Visual function after foveal translocation with scleral shortening in patients with myopic neovascular maculopathy

Novel Predictors of Visual Outcome in Anti-VEGF Therapy for Myopic Choroidal Neovascularization Derived Using OCT Angiography

PURPOSE

To explore novel prognostic factors associated with visual function and number of anti-vascular endothelial growth factor (VEGF) treatments in eyes with active myopic choroidal neovascularization (mCNV) using OCT angiography (OCTA).

DESIGN

Prospective case series.

PARTICIPANTS

Twenty-eight treatment-naïve eyes with active mCNV from 27 consecutive patients (mean age, 64.4 ± 11.1 years).

METHODS

All eyes received through injection a single loading dose of intravitreal aflibercept (IVA), followed by additional IVA on a pro re nata (PRN) basis during the subsequent 12 months. At baseline, OCTA images of a 3 × 3-mm macular cube were acquired using an OCTA scanner. On binarized and skeletonized OCTA images of the outer retinal layer, OCTA-derived baseline parameters of mCNV-including lesion size, vessel density, vessel length density (VLD), vessel diameter index, and fractal dimension (FD)-were measured and evaluated for correlation with 12-month best-corrected visual acuity (BCVA) and number of additional injections.

MAIN OUTCOME MEASURES

The primary and secondary outcomes were BCVA 12 months after initial treatment and number of additional injections, respectively.

RESULTS

There was no significant difference between baseline and 12-month BCVA (0.37 ± 0.30 and 0.30 ± 0.35 logarithm of the minimal angle of resolution, respectively; P = 0.23). The number of additional injections was 0.93 ± 1.02 (mean ± standard deviation). Baseline VLD, FD, and BCVA were correlated with 12-month BCVA (P = 0.02, r = 0.46; P = 0.02, r = 0.46; and P = 0.02, r = 0.45, respectively), and VLD also was correlated with the number of additional injections (P = 0.03, r = 0.42).

CONCLUSIONS

Exuberant mCNV, which is characterized by high VLD and FD derived using OCTA, is a predictor of poor visual outcomes after a single IVA injection followed by a PRN regimen. Only baseline VLD was correlated with the number of additional IVA injections, which indicates that this parameter could help to determine the optimal anti-VEGF treatment regimen for individual eyes with mCNV.

Choroidal neovascularization in pathological myopia

Myopic choroidal neovascularization (CNV) is one of the leading causes of visual impairment worldwide. The clinical and socioeconomic impact of myopic CNV in Asian countries is particularly significant due to rising trend in the prevalence and severity of pathological myopia. The exact pathogenesis of myopic CNV remains unclear and there is paucity of information with respect to incidence and risk factors for myopic CNV from prospective studies. Furthermore, there are no recognized measures that may prevent or delay the development of CNV in eyes with pathological myopia. Advances have been made in the diagnosis and characterization of myopic CNV over the years. Until recently, treatment modalities for myopic CNV were limited to thermal laser photocoagulation and photodynamic therapy with verteporfin, both these modalities primarily aim at prevention of further visual loss. In the last 5 years, inhibitors of vascular endothelial growth factor (VEGF) have been used successfully and may improve vision to some extent. Nevertheless, the long-term safety and efficacy of anti-VEGF agents remains unknown. Furthermore, the risk of developing chorioretinal atrophy remains the key factor in determining the final visual outcome. This review article summarizes the current literature on myopic CNV, highlighting new evolving diagnostic and treatment modalities, prognostic factors influencing visual outcome, and areas of future research.

Diplopia and strabismus following ocular surgeries

Postoperative diplopia and strabismus may result from a variety of ocular surgical procedures. Common underlying mechanisms include sensory disturbance, scarring, direct extraocular muscle injury, myotoxicity from injections of local anesthesia or antibiotics, and malpositioning of extraocular muscles by implant materials. The most common patterns are vertical and horizontal motility disturbance. Treatment options include prisms, botulinum, occlusion, or surgery.

Photodynamic therapy vs limited macular translocation in the management of subfoveal choroidal neovascularization in pathologic myopia: a two-year study

PURPOSE

To compare the results of limited macular translocation and photodynamic therapy (PDT) in subfoveal choroidal neovascularization (CNV) attributable to pathologic myopia with a 24-month follow-up.

