ANGIOGRAPHIC EVIDENCE FOR REVASCULARIZATION OF AN RPE-CHOROID GRAFT IN PATIENTS WITH AGE-RELATED MACULAR DEGENERATION

Long-term clinical outcomes of submacular blood removal with isolated autologous retinal pigment epithelium-choroid patch graft transplantation in long-standing large-sized submacular hematomas: An Indian experience

Purpose:

To study the outcomes of submacular blood removal with isolated autologous full-thickness retinal pigment epithelial (RPE)-choroid patch graft transplantation in long-standing large-sized submacular hematomas in Indian population.

Methods:

A retrospective study was done on eight consecutive patients of long-standing large-sized submacular hematoma from east India. In all cases, 23G vitrectomy was performed with the induction of retinal detachment (performed with or without 38G or 41G subretinal cannula) and a temporal 180° retinectomy was done. Submacular blood along with choroidal neovascular tissue was removed. A full-thickness RPE-choroid autologous patch graft was taken from a relatively healthy quadrant at the mid periphery and then the graft transferred under perfluorocarbon liquid (PFCL) to place it in the subfoveal area. Then, retina was re-attached using PFCL and laser completed. Silicone oil (5000 cst) was used as a tamponade. Post-operatively, wide-field fundus photographs (Optos), serial optical coherence tomography (OCT), indocyanine green angiography (ICGA), and multifocal electroretinography (ERG) were done.

Results:

The mean age of the patients at presentation was 67.88 ± 10.03 years. Mean pre-operative best corrected visual acquity (BCVA) was 2.64 ± 0.3 log MAR and mean postoperative BCVA was 1.095 ± 0.27 log MAR (P < 0.05). The mean follow-up was 20 ± 16.57 months. ICG showed re-vascularization of translocated graft in all at 2 months. Multifocal ERG (after 6 months) showed some waveform in all. None of the cases developed re-bleed.

Conclusion:

Removal of submacular blood and neovascular membrane with autologous RPE-choroid graft is a viable option in cases with long-standing large submacular hematomas.

Deep Scleral Exposure: A Degenerative Outcome of End-Stage Stargardt Disease

PURPOSE

To describe a distinct phenotypic outcome of outer retinal degeneration in a cohort of genetically confirmed patients with recessive Stargardt disease (STGD1).

DESIGN

Retrospective case series.

METHODS

Twelve patients, who were clinically diagnosed with STGD1 and exhibited a unique degenerative phenotype, were included in the study. Two disease-causing mutations were found in all patients by direct sequencing of the ABCA4 gene. Clinical characterization of patients were defined on fundus photographs, autofluorescence images (488-nm and 532-nm excitation), spectral-domain optical coherence tomography (SD-OCT), and full-field electroretinogram (ffERG) testing.

RESULTS

Mean age at initial presentation was 67.8 years and reported age of symptomatic onset was 14.1 years (mean disease duration = 53.8 years). Best-corrected visual acuity ranged from 20/400 to hand motion. All patients exhibited advanced degeneration across the posterior pole resulting in a reflectively pale, blonde fundus owing to unobstructed exposure of the underlying sclera. SD-OCT revealed complete loss of the outer retinal bands (external limiting membrane, ellipsoid zone, interdigitation zone, and retinal pigment epithelium) and choroidal layers. Scotopic and photopic waveforms on ffERG were nonrecordable or severely attenuated in 8 patients who were tested.

CONCLUSIONS

Widespread scleral exposure is a clinical outcome in a subset of STGD1 following a long duration of disease progression (∼50 years). The blonde fundus in such cases may exhibit phenotypic overlap and shared therapeutic implications with other aggressive chorioretinal dystrophies such as end-stage choroideremia, gyrate atrophy, or RPE65-Leber congenital amaurosis.

COMBINED AUTOLOGOUS TRANSPLANTATION OF NEUROSENSORY RETINA, RETINAL PIGMENT EPITHELIUM, AND CHOROID FREE GRAFTS

PURPOSE

To evaluate the feasibility and initial functional and anatomical outcomes of transplanting a full-thickness free graft of choroid and retinal pigment epithelium (RPE), along with neurosensory retina in advanced fibrosis and atrophy associated with end-stage exudative age-related macular degeneration with and without a concurrent refractory macular hole.

