Iris pigment epithelial translocation in the treatment of exudative macular degeneration: a 3-year follow-up

OBJECTIVE

To report the functional and anatomical outcome of 20 patients who underwent surgical removal of choroidal neovascularization combined with transplantation of autologous iris pigment epithelial cells to the subretinal space 3 years after treatment.

METHODS

Freshly isolated autologous iris pigment epithelial cells were translocated to the subretinal space in 20 patients after membrane extraction. Patients were followed up by funduscopy, angiography, microperimetry, and visual acuity testing.

RESULTS

After a follow-up of 3 years, 1 patient showed improved visual acuity, 13 patients retained stable visual acuity, and 3 patients had reduced visual acuity. No macular edema or recurrent choroidal neovascularization was apparent at any time during the follow-up.

CONCLUSIONS

Transplanted autologous iris pigment epithelial cells were well tolerated for 3 years and stabilization of visual acuity was achieved in most patients. These results suggest that iris pigment epithelial cells may serve as a substitute for retinal pigment epithelial cells after choroidal neovascularization removal in patients with exudative macular degeneration; however, whether these cells will be of any value for the restoration of vision and possible protection against choroidal neovascularization recurrence awaits further clinical observation and additional research.

Hornhautstaphylom-Vorderkammeragenesie-Mikrophakie-Syndrom (kongenitales anteriores Staphylom)

CASE REPORT

Shortly after birth, a massive enlargement of the right eye was observed in an otherwise healthy male child. The cornea of the affected eye was vascularized and completely cloudy without a sharp border between cornea and sclera. The diagnosis of a congenital glaucoma was made but an operation was not undertaken because of the difficult anatomical situation and the lost function. When the child was almost 3 years old enucleation was performed to prevent complications due to corneal exposure, and to improve the cosmetic aspect.

RESULTS

The morphological investigations of the enucleated eye disclosed findings typical of what is called in the literature "congenital anterior staphyloma" or "congenital corneal staphyloma", namely a massively staphylomatous cornea with superficial neovascularization, destruction of Bowman's layer, and absence of Descemet's layer as well as corneal endothelium. Angle structures were completely absent, and the corneal back-side was lined by a pigment epithelial layer and focally by an additional inner layer of non-pigmented epithelium. There was no anterior chamber. The lens was markedly diminished in size (microphakia) and partly embedded in the corneal stroma. Pars muscularis and pars ciliaris of the ciliary body were separated. Elongated, thin ciliary processes were extended towards the small lens while the pars muscularis was fully covered by the retina.

CONCLUSIONS

This rare, complex malformation syndrome which can be easily distinguished from primary congenital glaucoma should not be reduced conceptually to the corneal staphyloma because this staphyloma constitutes only a part of the whole. Taking the leading morphological aberrations into consideration we would rather propose the new term " corneal staphyloma- anterior chamber agenesia- microphakia syndrome (CSAMS). We hypothesize that CSAMS may be due to a pathological fusion of the early anterior optic cup. As the posterior eye segment is often normal in CSAMS, a staphyloma excision along with a sclero-keratoplasty might be an alternative therapeutic option to avoid enucleation and restore ambulatory vision.

Karunkeltumor unklarer Dignität

CASE REPORT

A sixty year old woman presented with a tumor of the caruncle that had persisted for one year. Ophthalmologic history was unremarkable. Physical examination disclosed an indolent, tight elastic, highly vascularizated tumor. The lesion measured five millimeter in diameter. Histopathology revealed tall columnar cells with small round nuclei. The cytoplasm stained positive with hematoxylin and eosin. The typical histopathologic features were consistent with an oncocytoma.

CONCLUSION

Tumors of the caruncle are very heterogenous because the caruncle contains tissues of the conjunctiva and the epidermis. Therefore to exclude a malignant process an excisional biopsy should always be performed even so in general tumors of the caruncle are benign. The most frequent tumors of the caruncle are papilloma, nevi, pyogenic granuloma, epithelial inclusion cyst and chronic inflammation. In only 4 % of the cases oncocytomas are found even the oncocytoma is considered to be a typical tumor of the caruncle.

