Evolution of the management of myopic macular hole retinal detachment in Egypt by Omar Rashed, M.D. Professor of Ophthalmology Ain Shams University 1
1920 Jules Gonin The father of modern retinal surgery The first to discover the causal relationship between rhegmatogenous RD and retinal breaks Macular buckle The treatment available in the pre vitrectomy era was scleral buckling and treatment to the macular hole. Drawbacks of macular buckle - Anatomical difficulties necessitating special surgical skills - Destruction of macular function - Only anatomical success was hoped for 2
Macular buckle Anatomical difficulties I.O 3
1969 Siam AL. 1969 Macular hole with central retinal detachment in high myopia with posterior staphyloma. Br J Ophthalmol; 53: 62-63 1973 Management of central retinal detachment due to a macular hole. Br J Ophthalmol. May;57(5):351-4. One of the earliest pioneers in macular hole surgery 1982 Gonvers M. & Machemer R. A new approach to treating retinal detachment with macular hole. Am J Ophthlamol, 94(4):468-72. 4
1982 Gonvers M. & Machemer R. A new approach to treating retinal detachment with macular hole. Am J Ophthlamol, 94(4):468-72. 6 Cases treated by PPV + fluid/gas exchange + prone positioning No treatment was applied to the hole This paper highlighted the role of traction in the pathogenesis of macular holes. The concept changed from retinal break as being the cause of retinal detachment to being the means by which retinal detachment occurs. Techniques available in this era: - Pneumatic retinopexy - Simple PPV without treatment to the hole - PPV + laser treatment to the hole - PPV + Gas tamponade - PPV + Silicone oil tamponade - PPV + adjuvant treatment ( autologous serum, TGF β, bovine thrombin.) 5
1986 Zayed A. 1986 Zayed A. & Rashed O. Vitrectomy for the treatment of retinal detachment due to macular holes. Presented at Club Jules Gonin meeting at Copenhagen. 2002 Myopic macular holes: different colors with different prognosis. Presented at Club Jules Gonin meeting at Taormina. Differentiated between white and red holes with their different prognoses 1989 Rashed O. & Sheta S. Evaluation of the functional results after different techniques for treatment of retinal detachment due to macular holes. Graefes Arch Clin Exp Ophthalmol. 1989;227(6):508-12. 6
1989 Rashed O. & Sheta S. Evaluation of the functional results after different techniques for treatment of retinal detachment due to macular holes. Graefes Arch Clin Exp Ophthalmol. 1989;227(6):508-12. A total of 50 eyes with macular hole retinal detachment -10 eyes treated by pneumatic retinopexy -30 eyes treated by PPV + air tamponade -10 eyes treated by PPV + Si Oil tamponade Comparison of functional results by: -BCVA -Color vision -Field of vision 1990 Sheta SM, Hida T, McCuen BW Cyanoacrylate tissue adhesive in the management of recurrent retinal detachment caused by macular hole. Am J Ophthalmol. 1990 Jan 15;109(1):28-32 7
Limitations in the seventies & eighties These decades witnessed great improvements in the success rate. But.. - Differentiation between full thickness and lamellar holes was definite only intra-operatively. - Posterior staphyloma cases had poor prognosis. The OCT era The introduction of OCT brought about advances: -Differentiation between lamellar and true holes -Identification of different healing patterns after surgery -Discovery of foveoschisis 8
2004 Rashed O. & Gaber A. Reappraisal of surgery for myopic macular hole based on OCT findings. Presented at the Vail meeting. 2004 Rashed O. & Gaber A. Reappraisal of surgery for myopic macular hole based on OCT findings. Presented at the Vail meeting. 9
2004 Rashed O. & Gaber A. Reappraisal of surgery for myopic macular hole based on OCT findings. Presented at the Vail meeting. 2004 Rashed O, & Gaber A. Reappraisal of surgery for myopic macular hole based on OCT findings. Presented at the Vail meeting. 10
Healing Patterns U-pattern Restoration of normal foveal pattern V-pattern Foveal area shows a thin layer of neurosensory retina W-pattern Foveal defect of neurosensory retina Hole Patterns Flat and open Flat and closed 11
OCT images of myopic macular holes invariably appear as full-thickness defects in detached retina. The postoperative appearance of closed holes can be classified into 3 patterns as in idiopathic macular holes. The W pattern correlated with the worst visual acuity. Foveoschisis 12
2004 Tano Y. Vitrectomy and Internal Limiting Membrane Peeling for Myopic Foveoschisis. Am J Ophthalmol 2004;137:719-24. PPV + Vitreous cortex removal + ILM peeling + Gas tamponade - Operated on 6 eyes - Foveal detachment completely resolved in 5 eyes and partially in one. 13
2006 Mortada H. Myopic foveoschisis in highly myopic eyes. Presented at Egyptian vitreoretinal society meeting in Cairo. PPV + Vitreous cortex removal - no ILM peeling + Gas tamponade ILM peeling 2005 K. El-Rakhawy Demonstrated that ILM removal is feasible in Myopic Macular Hole Detachment (and not only in Idiopathic macular hole surgery) ILM removal may reduce recurrence rate especially after silicone oil removal Blue dyes : (Trypan blue,and later Dual blue & Brilliant blue) are very helpful in ILM removal from detached retina 14
Revival of Macular Buckle 2005 Theodossiadis GP, Theodossiadis PG. The macular buckling procedure in the treatment of retinal detachment in highly myopic eyes with macular hole and posterior staphyloma: mean follow-up of 15 years. Retina. 2005 Apr-May;25(3):285-9. 2007 Ando F, Ohba N, Touura K, Hirose H. Anatomical and visual outcomes after episcleral macular buckling compared with those after pars plana vitrectomy for retinal detachment caused by macular hole in highly myopic eyes. Retina. 2007 Jan;27 (1):37-44. 2008 Siam AL. Revival of macular buckling for retinal detachment due to a macular hole in high myopia. Presented at the Club Jules Gonin meeting. 15
Revival of Macular Buckle Indications: - Recurrent cases after PPV with various techniques including silicone oil tamponade - Very atrophic background ; white holes - High myopia with posterior staphyloma Where do we stand now? Better investigations. Multiple techniques. No single technique suits all cases. 16
1920 s Jules Gonin 1960 s Abdel Latif Siam 1970 s Amin Zayed Robert Machemer 1980 s Omar Rashed Brooks McCuen 1990 s 2000 s Sherif Sheta Yasuo Tano Hassan Mortada THANK YOU 17