METHODS

During vitrectomy, an RPE-choroidal and neurosensory retinal free graft was harvested in nine eyes of nine patients. The RPE-choroidal and neurosensory retinal free graft was either placed subretinally (n = 5), intraretinally to cover the foveal area inside an iatrogenically induced macular hole over the RPE-choroidal graft (n = 3) or preretinally (n = 1) without a retinotomy wherein both free grafts were placed over the concurrent macular hole. Silicone oil endotamponade was used in all cases.

RESULTS

Mean follow-up was 7 ± 5.5 months (range 3-19). The mean preoperative visual acuity was ∼count fingers (logarithm of the minimum angle of resolution = 2.11, range 2-3), which improved to ∼20/800 (logarithm of the minimum angle of resolution 1.62 ± 0.48, range 0.7-2, P = 0.04). Vision was stable in 5 eyes (55.6%) and improved in 4 eyes (44.4%). Reading ability improved in 5 eyes (55.6%). Postoperative complications were graft atrophy (n = 1), epiretinal membrane (n = 1), and dislocation of neurosensory retina-choroid-RPE free graft (n = 1).

CONCLUSION

Combined autologous RPE-choroid and neurosensory retinal free graft is a potential surgical alternative in eyes with end-stage exudative age-related macular degeneration, including concurrent refractory macular hole.

VISUAL RECOVERY AFTER AUTOLOGOUS RETINAL PIGMENT EPITHELIUM AND CHOROIDAL PATCH IN A PATIENT WITH CHOROIDAL NEOVASCULARIZATION SECONDARY TO ANGIOID STREAKS: LONG-TERM RESULTS

PURPOSE

To describe a successfully treated case of autologous retinal pigment epithelium and choroidal patch in a patient with choroidal neovascularization secondary to angioid streaks.

METHODS

A 53-year-old man with angioid streaks and a subfoveal choroidal neovascularization underwent autologous retinal pigment epithelium and choroid transplantation. Lensectomy, pars plana vitrectomy, 200° peripheral temporal retinotomy, isolation of the patch, endolaser, and silicone oil tamponade 1,000 cts were performed. Preoperative and postoperative ophthalmic examinations included best-corrected visual acuity, fluorescein angiography, indocyanine green angiography, autofluorescence, and optical coherence tomography.

RESULTS

Two months after surgery, best-corrected visual acuity (Snellen equivalent) improved from 20/200 to 20/100. At 6 months, best-corrected visual acuity further increased to 20/40 and the reading ability, which was absent preoperatively, improved to J2. Visual results were maintained after 2.5 years and no recurrence of choroidal neovascularization was observed.

CONCLUSION

Transplantation of a full-thickness patch of retinal pigment epithelium and choroid under the fovea may be considered to prevent retinal atrophy with significant visual improvement in the case of a low active choroidal neovascularization secondary to angioid streaks. Moreover, preoperative optical coherence tomography might guide in highlighting those patients in whom the outer retinal layers are still visible as the best candidate for surgery.

Direct Blood Flow Measurements in a Free RPE-Choroid Graft with Phase-Resolved Doppler OCT

PURPOSE

We directly demonstrated the revascularization in a free retinal pigment epithelium (RPE)-choroid graft with direct blood flow detection by experimental phase-resolved Doppler optical coherence tomography (PRD-OCT).

METHODS

Seven patients with age-related macular degeneration underwent an RPE-choroid graft translocation in a prospective institutional cohort study. Spectral domain optical coherence tomography (SD-OCT) was used to measure the revascularization stage. With PRD-OCT the presence of flow was imaged postoperatively.

RESULTS

The PRD-OCT confirmed flow in three patients when SD-OCT indicated the afferent vessel ingrowth stage, and in all seven patients when the SD-OCT indicated the efferent vessel ingrowth stage.

CONCLUSIONS

The PRD-OCT study was able to detect the presence of blood flow in a free RPE-choroid graft. The PRD-OCT findings directly confirmed the revascularization that was otherwise based on the more circumstantial evidence provided by SD-OCT images and angiography.