Experimental Implantation and Long-term Testing of an Intraocular Vision Aid in Rabbits

OBJECTIVE

To develop an intraocular vision aid to provide artificial vision in severely traumatized eyes, where neuroretinal function could be preserved but irreversible anterior segment opacification resulted in blindness.

METHODS

The basis of an intraocular vision aid is in principle a telemetric circuit to bridge the opaque cornea and to allow for artificial light stimulation of the retina. The visual prosthesis comprises an external high-dynamic range complementary metal oxide semiconductor camera and digital signal processing unit and an intraocular miniaturized light-emitting diode array to project the image onto the retina. For in vivo testing of long-term function and biocompatibility, silicone-encapsulated active photodiodes were implanted in 13 pigmented rabbits and were followed up for up to 21 months.

RESULTS

Lens extraction and stable fixation of the device in the ciliary sulcus were successful in all cases. For up to 21 months inductive energy transmission and wireless stimulation of the implants could be maintained. Electrophysiologic data and histology demonstrated a good tissue biocompatibility in the long-term follow-up.

CONCLUSION

The results demonstrate the general feasibility and biocompatibility to implant and fixate an intraocular light-emitting diode prosthesis. Inductive energy transmission to the intraocular device and wireless light stimulation are assured in the long term but depend on meticulous water-impermeable encapsulation of the delicate microelectronic components. Clinical Relevance An intraocular vision aid compound system with a high-resolution light-emitting diode matrix might be a future treatment option to restore vision in blind eyes with severe anterior segment disorders.

Empfehlung für die Durchführung von intravitrealen Injektionen

The intravitreal injection as a minimally invasive intervention has proved to be an effective therapy in the management of numerous vitreoretinal diseases. However, non-standardized performance of the procedure might cause severe complications. The recommendations for intravitreal injections discussed here are intended to contribute to a minimization of the risk for complications. Of particular importance are a meticulous preoperative antisepsis with povidone iodine, a sterile environment using a sterile lid speculum, drape and gloves, the use of an adequate injection technique and the exclusion of postoperative retinal non-perfusion.

Decorin Modulates Wound Healing in Experimental Glaucoma Filtration Surgery: A Pilot Study

PURPOSE

To analyze the effect of perioperative decorin in an experimental setting of glaucoma filtration surgery.

METHODS

Glaucoma filtration surgery, similar to that performed in clinical practice, was performed on 35 chinchilla rabbits (ChBB:CH). The animals received a unilateral subconjunctival injection of decorin (40-100 microg) or the vehicle alone before surgery and at different time intervals thereafter. Antifibrotic efficacy was established by clinical response and histologic examination. The animals were killed on day 14, and the eyes processed for histology.

RESULTS

Both the vehicle and the decorin solution were well tolerated. No adverse effects such as inflammation or blurring of the optical media were observed. Conjunctival scarification occurred within 1 week in the control groups but was suppressed in the experimental groups. The intraocular pressure correlated with the fibrotic process and reached normal levels within 7 days after surgery in control animals, but remained significantly (P <0.001) reduced in the experimental groups. Histologic examination of the surgical area 14 days after surgery disclosed massive fibrosis in the control animals, but little deposition of extracellular matrix in the experimental groups.

CONCLUSIONS

The data of this pilot study suggest that perioperative subconjunctival decorin applications significantly affect conjunctival scarring and surgical outcome of glaucoma filtration treatments in rabbits.

Histopathological analysis in experimental macular surgery with trypan blue

AIM

To analyse the effect of trypan blue on the retina in an experimental setting of macular surgery.

METHODS

Porcine eyes were used within 3 hours after death. The eyes were hemisected and the vitreous removed. Trypan blue (0.15%) was applied over the trephined posterior pole, whereas the rest of the eye cup was filled with a balanced salt solution (BSS). The dye and the BSS were removed after 1 minute and the complete eye cup irrigated and filled with fresh BSS. Both the treated and untreated retinas were illuminated with a standard surgical light pipe and source at maximum power for 10 minutes. Both the trypan blue exposed retina and the non-treated surrounding retina were processed for histology.