DESIGN

Retrospective analysis of nonrandomized interventional clinical study.

METHODS

Retrospective review of 66 consecutive patients: 34 myopic eyes with subfoveal neovascularization treated by PDT and 32 operated on with the translocation technique. Translocation was considered principally when the lesion size was adequate (nasal inferior margin of the membrane less than half a disk diameter away from the center of the fovea) with duration of symptoms of less than four months. Main outcome measure was the postoperative change in visual acuity.

RESULTS

In the translocation group, mean gain in visual acuity was greater than in the PDT group (+2.8 lines and -1.8 line, respectively, P = .001). In the translocation group, 55% of eyes gained 3 lines or more at two years compared with 10% in the PDT group. Sixty percent of eyes in the translocation group vs 40% in the PDT group had an improvement of at least five letters. Mean foveal displacement after translocation was 906 mum; postoperative complications included retinal detachment (three eyes), macular fold (one eye), and transient diplopia (four eyes). In young patients, the postoperative gain was better in both groups. In the translocation group, mean survival time for choroidal neovascularization recurrence was 40 months for patients younger than 40 years and 20 months for older patients.

CONCLUSIONS

Translocation showed better results than PDT at two years. Further studies are required to confirm these findings.

Étude rétrospective comparant la translocation maculaire limitée et la photothérapie dynamique dans la néovascularisation choroïdienne rétrofovéale de la myopie forte

PURPOSE

To analyze the results of limited macular translocation (MT) and photodynamic therapy (PDT) in subfoveal choroidal neovascularization due to degenerative myopia, with a minimum follow-up of 12 months.

METHODS

Retrospective review of 55 consecutive patients: 31 eyes were treated using PDT and 24 were operated on with the limited macular translocation technique with chorioscleral infolding described by de Juan. Before and after each treatment, a complete examination comprised visual acuity, fundus examination, fluorescein angiography, and optical coherence tomography. Mean follow-up was 14 months in the PDT group and 19 months in the MT group.

RESULTS

The improvement in visual acuity was better in the MT group than in the PDT group and was correlated with younger age (p<0.001). At month 12, visual acuity improved by 3 ETDRS lines or more in 6 six eyes of the PDT group (19%), with no improvement over 6 lines. In the MT group, visual acuity improved by 3 lines in 14 eyes (58%) including 8 eight eyes (33%) with an improvement of 6 lines or more. Final visual acuity remain unchanged (+/-2 lines) in 16 eyes of the PDT group (66%) and 8 eight eyes of the MT group (33%), and decreased in 9 nine eyes in the PDT group (29%) versus 2 two eyes in the MT group (8%). Mean gain in visual acuity at 12 months was +3.5 ETDRS lines in the MT group and -0.1 line in the PDT group (p=0.001). The mean displacement of the fovea after translocation was 950 microm. The mMean number of PDT treatments was 2.3 during the 12-month follow-up.

CONCLUSIONS

Limited macular translocation allowed provided a significant improvement in visual acuity in some eyes with subfoveal neovascularization in myopia, especially in young patients, and resulted in a moderate rate of complications. Longer follow-up and further controlled and randomized studies are required to confirm these encouraging findings.

Field-Dependent Aniseikonia Associated with an Epiretinal Membrane

PURPOSE

Aniseikonia is a binocular anomaly in which the two eyes perceive images of different sizes and/or shapes. It is usually assumed to be constant as a function of visual field angle (VFA) (i.e., angular distance from the line of sight). This is correct for optically induced aniseikonia, such as the aniseikonia that is associated with anisometropia and probably also pseudophakia. The purpose of this article is to show that if the aniseikonia is of retinal origin, then the aniseikonia may no longer be constant as a function of VFA (i.e., field-dependent aniseikonia).

DESIGN

Case report, with the patient having a unilateral epiretinal membrane.

METHODS

The aniseikonia was measured in vertical and horizontal directions with a customized version of the Aniseikonia Inspector software. The VFA was made variable by changing the dimensions of the comparison targets in the direct comparison procedure.

MAIN OUTCOME MEASURE

Aniseikonia as a function of VFA.

