You are on page 1of 8

Surgical Technique Edited by George A.

Williams
Degenerative Myopia: Myopic Macular Schisis and
the Posterior Pole Buckle
S
afe and effective treatments are needed for degen-
erative myopia and its complications until a nal
genetic cure is found. The loss of vision is most com-
monly the result of myopic macular degeneration, the
risks of which are functions of the eyes axial lengths
and the patients ages.
1
Myopic macular degeneration is the result of an
inherited scleral abnormality.
2
In an affected individual,
the precursor of degenerative myopia appears as acceler-
ated ocular growth during childhood. Subsequently, this
is followed by episodes of intermittent scleral stretching
that may continue throughout adult life. The inuence of
environmental factors is being increasingly recognized as
relevant to the development of the phenotype, although
the mechanisms involved are unknown at this time.
Degenerative myopia occurs in eyes with axial
myopia in excess of 6.00 diopters and axial lengths
.26 mm. The prevalence of this condition in the pop-
ulation of the United States is reported to be approx-
imately 2%; but the gure can be at least 10% in some
regional groups in China, Singapore, and Japan. This
high incidence in some Asian countries reects the
high prevalence of the genotype in their populations
as well as some unknown environmental factors.
13
To control a scleral disorder, it is reasonable to
consider approaches that access that tissue directly. In
a recent study of a surgical treatment for the control of
progressive myopia, posterior pole buckles were shown
to be able to constrain axial extension in adult eyes. In
that reported series of 59 patients, one treated eye had
preexisting macular schisis and tractional detachment,
both of which were corrected by the buckling procedure.
4
After this single example with a favorable outcome, other
eyes with schisis and tractional detachments have been
treated by a modied version of the same technique. This
work was motivated by the fact that scleral buckling
would be an attractive alternative to the current treatment
by vitrectomy and internal limiting membrane(ILM) peel-
ing described rst by Tano and Kishi in 1999.
5
This report covers the outcomes of posterior pole
buckling for the treatment of myopic schisis and
macular detachments in 10 adult eyes. It is part of an
on-going series.
Method
Of the 10 adult eyes with progressive high axial
myopia, 8 had macular schisis, 2 eyes had both
macular schisis and tractional retinal detachments,
and 2 eyes had schisis plus a lamellar macular hole.
The preoperative studies involved a complete eye
examination, visual acuity measurement, photographic
documentation, macular cross-sectional imagery by
optical coherence tomography (OCT) (Zeiss-Hum-
phrey, Dublin, CA) and axial length measurement by
IOL-master (Zeiss-Humphrey). The same observations
and measurements were made periodically during the
postoperative follow-up examinations.
Figure 1 is a schematic representation of a tensioned
buckle in position over the posterior pole of a right eye.
The tendency for the buckle to slip temporally is coun-
tered by careful selection of the anchor points to the
recipient globe. The central portion of the buckle rests
nasal to the inferior oblique muscle insertion and tem-
poral to the optic nerve and the short posterior ciliary
arteries. The placement technique was designed to avoid
the eye trauma inevitably associated with the exposure
of the posterior pole for scleral suture placement.
The buckling elements were prepared from the
sclera of donor eyes supplied by a regional eye bank.
The material was fashioned into a strip at least 65 mm
long and 10 mm wide in its middle third. The width of
the strip was tapered to 5 to 6 mm at each end. The
outer surface of the strip was marked with an ink stripe
from a skin pencil, to enable the surgeon to be able to
detect any twisting that might be inadvertently induced
during the placement procedure.
From the *Retinal Diagnostic Center, Campbell, California; and
Department of Ophthalmology, Good Samaritan Hospital, San Jose,
California.
Part of this material was presented at the Squaw Valley Retinal