RESULTS

Exposure of the retina to trypan blue for 1 minute, followed by illumination caused no histologically detectable damage compared to the controls. No microarchitectural disorganisation, cellular disruption, or affection of the vitreoretinal interface was detected.

CONCLUSIONS

These findings indicate that a 1 minute exposure of trypan blue followed by illumination does not cause an acute morphologically detectable toxic effect on the porcine retina.

Augenverletzungen im Kindes- und Jugendalter

Childhood trauma of the eye and its adnexa represents approx. 4 - 20 % of all eye injuries. Due to ambiguous patient history and limited cooperation a comprehensive diagnosis of pediatric eye trauma is often difficult. The weakness of the infantile cornea, the thin and elastic anterior lens capsule, and the firm vitreous with its strong adherence to the retina bear particular intra- or postoperative problems. Moreover, the quick development of secondary cataract and the high risk of PVR may complicate the posttraumatic and postoperative course. Small infants represent a special subgroup in various regards mainly because of the risk of amblyopia which often causes functional loss in spite of a good anatomical reconstruction. The relative frequency of certain injuries differs between children and adults. The ocular manifestation of child abuse as well as bite and fireworks injuries are characteristic for childhood and will be discussed more in detail.

Immunohistopathologic evaluation of choroidal neovascular membranes following verteporfin-photodynamic therapy

PURPOSE

To evaluate the vascularization and proliferative activity in choroidal neovascular membranes due to age-related macular degeneration after verteporfin photodynamic therapy and submacular removal.

DESIGN

Interventional case series.

METHODS

In a retrospective review of seven patients who underwent removal of subfoveal classic choroidal neovascular membranes after treatment with photodynamic therapy 3 to 146 days earlier, membranes were stained for CD 34, CD 105, and Ki-67 and correlated with clinical pictures and fluorescein angiography.

RESULTS

Fluorescein angiography performed on the day of surgery disclosed nonperfusion of the treated area 3 days after photodynamic therapy, but perfusion and leakage were seen at greater post-photodynamic therapy intervals. Membranes excised 3 days after photodynamic therapy showed CD34 and CD105 positive, mostly occluded vessels. The endothelial cells appeared damaged. Ki-67 activity was low. In membranes excised 34 to 146 days after photodynamic therapy, all vessels appeared patent and were lined by healthy endothelial cells with strong expression of CD34 and CD105. Ki-67 expression was elevated after 34 days but decreased thereafter.

CONCLUSION

Photodynamic therapy did not cause a general or complete occlusion of vessels within the choroidal neovascular membranes, as suggested by fluorescein angiography 3 days postintervention, but the endothelial cells appeared to be severely damaged. Proliferative activity within these specimens was reduced. At longer intervals after photodynamic therapy, the fibrovascular tissue seemed to recover; perfusion, hyperfluorescence, and leakage of the choroidal neovascular membranes could be detected by fluorescein angiography. The clinical appearance showed a correlation with the immunohistologic characteristics of an increased proliferative activity and patent vascularization.

Contact lens, hyperopia and endothelial changes. A case report

INTRODUCTION

We report on a 62-year-old healthy woman who suffered from bilateral predescemetic opacities, where the underlying disorder could not be identified. She had bilateral keratopathy with corneal edema, a diffuse predescemetic avascular haze and deszemetic folds. Because of high hyperopia (right +7.50/left +7.75) she weared soft contact lenses for years.

METHODS

Removal of contact lenses. Treatment with local steroids and tear substitutes.

RESULTS

One year after cessation of contact lenses VA recovered from RE 0.3/LE 0.1 to 0.8/0.63, the deep stromal opacity cleared up, the corneal edema recessed slightly.

DISCUSSION

The differential diagnosis concludes either a pure contact lens change that is not completely reversible or a possible posterior polymorphous dystrophy that worsens with long-term contact lens wear and improves on cessation.

