression nature of MTM, genome-wide association study and proper classification of MTM might still be the frontiers of MTM researches.

Macular Buckling Surgery Using a Novel L-shaped Buckle for Patients with Myopic Tractional Maculopathy

Purpose: To describe the clinical characteristics and surgical outcomes of patients with myopic tractional maculopathy (MTM) who underwent macular buckling (MB) surgery using a novel L-shaped buckle.Methods: A titanium stent, a style 507 sponge, and a silicone sleeve were used to create an L-shaped macular buckle. The titanium stent was bent through 90° over the last third. The sponge was cut to about 1 cm in length and placed on the extremity. The remaining part of the stent was then covered with a 2-cm-long silicone sleeve; the total buckle length was 3 cm. The buckle was implanted supero-temporally to allow access to the macular region. Intraoperative optical coherence tomography (Zeiss Rescan 700, Carl Zeiss, Jena, Germany) was performed to ensure that the buckle was appropriately positioned.Results: Three patients with MTM underwent MB surgery under general anesthesia. In all patients, the foveae lay at the greatest distances possible from the posterior staphyloma. Given the location of the posterior staphyloma and the posterior scleral expansion, anteroposterior traction was evident in every patient. After surgery, although the extent varied, all patients exhibited reduced anteroposterior traction, evidenced by decreased retinoschisis, staphyloma flattening, and smaller macular holes. In one case, vitrectomy was added to release epiretinal membrane-induced tangential traction. No patient reported any significant ocular complication after surgery.Conclusions: MB using an L-shaped buckle, safely and efficiently relieves anteroposterior traction and improves the macular anatomy in patients with MTM.

MACULAR SLING: A CUSTOMIZABLE METHOD FOR MACULAR BUCKLING USING AVAILABLE ELEMENTS.

Macular buckling surgery is used to treat certain cases of myopic traction maculopathy but is rarely performed in the United States. One of the main factors limiting its use is the lack of commercially available buckling elements. Here, we describe a novel technique for creating an effective macular buckle using readily obtainable buckling materials. By using a traditional circumferential 41 band as the anchoring point around the globe, a 240 band can then be attached and oriented posteriorly along the superonasal-inferotemporal axis. This posterior 240 band is then used to guide a grooved sponge (509G) under the macula to create a customizable and titratable tamponade effect along the posterior pole. This approach was used to provide external support in the case of a recurrent, complex tractional retinal detachment which had failed multiple prior vitrectomy-based repairs. Placement of the macular sling resolved the patient's recurrent retinal detachment with return of the visual acuity to her preoperative baseline. There have been no adverse effects related to the surgery aside from a large hyperopic shift due to the buckle effect on the macula. We believe the technical and material complexity of this technique is comparable with that of more common scleral buckling techniques. This macular sling technique can be used to create an effective posterior buckle without requiring specialized materials.

Vitrectomy for Macular Hole with Macular Foveoschisis in Myopic Tractional Maculopathy PPV for MH-MFS

Background: Macular Hole with Macular Foveoschisis (MH-MFS) represents one of the end stages of Myopic Traction Maculopathy (MTM). This study demonstrates the effectiveness of Pars Plana Vitrectomy (PPV) with appropriate Internal Limiting Membrane (ILM) peeling and use of an ILM flap without the conventional use of macular buckle for resolving this condition. Methods: Twelve highly myopic eyes with MH-MFS underwent PPV in a single institution. Careful fovea sparing Inner Limiting Membrane (ILM) peeling with inverted flap under repeated re-staining with brilliant blue was performed. Best Corrected Visual Acuity (BCVA) and rate of Macular Hole (MH) closure, as measured by Optic Coherence Tomography. Results: Primary MH closure was obtained in 90.9% of the cases. Best Corrected Visual Acuity (BCVA) improved in 9 patients (75%) from a baseline BCVA of 0.59 ± 0.26 log MAR (20/77) to a post-operatory BCVA of 0.35 ± 0.25 log MAR (20/44) with statistical significance (p=0.004). Foveoschisis resolution occurred as follows: 6 cases within the first month, and 9 cases by the first year. Partial resolution was achieved in 2 cases, while one failed to resolve during follow-up. Conclusions: PPV with ILM peeling and inverted flap is a safe and effective method for managing MH-MFS. Careful identification of ILM and a thorough understanding of the vitreomacular interface abnormalities is key to surgical success.

Macular buckling alone versus combined inverted ILM flap on macular hole-associated macular detachment in patients with high myopia.

