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1. Paracentesis air or gas tamponade +/- macular laser

2. Drainage of SRF air or gas tamponade +/- macular laser

3. Volume reduction, drainage, air injection, +/- macular Laser.

4. PP Vitrectomy: Gas or silicone oil tamponade.

± ILM peeling.

± Photocoagulation at the macular hole edges.

5. Macular buckling without physical treatment

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In our cases: Up to 40 %.

Li et al; 25 – 40% recurrence rate (Ophthalmology.

2009 Jun;116(6):1182-87.e1. Epub 2009 Apr 17).

Lam et al: 37 % recurrence rate. Am J Ophthalmol.

2006 Dec;142(6):938-44. Epub 2006 Sep 1.

Cho et al: 21% recurrence. Korean J Ophthalmol. 2004

Dec;18(2):141-7.

Uemoto et al: up to 50% recurrence rate. Retina. 2004

Aug;24(4):560-6.

Ichibe et al: 30% failure and recurrence. Am J

Ophthalmol. 2003 Aug;136(2):277-84.

Kwok et al: 25% failure. Ophthalmic Surg Lasers. 2002

Mar-Apr;33(2):155-7.

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And does not need physical treatment

Our thesis: 26 cases 100% success rate.

Schepens et al: AMA Arch Ophthalmol. 1957 Dec; 58(6):797-811.

Rosengreen B: Bibl Opthalmol 1966;70:253-6, 1966.

Paufique & Bonnet: Ann Ocul (Paris). Mar;201(3):290-302, 1968 [Article in French].

Haut et al: Arch Ophtalmol Rev Gen Ophtalmol. Aug-Sep; 32(8):541-8, 1972.

Siam A-L:Brit. J. Ophthalmol. 57; 351, 1973.

Kapuschinski W.J:, 1972

Harris G.S:Ophthalmol. Vol. 12, P. 337, Karger, Basel, 1974.

Theodossiadis:Mod. Frob. Ophthalmol. Basel, Karger, 12, 322, 1974.

Theodossiadis & Theodossiadiss. Retina, Apr-May; 25(3):285-9, 2005.

Ando F: Afr Asian J Ophthalmol, 11. 48, 1983.

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Failed & recurrent cases after PP

vitrectomy including cases with silicone oil

tamponade.

Very atrophic background ; white holes.

Very high myopia with posterior

staphyloma.

INDICATION FOR MACULAR

BUCKLING

Still ret. det. after PPV & S.O tamp. plus mac. PC

Reopening of the hole with re-detachment

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A new approach has been

discovered only after finding

clear-cut and constant

anatomical landmarks , to be

able to perform exact macular

buckling

Salzmann(1912) Wolff (1954)

Whitnall (1932)

El Massry

(1963)

Just one horizontal meridian ?!!

v

v SIAM (2011)

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ON 3 mm

5 mm ONS

Intra-scleral entrance

Of TLPCA

F:fovea midway between edge of optic nerve

sheath (ONS) & scleral entrance of temporal long

posterior ciliary artery,(TLPCA)

:

P ONHM

GHM

Optic

Disc=1.5mm

P F

.

FHM (Foveal Horizontal

Meridian)

FHM

(LPCAs)

GHM

ONHM

FHM

(LPCAs)

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v

v

3 , horizontal

meridians

GHM,ONHM & FHM

Not just one !!

Fovea (pin) : 5.75 mm from nasal end of IO insertion)

& a little to the nasal side of the mid point between TLPCA & ONS

Intrascleral course of TLPCA

F

TLPCA

ONS

5.75 mm

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ONS

ON

OD

IO

A relatively “simple”, “safe” and “easy”

technique is eagerly welcome

We have developed such a technique

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• The macular area is approached between

the superior and lateral rectus muscles.

• Hook the 4 recti with silk sutures.

• The superior oblique muscle is severed which

allows hooking and pulling on the inferior oblique

(IO) muscle belly & to hold its insertion

• This exposes the intra-scleral course of the TLPCA

and the space between the point of intra-scleral

entry of this vessel and the optic nerve sheath

(ONS)

HOW TO EXPOSE THE POSTERIOR POLE

DURING SUGERY

ONS

Press on the softened eye beyond the nasal end of IO insertion to take sutures

on either side of TLPCA

TLPCA

IO

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Sever the SO insertion.

Hook the IO inbetween SR & LR.

Soften the eye (paracentesis).

Remove the speculum.

Retract the lateral canthus with a retractor.

Flatten the sclera by gentle pressure with a non toothed forceps.

Take the suture bites at equal distances from the TLPSA.

Use fine round needles.

No need to pull much on the sutures.

Orbital Fat

IOM

NO SPECULUM

RETRACTOR

ةة 5ز1 ز

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Retinal re-attachment: 100 %.

Visual acuity:

One case CF.

Others 3/60 – 6/36.

Intraoperative difficulties:

Orbital fat prolapse: 6 / 26 (23%).

Tearing of sutures: 1 / 26 (4%).

Inadvertent perforation: 1 case (4%).

Subretinal hemorrhage: 1 case (4%).

Malposition of buckle: 1 case (4%).

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?

Macular hole central RD Macular buckle, dry macula, no

physical treatment

?

Dry macula following macular

buckling, no physical treatment

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The macular hole has closed ; disappeared !

?

Macular buckling offers the highest

success rate and best visual results

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The macular hole has closed ; disappeared !

?

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At least to deal with failed and recurrent cases

after PPV with various types of internal tamponade

and to avoid physical injury to the fovea

CONCLUSION