http://www.tvrs.gr/

1. IRCCS
Fondazione
G.B. Bietti
IRCCS
Fondazione
G.B. Bietti
per lo Studio e la Ricerca in
Oftalmologia
Rome - Italy
per lo Studio e la Ricerca in
Oftalmologia
Rome - Italy
G. Ripandelli
4° Thessaloniki Vitreo-Retinal
Summer School
June 16-21,2014
Posterior Buckling for Macular Hole
Retinal Detachment in High Myopic Eyes

2. MODERATE
MYOPIA
OCT scan of the macular region: differences of the vitreoretinal
relationship between moderate vs high myopiaHIGHMYOPIA

3. 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.

4. Surgical management
Buckling 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

5. 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

6. 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’.….

8. 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.

10. SURGICAL TECHNIQUE
After limbal 360 ° peritomy, superior, inferior and lateral recti (LR) muscles are
isolated
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 improve
exposition of the posterior sclera.
A 5-0 mersilene suture is threaded through the winglets of the terminal plate,
previous to its positioning.

11. 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

12. 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.

13. RD with MH
Posterior
episcleral buckle

15. 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 retina
2. Moderate chorioretinal dystrophy and
moderate posterior staphyloma
SURGERY

16. 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”)

17. Conclusions
PEBP for RD due to MH repair:
• technically challenging
• potentially dangerous (thin sclera, large
posterior staphyloma)

18. 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.

21. The author has no potential
conflict of interest
in this presentation