Nebenwirkungen und Komplikationen der intravitrealen Triamcinolonacetonid-Therapie

With the advent of intravitreal triamcinolone acetonid injections major focus was assigned to potential ocular side effects. The current discussion is dominated by the potential cytotoxicity of particular biologically incompatible components. Those are regarded as substantial pathogenetic factor of the sterile pseudoendophthalmitis that seems to be avoidable by meticulous purification of the commercially available preparations. Even sustained subretinal or epiretinal deposits disclosed no signs of retinal toxicity. Major ocular side effects comprise temporary corticosteroid glaucoma and progressive cataract formation. Infectious endophthalmitis represents a rare but serious complication that might be set into critical context with hygienic surgical standards applied. Due to steroid-induced immune suppression clinical signs of inflammation might be masked and a proper diagnosis delayed. Other rare complications reported include a transient central retinal artery occlusion, conjunctival ulcerations, retinal detachment and potential reactivation of a cytomegalovirus retinitis. In conclusion, ocular side effects and complications show a wide variety of clinical signs and underlying causal mechanisms. However, the consequences are mostly temporary and show a good response to therapeutic intervention.

Expression of endoglin in choroidal neovascularization

Endoglin (CD105) is a membrane protein involved in the TGF-beta receptor signalling pathway with predominant expression by proliferating endothelial cells. The aim of this study is to analyze the expression of Endoglin in choroidal neovascularization membranes (CNVM) and to compare it to the overall proliferative status of CNVM. Thirty surgically excised CNVM, secondary to age-related macular degeneration, were investigated using light microscopic immunohistochemistry and confocal immunofluorescence microscopy using verified antibodies directed against the endothelial cell markers Endoglin, von Willebrand factor (vWF) and CD34 and the proliferation marker Ki-67. Donor eyes were used as controls. A selective expression of CD34 and vWF as well as Endoglin was found in endothelial cells. Endoglin expression was elevated in vascular endothelial cells contained within CNVM, but a moderate Endoglin expression could also be visualized in quiescent CD34 and vWF positive ocular vasculature. Ki-67 positive cells were detected in CNVM, but these were rarely endothelial cells. Endoglin expression in endothelial cells of CNVM is increased, but rarely associated with a concomitant expression of the proliferation marker Ki-67. The elevated expression of Endoglin in surgically excised CNVM suggests a persisting post-mitotic activation in an advanced stage of this neovascular tissue.

Histological Findings in Experimental Macular Surgery with Indocyanine Green

PURPOSE

To analyze the effect of different concentrations and application intervals of indocyanine green (ICG) on the retina in an experimental setting of macular surgery.

METHODS

Twenty-one porcine eyes were used within 5 hours after enucleation. The eyes were hemisected and the vitreous removed. Different doses of ICG (up to 1 mg) were applied over the trephined macula, and the remainder of the eyecup was filled with a balanced salt solution (BSS). Both the ICG solution and the BSS were drained after 30 or 60 seconds and the complete eyecup irrigated and filled with fresh BSS. The posterior pole was then illuminated with a standard surgical light pipe and light source at maximum power for 3 minutes. Both the ICG-treated retina and the nontreated surrounding retina were processed for histology.

RESULTS

Exposure of the retina at different concentrations of ICG either for 30 or 60 seconds, followed by illumination, caused no histologically detectable damage compared with the controls. No microarchitectural disorganization or cellular disruption was detected. The vitreoretinal interface seemed unaffected.

CONCLUSIONS

Previously described severe damage to the inner retina of human donor eyes could not be found with even higher doses of ICG in this porcine model. Although differences within the species may contribute to these contradictory results, it is conceivable that the postmortem time and the vitality of the tissue influence the outcome in this ex vivo system.

Clinicopathological correlation of choroidal neovascularization after external beam radiotherapy in age-related macular degeneration

PURPOSE

To analyze the histopathology of choroidal neovascularization after external beam radiotherapy in age-related macular degeneration.

METHODS

A retrospective non-case-matched comparative histopathologic study. The histoarchitecture of nine surgically removed subretinal specimens from nine patients that had undergone external beam radiotherapy for exudative age-related macular degeneration was studied. Seven patients had received 20 Gy in 10 fractions and two 15 Gy in 5 fractions with an average time interval between radiotherapy and surgical extraction of 14 months (range 3-28). A consecutive series of classic, mixed and occult choroidal neovascular membranes served as controls.