TRANSLATIONAL RELEVANCE

The use of both techniques to monitor the revascularization process in a free graft in patients are an interesting example of replacing more invasive by noninvasive techniques. There is potential future use of PRD-OCT for the visualization of vascularization patterns in other pathologies.

Histology and immunochemistry evaluation of autologous translocation of retinal pigment epithelium-choroid graft in porcine eyes

PURPOSE

To evaluate structure and cellular functionality of retinal pigment epithelium (RPE)-choroid grafts after autologous translocation in porcine eyes.

METHODS

Retinal pigment epithelium-choroid grafts were obtained from the nasal midperiphery donor site and translocated to the central area in 12 pigs (12 eyes). Grafts were placed under the central retina through a retinotomy. Ophthalmoscopic and pathological evaluations were performed immediately (n = 1) and at 15 (n = 3) and 30 (n = 3) days after surgery. Untranslocated nasal RPE-choroid grafts were obtained at time of surgery and used as controls. Specimens were evaluated by standard histology and by immunochemical studies of RPE65, CRALBP and GFAP.

RESULTS

Five animals were lost to follow-up owing to surgery or anaesthesia complications. Ophthalmoscopic examination revealed that the grafts remained in place at all time-points studied. Fifteen and thirty days postsurgery, some areas of the transplanted RPE maintained a monolayered structure. Retinal pigment epithelium cells were firmly attached to Bruch's membrane and predominantly preserved polarity and pigment distribution. However, RPE65, CRALBP and GFAP patterns of expression and distribution were diminished and modified during follow-up. Ophthalmoscopic retinal detachment and proliferative vitreoretinopathy (PVR), confirmed by microscopic evaluation, complicated all cases at 30 days of follow-up.

CONCLUSION

Autologous RPE-choroid grafts survived up to 30 days in porcine eyes. Histological and immunochemical evaluation revealed preserved transplanted RPE cells morphology accompanied by alterations in the immunoreactivity expression of functional proteins, and development of significant PVR. The data presented in this manuscript provide insights into the fate, viability and cellular functionality of the transplanted RPE-choroid graft, serving as foundation for further knowledge and improvement of this technique.

A pedicled autologous choroid RPE patch: a technique to preserve perfusion

The aim of the study is to report a technique of a pedicled autologous choroid retinal pigment epithelium (RPE) patch that aims to preserve perfusion of the transplanted tissue. A case report of a patient with sudden vision deterioration due to submacular hemorrhage in age-related macular degeneration. The surgery involved a 180-degree peripheral retinectomy and the creation of a pedicled graft instead of an isolated one. Outcome measures included preoperative and postoperative visual acuity and optical coherence tomography scans at 1, 3, 6, 12 months and patch vascularization on postoperative indocyanine green angiography. Postoperatively the patch was positioned under the fovea with an intact pedicle. Indocyanine green angiography showed perfusion through the pedicle and patch vasculature on the third postoperative day. Best corrected visual acuity improved from 0.5/50 to 5/50 at 1 month and remained stable over 1 year follow-up. No choroidal neovascularization recurrence was observed. This case report demonstrates the feasibility of a pedicled RPE-choroid graft that is an alternative to a free isolated graft. Our modification of patch surgery, by demonstrating early perfusion, offers an advantage, similar to macular translocation, when photoreceptors are embedded in RPE and choroid with blood circulation immediately after the surgery.

Autologous translocation of the retinal pigment epithelium and choroid in the treatment of neovascular age-related macular degeneration

PURPOSE

To evaluate clinical results of an autologous translocation of retinal pigment epithelium (RPE) and choroid in the treatment of neovascular age-related macular degeneration (AMD).

METHODS

Twelve eyes which underwent surgery for neovascular AMD were included into the study, in four eyes moderate or massive submacular haemorrhage was present. The surgical procedure included standard pars plana vitrectomy; cataract surgery in phakic patients; peripheral 180°-retinotomy; extraction of the submacular neovascular complex and removal of blood if present; preparation of a full-thickness graft consisting of RPE, Bruch's membrane and choroid; translocation of the graft to the macular area; and silicone oil endotamponade.

