Current concepts and cutting-edge techniques in myopic macular surgeries

Myopic foveoschisis and macular hole with a retinal detachment are two major diseases associated with posterior staphyloma that are specific to high myopia. The pathogenesis is a combination of various types of traction from the vitreous cortex, epiretinal membrane (ERM), internal limiting membrane (ILM), and microvessels. Foveoschisis typically starts with retinoschisis, and a retinal detachment subsequently develops as a result of traction on the inner retina. The stress on the fovea eventually opens a small hole and leads to retinal detachment from a macular hole; thus, both are closely related. These two pathologies can be treated with vitrectomy. A foveal detachment is the best indication for surgery because of the greatest visual improvement. The routine surgical procedures are vitreous cortex removal with triamcinolone acetonide, ERM peeling, ILM peeling stained with Brilliant Blue G, and gas tamponade. The necessity for ILM peeling and gas tamponade for myopic foveoschisis remains controversial. A postoperative macular hole is a severe complication in foveoschisis, and a photoreceptor inner/outer segment defect seen on optical coherence tomography images obtained preoperatively is a risk factor for macular hole. A foveal nonpeeling can be considered to avoid foveal trauma. The inverted ILM peeling technique is a new option to enhance macular hole closure. Both techniques seem to enhance retinal restoration; however, the visual benefit has not been confirmed. A long-shaft forceps facilitates precise maneuvers. Vitrectomy for highly myopic macular diseases remains challenging; however, an understanding of the pathogeneses and innovations in vitreous surgical instruments and techniques will facilitate safer surgeries.