RESULTS

Clinical findings. Radiation-associated choroidal neovasculopathy was angiographically suspected in four patients: a coarse net of vessels on fluorescein angiography developing at the border of previously irradiated choroidal neovascularization was observed in three patients; blebs at the margin of a plaque on indocyanine green angiography were observed in two patients. Pathological findings. Diffuse drusen as well as intra-Bruch's fibrovascular tissue was found in all irradiated specimens. In four specimens an edematous vascularized layer was seen between diffuse drusen and normal-appearing intra-Bruch's fibrovascular tissue. This lesion was not found in the control specimens. A particular correlation for the bleb lesion was not recognized.

CONCLUSION

The appearance of an edematous subretinal pigment epithelial vascularized layer between diffuse drusen and normal-appearing fibrovascular tissue in four of nine irradiated membranes may be secondary to previous irradiation. It may correlate with the unusual exudative manifestations observed after external beam radiotherapy.

Outcome of combined penetrating keratoplasty with vitreoretinal surgery for management of severe ocular injuries

PURPOSE

To assess the effectiveness of a combined procedure (pars plana vitrectomy with temporary keratoprosthesis, vitreoretinal surgery, and penetrating keratoplasty) and to determine which factors influence corneal transplant success rates.

METHODS

Records for 34 severely injured eyes of 31 consecutive patients who underwent penetrating keratoplasty in combination with vitreoretinal surgery between 1991 and 1998, with a follow-up of at least 12 months, were evaluated retrospectively. Analysis was focused on ocular history, functional and anatomic anterior and posterior segment outcome, and complications.

RESULTS

Penetrating keratoplasty was performed in 10 eyes (29%) within 8 weeks of trauma and in 24 eyes (71%) as a secondary procedure. Initial improvement in visual acuity (VA) was achieved in 47% of eyes; at the end of the follow-up, 74% of the eyes had attained equal or better VA than the initial postsurgical VA. Reasons for poor final VA were hypotony or phthisis (35%) and recurrent retinal detachment (11%). Corneal grafts remained clear for 1 year in 65% of eyes. Transplant failure was less in eyes that did not need a permanent silicone oil tamponade, when the retina was attached before surgery, and in eyes that were grafted later after trauma and received no further surgery. These were some conditions that were associated with a longer mean graft survival time, but without statistical significance. There was no difference in eyes according to the trauma mechanism, preoperative intraocular pressure, or graft size.

CONCLUSIONS

Penetrating keratoplasty in severely injured eyes is often complicated by ciliary body malfunction and secondary transplant failure. Although the functional outcome of a combined procedure is limited by primary and secondary tissue destruction, preserving ambulatory vision is possible and thus improves the quality of life, at least in patients with single remaining eyes.

["Masquerade foreign body" of the conjunctiva]

CASE REPORT

An eight months old child presented with a "red eye" and a corneal erosion since a week. The parents reported on a "hair" which was invisible most of the time but appeared intermittently at the lid margin. The medical history was otherwise unremarkable. In general anaesthesia, a long structure could be easily extracted. The tapering structure disclosed several tiny hair-like filaments sprouting from the thickened end. This end was embedded within a fold of conjunctiva, thus giving the impression of a hair sheath. Clinically, an ectopic "giant hair" was supposed. Histology, however, revealed plants cells and a birefringence too high for a hair so that a diagnosis of a plant foreign body was established.

CONCLUSION

Conjunctival foreign bodies may be overlooked especially in young children with no history of foreign body acquisition. They may occur as a "masquerade foreign body".

Combined penetrating keratoplasty and vitreoretinal surgery with silicone oil: a 1-year follow-up

BACKGROUND

The aim of this study was to assess the functional outcome of eyes with corneal and vitreoretinal diseases following combined surgical procedures (pars plana vitrectomy with temporary keratoprosthesis, vitreoretinal surgery, and penetrating keratoplasty with intravitreal silicone oil tamponade) and to evaluate the factors preserving the clarity of grafts.

METHODS

Fifty-three eyes from 49 consecutive patients, operated on between 1991 and 1998 and followed up for at least 12 months, were evaluated retrospectively. The evaluation focused on ocular history, visual acuity (VA), intraocular pressure, anterior and posterior anatomical outcome, and complications.