RESULTS

The patient exhibited good repeatable aniseikonia, ranging from 23% to 2.5% for VFAs ranging from 0.36 degrees to 5.7 degrees . Higher angles had lower aniseikonia. A control subject did not show this field-dependent aniseikonia.

CONCLUSIONS

Aniseikonia may vary with VFA due to a retinal cause such as an epiretinal membrane. The problem with field-dependent aniseikonia is that it cannot be corrected fully with conventional optics, which exhibit an approximately constant magnification as a function of VFA. Nevertheless, by correcting 5% to 10% aniseikonia, which showed up in the VFA measurement range at 2 degrees to 3 degrees , our patient had improved visual comfort, especially for reading.

Choroidal neovascularisation in pathological myopia: an update in management

Choroidal neovascularisation (CNV) secondary to pathological myopia is an important cause of significant visual impairment in young and middle aged adults globally and is particularly prevalent in Asian populations. In the past few years, there have been rapid advancements in the different treatments for myopic CNV. The purpose of this perspective is to give an overview of the natural history of myopic CNV and the various treatment options including laser photocoagulation, photodynamic therapy, sub-macular surgery, and macular translocation surgery. Future directions in the management of myopic CNV are also discussed.

Effect of experimental scleral shortening on axial length of the rabbit eye

PURPOSE

To evaluate the change of axial length (AL), intraocular pressure (IOP), and corneal astigmatism after scleral shortening with scleral invagination in the rabbit eye.

METHODS

The authors performed scleral shortening (3 mm) with scleral invagination in two groups of 6 eyes each: 180 degrees (group 1) and 360 degrees (group 2).

RESULTS

Average AL shortening was more prominent in group 2 (0.5 +/- 0.17 mm) than in group 1 (0.37 +/- 0.29 mm), but the difference was not statistically significant. IOP increased immediately after the procedure and was maintained at a high level through 2 months postoperatively. Induced corneal astigmatism was more prominent in group 1 than in group 2. The difference was statistically significant in group 1 (p<0.05) but not in group 2.

CONCLUSIONS

In the scleral shortening with scleral invagination procedure, a large amount of scleral invagination resulted in more shortening of axial length, but there was more corneal astigmatism in 180-degree invagination of the sclera than in 360-degree. Further research is required to determine the effect of the extent of scleral invagination on the change of these values.

Photodynamic therapy with verteporfin for subfoveal choroidal neovascularisation of pathologic myopia in Chinese eyes: a prospective series of 1 and 2 year follow up

AIMS

To evaluate the visual and fluorescein angiographic outcomes of photodynamic therapy (PDT) with verteporfin in patients with subfoveal choroidal neovascularisation (CNV) caused by pathologic myopia in the Chinese.

METHODS

Prospective, non-comparative, two centre interventional study. Patients with CNV secondary to pathologic myopia of Chinese ethnicity were recruited and treated with a standard regimen of PDT with verteporfin. Results of this study in Chinese eyes with pigmented retinal pigment epithelium were compared with those from the Verteporfin in Photodynamic Therapy (VIP) Study of predominantly white eyes.

RESULTS

Thirty one and 22 eyes that completed the 12 month and 24 month follow up studies respectively were analysed. The mean and median best corrected visual acuities (BCVA) could be maintained at the baseline level at the 12 month and 24 month visits. Fourteen (63.6%) eyes had stable or improved BCVA at 24 months and six (27.3%) of them had a moderate gain in vision (improved by three or more lines). Visual results were comparable with that of the VIP study, but the average accumulative PDT treatments required in one and two years were 1.7 and 2.3 respectively, which were significantly less than 3.4 and 5.1 treatments in VIP study. Mean logMAR BCVA of the younger age group (<55 years) at 24 months was 0.41 (SD 0.29), which was significantly better than the older age group (>/= = 55 years) of 0.82 (SD 0.40) (Mann-Whitney U test, p = 0.029).

CONCLUSIONS

PDT using the predetermined treatment protocol has achieved similar visual outcomes in the Chinese population as in white people with subfoveal myopic CNV over a 2 year study period. The complete cessation of CNV leakage can be accomplished, on average, with fewer PDT retreatments than reported in the VIP study. The disparity may be due to ethnic differences in these two populations.