Symposium, February 2011 and the Frankfurt Retina Meeting,
Frankfurt, Germany, March 2012.
The author has no nancial or conicts of interests to disclose.
Supplemental digital content is available for this article. Direct
URL citations appear in the printed text and are provided in the
HTML and PDF versions of this article on the journals Web site
(www.corneajrnl.com).
Reprint requests: Brian Ward, PhD, MD, Retinal Diagnostic
Center, 3395 South Bascom Avenue, Suite 140, Campbell, CA
95008; e-mail: bwardrdc@yahoo.com
224
Small and moderate degrees of schisis layer sepa-
ration required no augmentation. However, eyes
having larger degrees of posterior retinal layer sepa-
ration, or tractional detachments, were treated by the
addition of rectangular pillows for additional indenta-
tion at the posterior pole. They were secured to the
underside of the central portion of the buckling strip
by means of four 5-0 Dacron sutures (Surgidac SS24
Spatula, Covidien, Boston, MA).
The dimensions of the pillows were 14 8 mm,
with overall thicknesses ranging from 1.0 mm to 2.5
mm. The pillows consisted of either layered sclera (1.0
to 2.0 mm in thickness) or silicon sponges (2.0 to 2.5
mm in thickness).
The band was given its initial tensioning during the
tying of the sutures securing its ends to the recipient
globe. Further tension could be produced by means of
a variable tuck that could be created by means of two
5.0 Dacron sutures preplaced near the end of the strip
anchored in the superonasal quadrant of the recipient
eye (Figure 2).
Surgical Procedure
The procedure is carried out under general anesthe-
sia to avoid the creation of orbital edema by the
injection of regional anesthetic uids. A parasym-
pathetic blocking agent is administered intrave-
nously to prevent cardiac slowing that might result
from the oculocardiac reex.
A limbal peritomy is created, and blunt dissection is
used to expose the scleral quadrants and the inser-
tions of the four rectus muscles. Silk ties are passed
under each of the muscles, to provide means for the
manipulation and the stabilization of the globe, as
required during the surgical procedure.
The insertion of the inferior oblique muscle is then
visualized with the aid of both an Arruga spoon
retractor (Bausch & Lomb-Storz, Bloomington, MN)
and a strategically positioned operating light. The
entire insertion is captured in the loop of a 00 silk
tie. Any attachments between the muscles are
cleared. This is a crucial step in providing a passage-
way through which the buckle may smoothly slide to
the posterior pole.
Adhesions between the rectus muscles and the globe
are then divided by passing a muscle hook between
the bellies of the muscles and the globe. The medial
rectus is excluded from this step.
The prepared buckling strip is then placed under the
superior rectus muscle. Two 5-0 Dacron sutures had
previously been preplaced near its nasal end to
allow a tensioning tuck to be created laterif
required (Figure 2). The two partial thickness bites
taken for each preplaced tucking suture had been
positioned 5 to 6 mm apart.
The end of the buckle is then secured to the outer
layers of the recipient sclera by means of two white
5-0 Dacron sutures with spatula needles. The scleral
bites are placed so that the anterior end of the intra-
scleral tunnel is 2 to 3 mm posterior to the line of
insertion of the adjacent rectus muscles.
The free end of the strip is passed between the lat-
eral rectus muscle and the globe, and then behind
the insertion of the inferior oblique muscle. The
nal step is to pass the free end between the inferior
rectus muscle and the globe so that it presents in the
inferonasal quadrant of the orbit. The strip, previ-
ously marked on its outer surface with an ink stripe
is then inspected to ensure that no accidental twist-
ing has occurred during its passage around the eye.
At this point, the strip is positioned around the equa-
tor of the globe. Care must be taken that the free end
does not slip posteriorly because its retrieval can be
time consuming. The strip is then grasped in straight
forceps, and a series of vertical elliptical movements
