NPB Macular Buckle


 Retinal detachment is a disorder of the eye in which the retina separates from the layer underneath. Symptoms include an increase in the number of floatersflashes of light, and worsening of the outer part of the visual field. This may be described as a curtain over part of the field of vision. In about 7% of cases both eyes are affected. Without treatment permanent loss of vision may occur.


There are three different types of retinal detachment:

Rhegmatogenous —A tear or break in the retina allows fluid to get under the retina and separate it from the retinal pigment epithelium (RPE), the pigmented cell layer that nourishes the retina. These types of retinal detachments are the most common.

Tractional—In this type of detachment, scar tissue on the retina’s surface contracts and causes the retina to separate from the RPE. This type of detachment is less common.

Exudative—Frequently caused by retinal diseases, including inflammatory disorders and injury/trauma to the eye. In this type, fluid leaks into the area underneath the retina, but there are no tears or breaks in the retina.

Macular buckling is a reversible surgical technique that can improve the anatomic and functional outcomes of highly myopic patients with retinal detachment due to macular hole by counteracting the staphyloma action. The interest in macular indentation has increased over the last few years as treatment for problems of macular traction in high myopia. Macular indentation is an “ancient” surgical technique designed to reduce the traction effect of staphyloma in patients with high myopia and suffering from secondary retinal detachment to a macular hole. We show here some of the basic principles of macular indentation using AJL indenter.


The AJL macular buckle is made of silicone-coated PMMA,which increases its biocompatibility and makes it rigid and does not allow bending. It has a groove in the indenting platform to insert an optical fiber. It has an indented surface with a spherical shell at the top and an arm whose length varies depending on the axial length of the patient's eye. The silicone strap inserted in the arm of the implant facilitates the incorporation of a lighting probe that uses reflection for correct positioning of the indentation in the desired location.

The first step is to carry out a conjunctival peritomy in the supero-temporal quadrant, an area where the macular indenter will be implanted. In order to mobilise the eye, the superior rectus and lateral rectus muscles are tied with silk suture.


The distance to the limbus is variable, but it is normally about 20 mm


It must be taken into account that some patients with high myopia have scleral atrophy areas and, in these cases, it is not easy to find a safe place to position the initial suture. In addition, we can come across eyes that have undergone previous surgical procedures with placement of cerclages at 360º. In these cases, it is not difficult to find a place to position the posterior suture between the insertion of the oblique muscles. In some phakic patients a pars plana lensectomy can be carried out leaving the anterior capsule polished and transparent. This improves the view of the macular area making the peeling of the inner limiting membrane easier. Moreover, if necessary, an intraocular lens can be placed in the posterior chamber during the post-operative period. After this a pars plana vitrectomy is carried out and the posterior hyaloid membranes are removed.
Many surgeons prefer to use triamcinolone to allow the superior hyaloid membranes to be viewed. Removal of the posterior hyaloid membranes can be carried out using forceps or a diamond-dusted Tano brush. We particularly prefer to use a stain, with a mixture of trypan blue and a viscoelastic
substance to avoid the colorant being transferred to the sub-retinal area. In cases of retinal detachment, we often wonder from where we should remove the sub-retinal fluid.


         Our best option is to inject liquid perfluorocarbon


to “push” the sub-retinal fluid towards the periphery, a place where we carry out a minor retinotomy through where we suction the sub-retinal
fluid. Our best option is to inject liquid perfluorocarbon When the retinal detachment is located in the macular area, it is not difficult to remove the inner limiting membrane below the liquid perfluorocarbon. The removal of the inner limiting membrane is “compulsory” for these patients. The liquid perfluorocarbon stabilises the retina, making it easier to work on.


Staining with trypan blue and viscoelastic substance avoid the colorant being transferred to the subretinal space


In the picture it is shown how to insert the optical fibre in the indentation surface of AJL indenter:
manufactured with PMMA coated with silicone, it is rigid and designed to be customised to the axial length of the eye.
The terminal platform of the indenter allows the optical fibre to be inserted and makes the placement easier. The implantation must be carried out with special care being paid to position it in the temporal area of the macula, far from the optic nerve.


The way to insert the optical fibre varies depending on the indenter used


Once the indenter has b een implanted, the light can be “switched on” and “switched off” to confirm the exact position of the indenter. When we are sure the indenter is in the correct position, additional sutures are made to stabilise it.


Checking the placement of the indenter.


Finally, the liquid perfluorocarbon is removed and it is concluded with a change-over for gas.


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