FOVEAL SENSITIVITY AND FIXATION STABILITY BEFORE AND AFTER MACULAR TRANSLOCATION WITH 360-DEGREE RETINOTOMY

PURPOSE

To evaluate the functional changes of the fovea by scanning laser ophthalmoscopy (SLO) fundus perimetry after macular translocation with 360-degree retinotomy, and to determine whether the preoperative macular function estimated by the sensitivity of the fovea and the stability of fixation can predict visual acuity after the surgery.

METHODS

Macular translocation with 360-degree retinotomy and simultaneous torsional muscle surgery were performed on 25 eyes of 25 patients with choroidal neovascularization. The index of foveal sensitivity (Isens) and the index of fixation stability (Ifix) before and after surgery were calculated from the microperimetric data. The preoperative Isens and Ifix were compared with postoperative Isens and Ifix, respectively. The correlations of preoperative Isens and Ifix with the visual acuity after the translocation surgery (VApost) were calculated.

RESULTS

Isens increased in 14 (56%) of 25 eyes. Ifix improved in 10 (40%) of 25 eyes. The preoperative Isens and VApost were moderately correlated (r = 0.434, P = 0.0295), while the preoperative Ifix and VApost were highly correlated (r = - 0.530, P = 0.0057).

CONCLUSION

An increase in foveal sensitivity and an improvement in the fixation stability were demonstrated quantitatively by microperimetry. The preoperative foveal sensitivity and fixation stability were correlated with the postoperative visual acuity. Microperimetry using SLO can be used to investigate foveal function before and after the translocation and to predict the postoperative visual acuity.

Retinal changes after macular translocation with 360-degree retinotomy in monkey eyes

PURPOSE

To determine the morphologic and functional changes of the fovea and retina of monkey eyes after macular translocation with 360-degree retinotomy.

DESIGN

Experimental study.

METHODS

The retinas of eight monkey eyes were surgically translocated with a 360-degree retinotomy with procedures similar to those used on human eyes. At 1, 2, and 3 months after the surgery, the six eyes that had successful surgery were studied by light and transmission electron microscopy, terminal deoxynucleotidyl transferase (TdT)-dNTP terminal nick-end labeling (TUNEL) assay, and immunohistochemistry with peanut agglutinin (PNA) lectin and glial fibrillary acidic protein (GFAP). Retinal physiology was assessed by scotopic and photopic electroretinograms (ERGs).

RESULTS

The fovea was successfully translocated approximately 30 to 40 degrees superiorly in six eyes. The translocated macula and fovea had a normal layered architecture with no TUNEL-positive cells, minimal misalignment of the outer segments, and strong immunoreactivity to GFAP. The mean amplitudes of the scotopic and photopic b-waves were significantly reduced at 1 month after the surgery, and there was only a slight recovery at 3 months. No significant changes were observed in the mean implicit times after the surgery.

CONCLUSION

These findings indicate that macular translocation surgery with 360-degree retinotomy results in minimal morphologic alterations but significant depression of electrophysiologic function.

Subretinal fibrosis after photodynamic therapy in subfoveal choroidal neovascularisation in highly myopic eyes

AIMS

To analyse the occurrence of subretinal fibrosis (SRF) after photodynamic therapy (PDT) with verteporfin in highly myopic eyes with subfoveal choroidal neovascularisation (CNV).

METHODS

PDT with verteporfin was performed on 33 eyes of 32 highly myopic patients with subfoveal CNV. Patients were followed for 14-24 months and best corrected visual acuity (BCVA) and angiographic and funduscopic findings were recorded.

RESULTS

Two patients (two eyes) were lost to follow up. SRF appeared in 14 of 31 eyes. SRF appeared more frequently in eyes with a spherical equivalent (SE) of less than -10 D, in patients of age equal to or less than 55 years, and when CNVs were larger than 1500 micro m in diameter. SRF appeared more frequently in the group of patients with worse final BCVA.

CONCLUSIONS

The appearance of SRF after treatment is correlated with size of the CNV and SE. The results of this study indicate that highly myopic eyes with CNV treated with PDT do not show a decrease in BCVA, even though they develop SRF. The appearance of SRF after PDT in highly myopic CNV does not always imply a loss of BCVA from baseline, though its presence is more frequent in eyes with lower BCVA.