Fig. 1. A diagram of anterior and posterior views of a right eye with an
augmented posterior pole buckle in position.
Fig. 2. Two 5-0 Dacron sutures secure the end of the buckle to the
recipients sclera. The bands tension has been increased by tying-off
a separate pair of pre-placed 5-0 Dacron sutures.
SURGICAL TECHNIQUE 225
are made with tension being applied to the band at the
lowest point of each excursion. This movement is
repeated until the central portion of the strip has slip-
ped posteriorly over the temporal globe and rests over
the posterior pole. When the eye is adducted, the
anterior edge of the strip can be barely seen by plac-
ing the Arruga spoon over the lateral rectus or over
the sclera of the inferotemporal quadrant of the globe.
Once correct positioning has been veried, the strip
is cut to length. Two 5-0 Dacron xation sutures are
passed through its end to secure it to the outer layers
of the recipient sclera, with tunnels that begin 5 mm
anterior to the cut strip and emerge behind the line
of the rectus muscle insertions. Tension is created in
the strip as these xation sutures are tightened and
tied-off.
Attention is then turned back to the superonasal
quadrant, where the anchoring sutures are checked
and the tension in the buckle is assessed. If more
tension is required, a tuck is created in the strip by
tightening and tying-off the two preplaced sutures
illustrated in Figure 2.
The intraocular pressure is checked and a complete
indirect ophthalmoscopic examination is per-
formed. The perfusion at the optic nerve is veried
and any change in the appearance of the fundus is
noted. In cases where there is a deep posterior
staphyloma, it may be possible to see a modest
attening of the center and the temporal parts of
the posterior pole.
The 0-0 muscle ties are then removed and Tenon
capsule and the conjunctive are repositioned using
6-0 plain gut sutures. A broad-spectrum antibiotic/
steroid combination is then injected under the con-
junctiva. Because temporary pressure increases and
small choroidal effusions are relatively common
after these procedures, intravenous doses of 500
mg of acetazolamide and 40 mg of Solumedrol are
given. Atropine drops and a combination (steroid/
antibiotic) ointment are placed on the cornea. The
eye is then padded closed and a metal shield is
secured over the cotton pads (see Supplemental
Digital Content, http://links.lww.com/IAE/A113).
Postsurgical Care
After surgery, oral prednisone is taken for 6 days
to reduce orbital congestion and swelling. It
also minimizes any small choroidal effusion that might
occur. Acetazolamide is taken orally until the intraoc-
ular pressure is ,17 mmHg, off the medication. A
topical pressure control agent is frequently substituted
for the acetazolamide on the second day. This is with-
drawn when the pressure is #17 mmHg without its
use. A topical antibiotic/steroid combination drop is
started on the rst day after surgery and its use is
tapered-off over a 3-week period.
The patient is instructed to wear a spectacle correc-
tion on the day after the surgery. This is to encourage
the early reestablishment of binocular fusion. Abduc-
tion exercises are given to hasten the recovery from the
anticipated postoperative abduction deciency.
Results
The outcomes of buckling for the correction of
myopic macular schisis and detachment are presented
as pairs of matched OCT in Figures 3 to 12. These
pairs of images are arranged according to the nature of
the presenting macular condition:
1. Figures 3 to 5 show maculae with small amounts of
retinal schisis and ILM avulsions.
2. Figures 6 to 8 show predominantly outer layer ret-
inal schisis.
3. Figures 9 and 10 show schisis and neurosensory
retinal detachment.
4. Figures 11 and 12 show schisis with an inner layer
(lamellar) macular hole.
Preexisting ILM avulsions and limited areas of
retinal schisis are evident in Figures 3 to 5. The retina
is thicker away from the areas of spontaneous ILM
avulsion. After buckling, generalized tissue thinning
is seen along with the closure of ILM avulsions.
Fig. 3. A central cystic central macular schisis with a segment of
avulsed ILM (Table 1; Patient 1).
226 RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES

2013

VOLUME 33

NUMBER 1
Redundancy in an avulsed ILM in Figure 3 is illustra-
tive of its relative inelasticity.
Figures 6 to 8 show considerable retinal thinning
after buckling. These three cases had originally pre-
sented with wide bands of posterior retinal schisis. The
band of schisis, tissue separation or rarefaction
appears to be at the anatomical level of the outer plex-
iform layer, except at the center of the macula where
most of the tissue anterior to the receptor layer seems
to be involved.
Figures 11 and 12 exhibit very different degrees of
retinal schisis but have the common feature of an
inner layer retinal discontinuity (a lamellar macular
hole). In these cases, the ILM has been interrupted at
the center of the macula. This break in the ILM may
result from processes related to local vitreous trac-
tion. Buckling resulted in some minimal decrease in
the diameter of the inner retinal hole. The broad
posterior schisis layer evident in Figure 12 showed
only about a one-third reduction in thickness after
buckling. In contrast, the anterior retinal schisis evi-
dent in the same case responded by closing. Signs of
radial neural or supporting tissue elements are pres-
ent within the broad posterior schisis cavity in
Case 10 (Figure 12). Some functionality of these
stretched retinal elements is attested to by the sur-
prisingly good levels of visual acuity recorded in this
case (20/30).
Posterior pole buckling resulted in modest visual
acuity improvements in four patients. Table 1 shows
the increases in visual acuity (at least 2 lines of
improvement on the Snellen chart) achieved by these
4 eyes (Cases 4, 6, 7, and 8). Both the eyes presenting
with tractional retinal detachments and macular schisis
are seen to be members of this group Cases 7 and 8).
The visual acuities of all the eyes were limited, to
some extent, by the presence of some degrees of
degeneration resulting from other myopic processes,
and in some cases media opacities affected the acuities
recorded. No vision loss, infection, or any other
serious complication occurred in any eye in this series.
Fig. 4. Partially avulsed ILM and anterior retinal schisis (Table 1;
Patient 2).
Fig. 5. Anterior retinal schisis and an ILM avulsion (Table 1; Patient 3).
Fig. 6. Posterior schisis in the nasal macula in a left eye (Table 1;
Patient 4).
SURGICAL TECHNIQUE 227
No patient experienced prolonged diplopia after the
surgery.
Discussion
Myopic macular schisis may be evident on slit-lamp
examination, but an OCT, or some other equivalent
image, is required for the analysis of its structural
details.
However, the correlation between the appearance of
the OCT image and the functional integrity of the
retinal tissue remains largely conjectural. In some
cases, visual functioning seems to be largely intact in
contrast to the impression that might be gained from
a cursory examination of the OCT images of the
macula.
Schisis usually occurs in eyes that have axial lengths
.28 mm. However, it may also occasionally be seen
in eyes with axial lengths as short as 26 mm, espe-
cially in globes having relatively small equatorial
diameters but with a deep, sharply circumscribed cen-
tral staphylomas.
Retinal schisis frequently coexists with other
forms of myopic maculopathy and other ocular
abnormalities. However, myopic avulsions, schisis,
tractional detachments, and some macular holes may
be usefully looked upon as being members of
a particular neural disruptive group of myopic
macular features. In this case, myopic macular
degeneration may be considered to have three
clinically recognizable components. All of them
being results of various forms of structural damage
to the choroid, the retina, and any attached cortical
vitreous:
a) Atrophic degeneration (direct cellular damage to
the tissues of the macula).
b) Exudative degeneration (choroidal membranes,
subretinal uid (serous or hemorrhagic), and scar-
ring.
Fig. 7. Chronic posterior retinal schisis (Table 1; Patient 5).
Fig. 8. Chronic posterior retinal schisis (Table 1; Patient 6). Fig. 9. Schisis and macular detachment (Table 1; Patient 7).
228 RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES

2013

VOLUME 33

NUMBER 1
c) Neural disruptive degeneration (tractional schisis,
ILM avulsions, macular holes [full or partial thick-
ness], and tractional retinal detachments).
In the 10 subjects presented in this study, posterior
pole buckling reduced or eradicated macular schesis in
all cases. The buckles force on the posterior sclera
seems to relax anterior directed forces from the ILM,
epiretinal membranes, and any adherent vitreous cor-
tex. The buckling force also opposes the posterior-
directed forces on the outer retina derived from the
stretching of the scleral shell. A variable rate of cor-
rection of the schisis was observed, with several
months being required in some of the earlier cases
treated with unaugmented buckles (Figures 46).
The overall efcacy of buckling was least in a case
of long-standing posterior retinal schisis with marked
separations of the retinal layers and a large inner layer
lamellar hole (Figure 12). Here, buckling caused about
a 30% reduction in the thickness of the outer schisis
but was more effective in correcting anterior layer
schisis and ILM avulsions. The lamellar holes in Fig-
ures 11 and 12 became somewhat smaller after buck-
ling, perhaps because of relaxation of tension in the
stretched ILM. A visual acuity of 20/30 in this eye
indicates a reasonable level of residual functioning of
the receptors and stretched neurons as well as the tis-
sues supporting them. Whether the anterior retinal hole
provides any relevant uid communication between
the posterior schisis layer and vitreous uid is
unknown.
An examination of the pre- and postoperative OCT
images suggest that retinal disruption rst begins as
the ILM reaches the limit of its elasticity, whereas the
outer retina continues to be dragged posteriorly by
progression of the axial myopia. In the normal course
of events, axial extension is seen to produce a thinning
of both the choroid and the retina. Yet, in many highly
myopic eyes, a local thickening of the neural retina is
seen before the appearance of schisis. This may well
be an early sign that radial forces are developing
across the layered retinal tissue. The recognition of
such a preschisis stage would allow treatment to be
Fig. 10. Schisis and macular detachment (Table 1; Patient 8).
Fig. 11. Anterior schisis with anterior lamellar break (Table 1; Patient 9).
Fig. 12. Chronic schisis with large anterior lamellar break (Table 1;
Patient 10).
SURGICAL TECHNIQUE 229
considered before a point of more obvious macular
tissue breakdown.
The treatment of macular schisis by buckling avoids
some of the risks of the intraocular procedure.
However, where detachment or preretinal brosis
remain after buckling, vitrectomy and membrane
peeling can be helpful.
The ideal physical properties required of the material
for this buckling procedure include ease of manipula-
tion, exibility, limited elasticity, smooth surface
texture, and absence of the risk of an edge cutting
into the recipients weak sclera (cheese-wiring). These
properties have been sought after in numerous natural
tissues and manufactured implantable materials. How-
ever, to date, donor sclera has met most of these
requirements; and it remains the material of rst
choice. The recent introduction of gamma irradiation
for sclera preservation means that this tissue no longer
requires very complicated handling and deep freezing
for its preservation. In the irradiated form, scleral tissue
may have a shelf life of up to 2 years (at room tem-
perature). All donor tissue must be tested and certied
free of potential pathogens according to accepted eye
bank procedures and protocols.
After surgery, all eyes have a temporary abduction
deciency with diplopia that is usually symptomatic
for only a few days. In some cases, however, it may
persist for longer time. Patients are prepared for this
possibility as part of the informed consent process.
To minimize the period of diplopia, patching stops on
the day after surgery and abduction exercises are
begun. To encourage the early reestablishment of
binocular fusion, a spectacle correction is also used
from the rst day after surgery.
Patients with a preexisting strabismus must be made
aware of the possibility that the angle of that
strabismus may change after surgery, presumably on
the basis of orbital scarring affecting an eye that has
limited rotational movements.
It has been concluded, from the experience to date,
that the most shallow schisis plane separations require
no augmenting pillow at the posterior pole. Wider
posterior retinal schisis cavities seem to be an
indication for 1.0-mm to 2.0-mm-thick pillows of
sclera or silicon sponge to be used. Broad schisis
separations and all tractional retinal detachments do
benet from the additional buckling effect provided by
2.0-mm to 3.0-mm-thick sponge pillows.
Wherever a spontaneous separation of the ILM
occurs, it is seen that the retina tends to resume its
stretched and thinned myopic appearance, and closure of
local schisis planes can occur. Surgical vitrectomy with
ILM peeling was designed to induce the same result.
However, this approach to the treatment of myopic
macular schisis does involve some risks inherent in the
direct manipulation of the physically weak retinal tissue.
Regarding the use of vitrectomy, another fact to
consider is that ILM peeling does nothing to prevent
the retina and choroid from continuing to be dragged
posteriorly by progressive elongation of the globe.
Buckling offers the opportunity of relieving myopic
macular traction while also limiting axial myopia
progression. The control of the axial myopia may help
to minimize future macular degeneration and stabilize
the power of lenses required for the eyes refractive
correction.
Conclusion
Macular schisis and tractional macular detachments
are the result of forces applied across the retina by scleral
growth and stretching. The extension of the sclera
applies a posterior force to the outer retina while the
inner retina is subjected to a constraining anterior force
derived from its relatively inelastic ILM. Posterior pole
buckling relaxes these forces, and in doing so, reduces or
corrects macular schisis and tractional detachment.
Table 1. A Summary of Patient Information for the 10 Cases Presented
Subject Age Sex
Axial Length (mm) Visual Acuity
Augmentation Follow-up (Months) Before After Before After
1 R 67 AM 29.8 29.4 20/50 20/50 None 6
2 L 48 CM 29.7 29.0 20/40 20/25 Sclera 19
3 R 66 CF 29.5 29.3 20/30 20/25 Sclera 16
4 L 70 AF 29.0 28.7 20/30+ 20/30 Sclera 24
5 L 47 AF 30.0 29.7 20/30 20/25 None 44
6 R 53 AF 32.6 32.6 20/70 20/50 Sclera 22
7 R 66 CF 30.0 30.0 20/300 20/125 Sponge 14
8 L 74 CF 28.2 27.8 20/80 20/50 Sclera 72
9 L 51 CF 27.0 27.0 30/30 20/25 None 12
10 L 47 CM 30.9 30.4 20/30 20/30 Sclera 03
AM, Asian male; AF, Asian female; CM, Caucasian male; CF, Caucasian female; L, left eye; R, right eye.
230 RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES

2013

VOLUME 33

NUMBER 1
Buckling the posterior pole before schisis occurs
may well prevent its occurrence while at the same
time limiting axial myopia progression and
hopefully minimizing future myopic macular degener-
ation. The stabilization of axial myopia prolongs the
effectiveness of any refractive correction, whether
provided by external optical devices or by surgically
induced refractive changes.
Four of the 10 eyes in this study showed some
visual acuity improvement. Although the stabilization
of the neural destructive complications of the myopic
maculopathy was the primary goal of this work,
the achievement of some short-term visual acuity
increases, in some of the eyes, is gratifying. On the
basis of our experiences of posterior pole buckling,
this procedure has now become our primary treatment
modality for these neural destructive complications of
degenerative myopia.
Key words: degenerative myopia, lamellar macular
hole, macular buckles, macular degeneration, macular
hole, macular schisis, malignant myopia, myopic mac-
ular degeneration, myopic macular schisis, myopic
macular traction, pathological myopia, progressive
myopia, retinal schisis, tractional macular detachment.
BRIAN WARD, PHD, MD*
References
1. Curtin BJ. The Myopias. Philadelphia, PA: Harper & Row;
1985:10;237239.
2. Mc Brien NA, Gentle A. Role of the sclera in the development
and pathological complications of myopia. Prog Retin Eye Res
2003;32:307388.
3. Tano Y. Pathological myopia: where are we now? Am J Oph-
thalmol 2002;134:645660.
4. Ward B, Tarutta EP, Mayer MJ. The efcacy and safety of
posterior pole buckles in the control of progressive high myopia.
Eye (Lond) 2009;23:21692174.
5. Takano M, Kishi S. Foveal retinoschisis and retinal detachment
in severely myopic eyes with posterior staphyloma. Am J Oph-
thalmol 1999;128:472476.
SURGICAL TECHNIQUE 231

You might also like