Current concepts of macular buckle in myopic traction maculopathy

Abstract

Since its introduction by Charles L. Schepens, macular buckle (MB) surgery has evolved over the past 60 years. Optical coherence tomography (OCT) has given a paradigm shift to the understanding of myopic macula, thereby helping in objective evaluation of the various manifestation of traction maculopathy. Staphyloma evaluation by ultrasound, wide-field fundus photography, and MRI scans along with OCT has led to the resurgence of MB surgery in the treatment of myopic traction maculopathy (MTM). Various surgical techniques with different buckle materials are being performed with encouraging anatomical and functional success rates. This article reviews the literature to explain the current concept of MB surgery based on its evolution, different kinds of buckle materials, rationale for planning MB surgery, and different surgical techniques for the management of MTM.

Keywords: Foveal schisis; macular buckle; macular retinal detachment; myopic macular hole; myopic traction maculopathy; posterior staphyloma; spectral-domain optical coherence tomography; vitrectomy.

Figure 1

Historical depiction of macular buckling

Figure 2

SS-OCT scan showing the deep posterior staphyloma having macular hole with macular detachment and shortened schitic retina of recent onset, underwent vitrectomy + MB. Postoperative scan showing macular indentation by the buckle with closure of the hole and resorption of SRF

Figure 3

Enumeration of various types of MB elements and techniques

Figure 4

Surgical steps of the placement of Morin–Devin T-shaped macular buckle. (a) Threading of Morin band into the Devin wedge. (b) Passing the band under the lateral rectus. (c) Passing one end of band under inferior rectus muscle. (d) Tagging the superior rectus and oblique muscle together and passing the other of band underneath it. (e) The flatter end of wedge is adjusted under lateral rectus with wedge toward the macula. (f) Insertion of 25-G Chandelier light. (g) Adjusting the macular indention under direct visualization. (h) Finalizing the suture of plate end under lateral rectus on either side. (i) The nasal end of bands is marked on sclera after adjusting the indentation and sutured, and the free edges trimmed. (j) Conjunctiva is liberally mobilized. (k) Suturing of conjunctiva and tenon in two layers carefully. In combined cases with vitrectomy, the Morin–Devin wedge is passed in similar manner followed by (l) 25-G sclerotomies made 3.5 mm from limbus. (m) Vitrectomy is performed with posterior vitreous detachment followed by fluid gas exchange. (n) ILM peeling using forceps, followed by adjustment of buckle under air. (o) Finalizing the sutures of MB. (p) Silicone oil infusion and buckle indent appreciated at posterior pole

Figure 5

A 48-year-old man, bilateral high myopia (−12 D). Color Fundus photo: (a) myopic fundus with patchy areas of chorioretinal atrophy and scarring and (b) SS-OCT demonstrating retinoschisis with foveal detachment and juxtafoveal scarred CNVM. Patient underwent macular buckle alone for recent worsening of symptoms. Postoperative 6 weeks fundus photo: (c) myopic fundus with buckle indent at macular area and (d) SS-OCT demonstrating the resolution of schisis, foveal reattachment, good indent, and stabilization of vision