Angiographic characteristics in patients undergoing macular translocation for subfoveal choroidal neovascularization secondary to age-related macular degeneration

PURPOSE

To review in a standardized fashion pre- and postoperative fluorescein angiographic characteristics in patients undergoing limited macular translocation (LMT) with scleral imbrication to treat subfoveal choroidal neovascularization (SFCNV) secondary to age-related macular degeneration (AMD). The current study was undertaken to assess any potential effects of the translocation procedure on altering the angiographic characteristics of SFCNV before laser photocoagulation.

METHODS

A consecutive series of patients undergoing LMT for AMD was identified retrospectively. The pre- and postoperative fluorescein angiograms were reviewed in a masked fashion. Angiographic characteristics evaluated included pre- and postoperative lesion components, stability of lesion, and the amount of retinal translocation obtained.

RESULTS

Eighty-eight patients (90 eyes) had angiograms of adequate quality to permit evaluation. Time between the preoperative and the prelaser angiogram ranged from 2 to 84 days (median 7.5 days). Neovascular complexes remained unchanged or decreased in size in 79% of patients. There was no statistically significant difference in lesion size between the pre- and postoperative periods (P = 0.34). Retinal movement ranged from 160 microm to 3,320 microm (median 960 microm), with 61% of cases undergoing effective translocation (i.e., the fovea was moved away from the neovascular complex). None of the lesion components or demographic factors evaluated affected the amount of translocation obtained. Larger lesions were more likely to remain subfoveal following translocation (P = 0.004).

CONCLUSION

The size and lesion characteristics appear relatively stable following translocation. Amount of retinal movement is not associated with angiographic lesion characteristics. Only size was associated with achievement of desired translocation in the final model, with large lesions being less likely to achieve desired translocation. In our study group, the amount of retinal translocation was variable with 61% of cases undergoing effective translocation.

Verteporfin photodynamic therapy in highly myopic subfoveal choroidal neovascularisation

AIMS

To analyse the visual and angiographic results of photodynamic therapy (PDT) with verteporfin in highly myopic patients with subfoveal choroidal neovascularisation (CNV).

METHODS

PDT was performed on highly myopic patients with subfoveal CNV. The patient population was divided into two groups according to age at onset of CNV (group 1 aged < or = 55 and group 2 aged >55 years old). Best corrected visual acuity (BCVA) and angiographic findings were considered.

RESULTS

At the end of follow up group 2 had worse BCVA than group 1. 76% of patients in both groups showed a complete closure of CNV at the end of follow up.

CONCLUSION

Visual prognosis of myopic CNV treated by PDT is influenced by age at onset.

Pathologic myopia: where are we now?

PURPOSE

To describe current concepts and available treatments for pathologic myopia.

DESIGN

Review of experimental and clinical studies.

METHODS

The demography, natural history, medical and surgical treatments for choroidal neovascular membrane, vitreoretinal interface disorders and future strategies for pathologic myopia are reviewed.

RESULTS

Several medical and surgical modalities are currently available to treat various complications of pathologic myopia. Macular translocation appears to stabilize or improve visual function in many eyes with choroidal neovascularization.

CONCLUSION

Newer strategies are emerging to better ameliorate or prevent the complications of pathologic myopia.

Surgical treatment of subfoveal neovascularization in myopia: macular translocation vs surgical removal

PURPOSE

To compare the visual outcome of two different surgical approaches for subfoveal neovascularization in degenerative myopia: macular translocation and surgical removal of choroidal neovascularization (CNV).

DESIGN

Interventional case series.

METHODS

Retrospectively, 32 eyes with degenerative myopia (axial length over 26 mm or refraction over -6 diopters) and subfoveal CNV of 32 consecutive patients operated on by either surgical removal of CNV or limited macular translocation were reviewed. Surgical removal of CNV was performed in 18 eyes and limited macular translocation with a twofold suture in 14 eyes. The main outcome measurements were best-corrected visual acuity (BCVA) and findings from fluorescein angiography. Postoperatively, mean +/- SD follow up was 14 +/- 15 months (range, 6-48 months) in the removal group and 11 +/- 4 months (range, 6-24 months, P =.37) in the translocation group.