To compare the efficacy of macular buckling (MB) alone against a combined internal limiting membrane (ILM) inversion flap for full-thickness macular hole (FTMH)-associated macular detachment (MD) in patients with high myopia. This was a prospective interventional case series of patients with high myopia surgically treated with MB alone or combined with an inverted ILM flap for FTMH- associated MD. Best-corrected visual acuity (BCVA) at the 24-month postoperative follow-up, rate of initial retinal reattachment and macular hole closure were measured. A total of 62 eyes from 62 participants (33 in the MB group, 29 in the combination group) were studied. Postoperative BCVA improved significantly in both the combination group (P < 0.001) and the MB group (P = 0.027). The postoperative BCVA at 12 months (P = 0.021) and 24 months (P = 0.041) was significantly better in the combination group than in the MB group. The postoperative BCVA was not significantly different between the eyes with closed and unclosed MH at each follow-up time point (P > 0.05). In the combination group, we observed earlier retinal reattachment and closure of the MH as well as a higher rate of MH closure (82.8% vs. 66.7%) than in the MB group, although this difference was insignificant (P = 0.248). MB combined with the ILM flap inversion technique achieved better postoperative BCVA and a higher success rate of MH closure than MB alone. We believe that combination surgery should be preferentially recommended.

MACULAR BUCKLING COMBINED WITH VITRECTOMY AND INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE FOR MACULAR HOLES WITH MACULAR RETINOSCHISIS WITHOUT RETINAL DETACHMENT IN HIGH MYOPIA.

To investigate the outcomes of macular buckling combined with vitrectomy and inverted internal limiting membrane flap technique for highly myopic full-thickness macular hole (FTMH) with macular retinoschisis. Twenty-six eyes of 26 consecutive patients were retrospectively included. Twelve eyes underwent macular buckling alone (buckling group). Fourteen eyes underwent macular buckling and vitrectomy with an inverted internal limiting membrane flap technique (combination group). Patients were followed for at least 9 months. Rates of FTMH closure and macular retinoschisis resolution, best-corrected visual acuity gained at the final visit were evaluated. The mean follow-up time was 13.00 ± 3.16 months. FTMH closed in six eyes (50%) of the buckling group and 13 eyes (92.86%) of the combination group ( P = 0.026) at the final visit. The macular retinoschisis resolution rate was close between two groups (100% vs. 92.86%; P = 1.000). Both groups achieved significant improvement in best-corrected visual acuity (10.42 ± 17.25 and 16.36 ± 10.39 Early Treatment Diabetic Retinopathy Study letters; P = 0.014 and P < 0.001). The combination group achieved slightly more best-corrected visual acuity improvement, but the difference fell short of significance ( P =0.312). Combination of macular buckling and vitrectomy with the inverted internal limiting membrane flap technique could achieve a high FTMH closure rate and significant best-corrected visual acuity improvement in FTMH with macular retinoschisis.

Preservation of choriocapillaris perfusion on optical coherence tomography angiography in an eye treated with macular buckle

Preservation of choriocapillaris perfusion on optical coherence tomography angiography in an eye treated with macular buckle

Factors Affecting Visual Prognosis of Myopic Foveoschisis after Macular Buckling.

Purpose To analyze the visual prognosis of macular buckling in patients with high myopia foveoschisis (FS) and to identify factors that predict the final visual outcome. Methods We retrospectively included 155 eyes of 155 patients who underwent foveoschisis-related macular buckling. Best-corrected visual acuity (BCVA) and coexisting macular pathologies were assessed as a measure of surgical outcome, and multivariate linear regression was performed to identify factors affecting final visual prognosis. Results The mean preoperative BCVA was 1.19 ± 0.55 logMAR (20/308), while the mean postoperative BCVA was 0.82 ± 0.51 logMAR (20/133) (P < 0.001). Anatomical success was achieved in 151/155 eyes (97.42%) after the first surgery and in 155/155 eyes (100%) at the 2-year follow-up visit. Both preoperative and postoperative BCVA were better in eyes without macular hole (MH) than in eyes with MH. In patients with MH, the postoperative BCVA was significantly better than that before surgery when the MH was closed. However, the difference was not significant in patients with unclosed MH. Univariate analysis identified that baseline BCVA, age, MH, atrophic myopic maculopathy category, and postoperative intraretinal cyst were significantly related to BCVA at the postoperative 2-year follow-up. Multivariate analysis revealed that preoperative BCVA and age were significant factors. Conclusion Better preoperative BCVA and younger age are predictors of better prognosis. Prompt surgery is advised for patients with myopic foveoschisis to improve their visual prognosis.

Custom-made Macular Buckle for Myopic Traction Maculopathy

Custom-made Macular Buckle for Myopic Traction Maculopathy