RESULTS

Visual acuity (VA) ranged from perception of hand movements (HM) to 20/125 (median, counting fingers (CF)-1/50) before surgery. During follow-up (FU) mean, 11.1 months, VA increased to a maximum median of 1/10 (range, HM-20/40). At the end of FU, VA had dropped to a median of CF-1/40 (range, HM-20/50). Comparing VA preoperatively and at the end of FU, VA had improved in six eyes, was unchanged in three eyes, and had deteriorated in three eyes. One eye had reading ability. Surgery-associated postoperative complications impairing the functional outcome occurred in five eyes, including rhegmatogenous retinal detachment and proliferative vitreoretinopathy. Revision surgery had to be performed in four eyes (30%). Three eyes had to be left with permanent silicone endotamponade. Results tended to be better in the subgroup of eyes with massive submacular haemorrhage preoperatively.

CONCLUSION

Functional results of a translocation of RPE and choroid were heterogeneous and rather disappointing in this study. Results may have been influenced negatively by case selection. We found a relatively high rate of adverse events in the postoperative course. In selected cases, e.g. massive submacular haemorrhage or progressive neovascular AMD unresponsive to other treatment options, autologous translocation of RPE and choroid may still be considered.

Phase-stabilized optical frequency domain imaging at 1-µm for the measurement of blood flow in the human choroid

In optical frequency domain imaging (OFDI) the measurement of interference fringes is not exactly reproducible due to small instabilities in the swept-source laser, the interferometer and the data-acquisition hardware. The resulting variation in wavenumber sampling makes phase-resolved detection and the removal of fixed-pattern noise challenging in OFDI. In this paper this problem is solved by a new post-processing method in which interference fringes are resampled to the exact same wavenumber space using a simultaneously recorded calibration signal. This method is implemented in a high-speed (100 kHz) high-resolution (6.5 µm) OFDI system at 1-µm and is used for the removal of fixed-pattern noise artifacts and for phase-resolved blood flow measurements in the human choroid. The system performed close to the shot-noise limit (<1dB) with a sensitivity of 99.1 dB for a 1.7 mW sample arm power. Suppression of fixed-pattern noise artifacts is shown up to 39.0 dB which effectively removes all artifacts from the OFDI-images. The clinical potential of the system is shown by the detection of choroidal blood flow in a healthy volunteer and the detection of tissue reperfusion in a patient after a retinal pigment epithelium and choroid transplantation.

Surgery for CNV and autologous choroidal RPE patch transplantation: exposing the submacular space

BACKGROUND

To evaluate the feasibility of transplanting a full-thickness patch of choroid, choriocapillaries, Bruch's membrane and RPE (RPE-choroid FTAP) from the peripheral to the subfoveal area of the same eye, after performing a 180 degrees peripheral retinotomy and removing subfoveal choroidal neovascularization. Thereafter, to study the surgical complications, anatomical outcome and patch perfusion during follow-up.

METHODS

A retrospective case series of 13 eyes of 13 consecutive patients with a follow-up of 4 to 20 months. All patients suffered from advanced subfoveal choroidal neovascularization and were non-responders to standard care. After performing a complete vitrectomy, a 180 degrees peripheral temporal retinotomy and the removal of subfoveal neovascularization, a FTAP of choroid, choriocapillaris, Bruch's membrane and the RPE were isolated from the mid periphery of the uveal bed, transpositioned under the fovea and covered with the retina. Patients received a complete ophthalmic examination, fluorescein angiography (FA), indocyanin green angiography (ICGA) and optical coherence tomography (OCT) during follow-up.

RESULTS

An FTAP could be harvested in every eye and transplanted under the fovea. No intraoperative complications occurred. The FTAP was recognizable at FA, ICGA and OCT at each time point, up to 20 months postoperatively. Perfusion of the choroidal bed were observed into the FTAP during follow-up, from one week after surgery.

CONCLUSION

The creation of an FTAP through a 180 degrees peripheral retinotomy is feasible and safe. The FTAP is vital and perfused. Further studies are needed to collect more data.