RESULTS

In both groups, there was no significant difference in preoperative age, sex, refractive error, or BCVA. The average of postoperative BCVA was statistically better after macular translocation (10 ETDRS lines or 20/100) than after surgical removal (6 lines 10/125, P =.019). Visual acuity improved by 3.8 lines after macular translocation and was unchanged after surgical removal (-0.7 line, P =.011). Macular translocation was successful in shifting the CNV to an extrafoveal location in 11 out of 14 eyes. Mean foveal displacement of all 18 translocated eyes was 695 +/- 426 microm (range, 100-1520 microm). Recurrence of CNV occurred in seven eyes (39%) after surgical removal and in two eyes (14%) after translocation. Retinal detachment occurred in two eyes in each group.

CONCLUSION

In this retrospective study, eyes with degenerative myopia and subfoveal neovascularization treated with limited macular translocation had better visual acuity recovery than eyes treated with surgical removal of the choroidal neovascularization. Further studies are required to confirm these results.

Limited macular translocation with scleral retraction suture

BACKGROUND/AIMS

Macular translocation with scleral imbrication is a new technique for treating subfoveal choroidal neovascular membranes (CNV). This procedure shortens the sclera but may result in a minimal decrease in the internal circumference of the globe and limits the amount of foveal displacement. The authors propose a new scleral retraction suture aimed at decreasing the internal circumference of the globe in an effort to increase foveal displacement.

METHODS

Using a cadaver model, they compared the amount of scleral shortening using a standard scleral imbrication technique and a modified three suture scleral retraction technique. Sections of the globes were digitised and specialised software was used to estimate the amount of scleral shortening. Three patients with subfoveal choroidal neovascularisation underwent limited macular translocation using pars plana vitrectomy and macular detachment with the modified scleral suture technique. The main outcome measures were visual acuity, foveal displacement, and complications.

RESULTS

In the cadaver model, the scleral retraction suture resulted in a flatter internal scleral fold compared to the standard suture technique and created approximately 890 microm of effective scleral shortening. In the patients who underwent macular translocation and laser photocoagulation of the CNV, visual acuity improved in two patients and worsened in one patient. The range of foveal displacement was 1400-2400 microm.

CONCLUSION

The foveal displacements achieved in this limited study compared to median displacement previously published using standard suture techniques demonstrates that the scleral retraction suture technique may be a useful adjunct to limited macular translocation. The advantage of this type of suture in conjunction with translocation may depend on the effective scleral shortening offered by this retraction suture.

Long-term visual acuity after argon green laser photocoagulation of juxtafoveal choroidal neovascularization in highly myopic eyes

PURPOSE

To evaluate visual outcomes in patients with high myopia afterjuxtafoveal choroidal neovascularization (CNV) treated with argon green laser photocoagulation.

PATIENTS AND METHODS

We retrospectively analyzed 23 eyes of 21 patients with high myopia (>6.0 diopters and/or axial length >26 mm) with juxta foveal CNV treated with direct Argon green laser photocoagulation. Mean age at diagnosis was 49.08+/-12.20 years (range, 29 to 71). Mean follow-up was 54.26+/-26.18 months (range 18 to 96).

RESULTS

Best corrected visual acuity (BCVA) before treatment was 0.09+/-0.10 (range, 0.01 to 0.40). Two months after treatment it was 0.14+/-0.12 (0.01 to 0.6), significant difference (p=0.02, Student's t-test forpaired data) and aftersix months 0.19+/-0.14 (0.01 to 0.5) (p=0.0002). Mean BCVA decreased with follow-up, to 0.19+/-0.15 (0.01 to 0.4) after two years, 0.16+/-0.15 (0.01 to 0.5) after three years and 0.16+/-0.19 (0.01 to 0.7) after four years, with no significant improvement after the third year (p=0.04). In two cases CNV reappeared.

CONCLUSIONS

Direct argon green laser photocoagulation in high-myopia juxtafoveal CNV can improve BCVA initially for between two and 24 months. The improvement fades with time, and is no longer significant after the third year.

Successful macular translocation with temporary scleral infolding using absorbable sture

PURPOSE

To describe successful macular translocation with temporary scleral infolding in a series of patients with small subfoveal choroidal neovascularization due to age-related macular degeneration or ocular histoplasmosis syndrome.

