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

Abstract

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.

Keywords: Macula; Retina.

Figure 1

Surgical procedure of macular buckle and postoperative outcome in a same case. (A) The buckling element was made of a piece of silicone tire (6×15 mm) sewn with an encircling silicone band (3 mm width). (B) Buckle was passed underneath the inferior oblique muscle. (C) Congested and tortuous vortex veins during surgical process. (D) After pars plana vitrectomy (PPV) and internal limiting membrane (ILM) peeling around macular hole (thin arrow), the buckle indentation initially located at equator (thick arrow). (E) Episcleral silicone (thick arrow) tire was moved to the posterior pole of the eyeball gradually under direct vision. (F) Location of buckle was adjusted under direct vision until macular indentation (thick arrow) was under macular hole (thin arrow). (G) Preoperative fundus photograph with macular hole retinal detachment (MHRD) (thin arrow). (H) 24 months postoperative fundus photograph with retina reattachment. I. Preoperative (upper) and 24 months postoperative (down) optical coherence tomography examination with unclosed macular hole and flattened staphyloma.

Figure 2

The schematic for surgical procedure. The encircling band was fixed and sutured on the sclera of nasal quadrant (thick arrows). The silicone band and buckle (dashed line) were located on the nasal side of inferior oblique muscle termination (thin arrow). The white arrow points to the macular hole.

Figure 3

Anatomical outcome comparison between two groups. The difference between the two groups were significant in the initial retinal reattachment (A) at 12 months postoperatively (*p<0.05, Fisher's exact test), and in macular hole closure rate (B) at 3, 12, 18 and 24 months postoperatively (*p<0.05, χ² test).

Figure 4

Preoperative and postoperative evaluation of best-corrected visual acuity (BCVA) (LogMAR) (A), axial length (B) and intraocular pressure (IOP) (C) (Wilcoxon matched pairs signed rank test). The different change between the two groups were significant in BCVA (LogMAR) of initial retinal reattached cases at 1, 6, 9, 12, 18, 24 months postoperatively (p<0.05), in axial length of all eyes at each follow-up point (p<0.05) and in IOP of all eyes at 1 month postoperatively (p=0.041).