RESULTS

The average follow-up was 28.4 months+/-18.8 months (range 12-84 months); at the final visit 58% of the eyes had better VA, and 73% had equal or better acuity; the cornea remained clear in 68% of the eyes. A decrease in VA was caused by: loss of light perception in 2 eyes, one of which had to be enucleated because of painful phthisis; hypotony or phthisis in 23 eyes; recurrent retinal detachment in 4 eyes that were operated because of trauma; and immunological reaction in 2 eyes. Preoperative factors that contributed to a clear graft, but were not significant, were: lack of trauma (74%), no actual silicone oil filling (78%), preoperative VA of hand movement or better (79%), and attached retina (73%). Further surgery was needed in 55% of cases. The risk of transplant failure was significantly lower in eyes that did not undergo additional surgery (p=0.0001).

CONCLUSION

The long-term results of combined surgery with penetrating keratoplasty in eyes that would otherwise be untreatable is often limited by anterior segment complications, mainly secondary graft failure and ciliary body malfunction. For optimal preservation of graft clarity, stable ocular status should be achieved before transplantation to minimize the necessity for further surgery.

Ultrasound biomicroscopy in chronic ocular hypotony: its impact on diagnosis and management

PURPOSE

To determine the value of ultrasound biomicroscopy (UBM) in the assessment of ocular hypotony in cases where the underlying pathologic mechanism remains unclear after extensive clinical examination.

METHODS

In a retrospective study, the records of 60 patients who had undergone UBM to elucidate the underlying structural abnormalities of chronic ocular hypotony (intraocular pressure of 0-8 mmHg) were evaluated. Most patients (47 of 60 eyes) had a history of intraocular surgery or of other ocular diseases (e.g., uveitis), and after careful clinical examination, the cause had remained unclear. All patients were observed up for a minimum of 12 months.

RESULTS

The associated pathoanatomy of the hypotony was demonstrated by UBM in 95% of the cases. Ciliary body abnormalities were present in 80% of the eyes. Therapeutic intervention was associated with restoration of normal ocular pressure in 50% of the cases. Often more than one intervention was necessary. A long duration of hypotony did not impede reaching the therapeutic goal of normalizing intraocular pressure and preventing phthisis.

CONCLUSIONS

Ultrasound biomicroscopy is a new tool for detecting the underlying structural abnormalities in ocular hypotony. In cases where clinical examination is not sufficient it can be of great help in deciding on a course of treatment.

Prediction of axial length on the basis of vitreous body length and lens thickness: retrospective echobiometric study

PURPOSE

To examine the predictability of axial length measurement when lens thickness and vitreous body length are known.

SETTING

Center of Ophthalmology, University of Cologne, Cologne, Germany.

METHODS

This study comprised 227 patients with a mean age of 70.01 years +/- 12.47 (SD). None of the eyes examined had a history of surgery or trauma. Patients with systemic disease were excluded from the study. Before cataract surgery, the length of the vitreous body and thickness of the lens were measured and the correlation between these data and the axial length was evaluated. Two ultrasonic devices were used for biometric measurements: the BMS 811 Biometric System (Grieshaber) and the Cooper Vision Ultrascan Digital A+B-Scan 2000. The correlations between the axial length and vitreous body length and the lens thickness and vitreous body length were analyzed using multiple linear regression.

RESULTS

The BMS 811 provided the best prediction of axial length based on vitreous body length. Considering sex but not age significantly improved the model fit. With the BMS 811, the following formula was developed to predict axial length: Axial length (mm) = 7.129 mm + 0.095 mm x sex (female = 0, male = 1) + 1.040 x vitreous body length (mm). An approximate 95% prediction limit may be calculated by the following formula: Axial length (mm) +/- 2 x 0.413 mm.

CONCLUSIONS

This study yielded an easy-to-use formula for predicting the axial length using the vitreous body length and the patient's sex. The remaining error in prediction is likely to be the result of patient heterogeneity in age, ocular globe size, and lens thickness (cataract formation). Good prediction of the axial length is important to refractive outcomes to distinguish corneal myopia from axial length myopia to choose grafts and the opening size in penetrating keratoplasty. Further studies to detect a clinically relevant improvement in such outcomes are required to assess the utility of the prediction formula.