METHODS

Ten eyes of 10 consecutive patients were studied in a prospective, nonrandomized clinical trial. Macular translocation with scleral infolding (MTSI) was performed. Absorbable polyglactin suture was used to create temporary scleral infolding. Distance and stability of retinal translocation, corneal topography, visual acuity, and rates of complications were measured.

RESULTS

The median distance of translocation in the early postoperative period was 1,700 microm (range, 680-3,200) and did not regress after resolution of the scleral infolding. Induced postoperative oblique corneal astigmatism resolved, coinciding with the disappearance of peripheral retinal elevation due to scleral infolding. Three patients gained more than two lines of vision, two patients were within two lines of preoperative vision, and five patients lost more than two lines of vision. Complications were similar to previously published reports.

CONCLUSION

Temporary scleral infolding is an effective technique in MTSI. The distance of translocation is comparable to that achieved with nonabsorbable suture or scleral resection, and does not regress after resolution of the scleral infolding. Induced postoperative corneal astigmatism appears to resolve.

Electrophysiological changes after 360 degrees retinotomy and macular translocation for subfoveal choroidal neovascularisation in age related macular degeneration

AIM

To evaluate electrophysiological changes after 360 degrees retinotomy and macular translocation for subfoveal choroidal neovascularisation in patients with age related macular degeneration (AMD).

METHODS

A consecutive series of 32 patients suffering from subfoveal choroidal neovascularisation secondary to AMD underwent 360 degrees retinotomy and macular translocation. The ERG served as the main parameter of the study and was recorded 1 day before the translocation surgery and no earlier than 4 weeks after the silicone oil removal.

RESULTS

The scotopic ERG amplitudes were significantly reduced after translocation surgery. Depending on the applied flash luminance the mean b-wave amplitude reduction of the scotopic ERG varied between 67% (0.2 cd.s/m2) and 74% (0.03 cd.s/m2). The a-waves and b-waves of the saturating light response decreased significantly by 46% and 59%, respectively. The photopic a-wave and b-wave amplitudes were significantly lower after the translocation surgery resulting in a mean reduction of 27% and 43%, respectively.

CONCLUSIONS

Although macular translocation may provide the potential of preserving and even restoring vision in patients with subfoveal choroidal neovascular membranes secondary to AMD the present study indicates that a significant electrophysiological decrease is caused by surgical procedures associated with this technique. Further research is necessary to clarify if certain modifications of the surgical procedure are able to substantially reduce the neuroretinal trauma.

Foveal translocation with scleral imbrication in patients with myopic neovascular maculopathy

PURPOSE

To report our surgical results of foveal translocation with scleral imbrication in patients with myopic neovascular maculopathy.

DESIGN

Noncomparative, interventional, consecutive case series.

METHODS

Ten eyes of 10 myopic patients with subfoveal neovascular membranes that had undergone foveal translocation with scleral imbrication were recruited for this retrospective study. Inclusion criteria were myopia 6.0 diopters or greater in refractive error (or axial length 26.5 mm or longer), subfoveal choroidal neovascularization, and preoperative best-corrected visual acuity of 20/100 or worse. None of these eyes had undergone prior laser photocoagulation or submacular surgery. The main outcome measures were surgical complications and postoperative visual function.

RESULTS

Postoperatively, visual acuity had improved more than 3 lines in the logarithm of minimum angle of resolution (logMAR) measurement in all eyes. The mean preoperative, postoperative best, and final visual acuity were 0.12, 0.59, and 0.51, respectively. Of the 10 eyes, six achieved a postoperative final visual acuity of 20/40 or better. The mean postoperative foveal displacement was 0.78 disk diameter (range, 0.3--1.3 disk diameter). Two patients underwent a reoperation because of insufficient foveal displacement. Furthermore, one of these two patients required a third operation to reduce an excessive retinal fold involving the fovea induced by the second surgery. Of the 10 patients, two noted transient diplopia. This complaint, however, resolved over time as suppression developed. Although unintentional iatrogenic retinal tears formed intraoperatively in two eyes, these were successfully treated without serious complications. Postoperatively, mild retinal pigment epithelial changes were observed in all cases, but none led to significant deterioration of visual acuity during the follow-up period. All patients but one were followed for a minimum of 6 months.

