Combined macular buckle and intraoperative OCT-guided 41-gauge drainage of refractory large bacillary layer detachments in neovascular age-related macular degeneration and diabetic macular edema

To describe a novel combined surgical technique for the drainage of large bacillary layer detachment (BLD) in patients with advanced neovascular age-related macular degeneration (nAMD) or diabetic macular edema (DME) refractory to intravitreal anti-vascular endothelial growth factor (anti-VEGF) or corticosteroid therapy.

This prospective pilot case series evaluated three eyes of three patients (two nAMD, one DME) with large BLDs runresponsive to intravitreal treatment. The standardized procedure consisted of ab-externo macular buckle placement followed by 23-gauge pars plana vitrectomy (PPV). Intraoperative OCT (iOCT) guided subretinal fluid drainage using a 41-gauge cannula. Primary outcomes were anatomical BLD resolution and changes in best-corrected visual acuity (BCVA) at six-month.

Immediate and complete anatomical resolution was achieved in all eyes. BCVA modestly improved from 20/400, 20/400, and 20/800 at baseline to 20/200, 20/200 and 20/400 Snellen at six-month follow-up. No intra- or postoperative complications occurred, and no additional anti-VEGF injections were required during follow-up.

Combined intraoperative OCT-guided subretinal drainage with macular buckling achieved immediate anatomical resolution of large, chronic bacillary layer detachments refractory to medical therapy. Functional recovery was limited, likely reflecting irreversible outer retinal and retinal pigment epithelium damage in advanced disease. This approach may represent a salvage option in carefully selected cases of refractory exudative macular disease. Further studies with larger cohorts and longer follow-up are required to define its long-term efficacy, optimal timing, and clinical role.