Macular translocation with 360 degrees retinotomy for exudative age-related macular degeneration

BACKGROUND

Macular rotation surgery comprises surgical extraction of choroidal neovascular membranes in age-related macular degeneration (AMD) and translocation of the foveal neural retina over adjacent retinal pigment epithelium.

OBJECTIVE

To determine whether macular translocation with 360 degrees retinotomy can stabilize and/or improve visual acuity in patients with subfoveal choroidal neovascularization (CNV) secondary to AMD.

DESIGN

This study consisted of a standardized surgical procedure on a series of 90 consecutive patients and follow-up examinations at fixed intervals for 12 months.

PARTICIPANTS

All patients in this study had experienced recent visual loss resulting from subfoveal CNV caused by AMD. Twenty-six patients had major macular subretinal hemorrhage, 39 patients had occult subfoveal CNV, and 25 patients had classic subfoveal CNV.

METHODS

Macular translocation surgery was performed between 1997 and 1999. The patients were examined preoperatively and at 3, 6, and 12 months postoperatively, including visual acuity, microperimetry, angiography, and orthoptic assessment.

RESULTS

Visual acuity increased by 15 or more letters in 24 patients, remained stable in 37 patients, and deteriorated by 15 or more letters in 29 patients at 12 months postoperatively. A secondary procedure was necessary in 17 patients because of severe complications; proliferative vitreoretinopathy was observed in 17 eyes, macular pucker in 5 eyes, and macular hole in 1 patient.

CONCLUSION

Macular translocation is a technically demanding surgical procedure. Although the procedure has a high rate of surgical and postoperative complications, the functional and anatomical results appear to be promising for selected patients with subfoveal CNV secondary to AMD.

[Macular translocation with 360 degree retinotomy in the treatment if exudative macular degeneration. Functional and angiographic results]

BACKGROUND

During surgical extraction of choroidal neovascular membranes (CNV) in age-related macular degeneration (AMD), the defective foveal retinal pigment epithelium (RPE) is removed. Subsequent translocation of the foveal neural retina to adjacent healthy RPE should result in stabilization and possibly improvement of visual acuity.

METHODS

A prospective case series was carried out using controlled surgery and examination protocols with examinations made at fixed intervals. The surgical procedures combine counterrotation of the globe, phacoemulsification and implantation of a posterior chamber lens, complete vitrectomy, induction of a total retinal detachment, 360 degrees anterior retinotomy, removal of the subfoveal neovascular complex, foveal translocation outside the RPE defect, reattachment of the retina using F6H8, peripheral laser retinopexy and temporary silicone oil tamponade.

PATIENTS

Macular translocation surgery was performed on 100 patients between December 1997 and December 1999. All patients had experienced recent visual loss due to exudative AMD and of these, 26 patients had major macular subretinal hemorrhage, 39 patients had occult and 25 patients classic subfoveal choroidal neovascularization. The preoperative findings in the remaining patients included tears in the pigment epithelium (n = 4), polypoidal choroidal vasculopathy (n = 1), recurrent subfoveal CNV following laser therapy (n = 2) and deep retinal vascular anomalous complexes (n = 3).

RESULTS

A total of 97 patients completed the 12-month examination. Visual acuity increased by 15 or more ETDRS chart letters in 24 patients, remained stable in 42 patients and deteriorated by 15 or more EDTRS chart letters in 34 patients 12 months postoperatively. The silicone oil tamponade was removed in 97 patients, in 10 patients, silicone oil had to be reinjected because of severe complications. A secondary procedure was necessary in 25 patients, primary PVR was observed in 9 eyes, secondary PVR developed in 10 eyes, a macular pucker in 5 eyes and a macular hole in 1 patient. Other postoperative complications included persistent hypotonia, macular edema, IOL dislocation, keratopathy and recurrent CNV (n = 3).

CONCLUSIONS

Macular translocation is a technically demanding operation, which requires a considerable learning curve. Although the procedure has a high rate of surgical and postoperative complications, the functional and anatomical results appear to be promising for selected patients with subfoveal CNV secondary to AMD.