CONCLUSIONS

In eyes with myopic neovascular maculopathy, foveal translocation with scleral imbrication may be useful in improving visual acuity. Further refinements in surgical technique and assessment of the long-term complications will be needed to make this procedure safer and more useful.

Macular translocation with chorioscleral outfolding: an experimental study

PURPOSE

Macular translocation by chorioscleral infolding has been proposed as a surgical intervention for exudative age-related macular degeneration, but the surgery is unpredictable and can be associated with severe complications. We tested a new surgical technique, macular translocation with chorioscleral outfolding secured by neurosurgical clips.

METHODS

This was a prospective interventional study in two parts; the first in human cadaver eyes and the second in pigs. Chorioscleral infolding was performed on six human donor eyes, and chorioscleral outfolding was performed on an additional six. The inner surface of the eye wall was measured, and then the fold was unfolded and the distance was measured again. In the second half of the study, macular translocation surgery was performed on 33 pig eyes with one of three sclera shortening methods: 1) a circumferential chorioscleral infolding using 5-0 nylon sutures, 2) a circumferential chorioscleral outfolding using scleral clips, or 3) a radial chorioscleral outfolding using scleral clips. Foveal translocation was measured.

RESULTS

The inner wall of the human cadaver eye was shortened in the chorioscleral infolding group by a mean of 1.6 mm, and in the chorioscleral outfolding group by 3.0 mm. In the pig eyes, the fovea was translocated a mean 2377 microm by circumferential suturing, 2582 microm by circumferential clipping, and 3386 microm by radial clipping. Irregular deformation of the globe was more apparent in the circumferential suture group. Undesirable retinal folds often formed after circumferential infolding but not after radial clipping.

CONCLUSION

Radial chorioscleral outfolding with clips is more predictable and effective than infolding. It produces more translocation and prevents folds across the fovea, one of the most undesirable complications in macular translocation surgery.

Induced corneal astigmatism after macular translocation surgery with scleral infolding

OBJECTIVE

To document the corneal astigmatism that occurs with macular translocation after scleral infolding surgery.

DESIGN

Retrospective case series of a nonrandomized clinical trial.

PARTICIPANTS

Eight consecutive age-related macular degeneration patients (eight eyes) with choroidal neovascularization who underwent macular translocation with scleral infolding at the Duke University Eye Center from December 1998 through October 1999.

METHODS

We retrospectively reviewed the charts of eight consecutive patients who underwent macular translocation surgery involving scleral infolding in the superotemporal quadrant. Two patients subsequently underwent release of scleral infolding.

MAIN OUTCOME MEASURES

After surgery, these eyes were evaluated for corneal astigmatism with manifest refraction, keratometry, and computerized corneal topography.

RESULTS

All eight eyes of eight patients revealed marked degrees of corneal astigmatism. Measurement of astigmatism via manifest refraction, keratometry, and corneal topography confirmed postoperative astigmatism corresponding to the axis of the scleral infolding. The amount of corneal astigmatism ranged from 1.75 to 7.37 diopters (D; mean, 4.60 D), with steepening along the axis of scleral infolding in the superotemporal quadrant of each eye (mean, 42.50 degrees from vertical; range, 24 degrees -66 degrees from vertical). Release of scleral infolding in two patients resulted in significant reduction of corneal astigmatism.

CONCLUSIONS

Scleral shortening procedures used in macular translocation surgery may induce large amounts of corneal astigmatism. These patients should be assessed with keratometry and corneal topography to determine the accurate amount and axis. Thereafter, contact lens fitting or scleral infolding release may be considered as therapeutic options for large amounts of astigmatism persisting after surgery.

Macular translocation: unifying concepts, terminology, and classification

PURPOSE

To describe some unifying concepts, terminology, and classification of macular translocation so as to facilitate communication within the scientific community.

METHODS

A panel of ophthalmologists with expertise in macular translocation reviewed available data and developed some unifying concepts, terminology, and classification of macular translocation.

RESULTS

Macular translocation may be defined as any surgery that has a primary goal of relocating the central neurosensory retina or fovea intraoperatively or postoperatively specifically for the management of macular disease. It may be classified according to the size of the retinotomy and, where applicable, the technique of chorioscleral shortening used. The direction of macular translocation is denoted by the movement of the neurosensory macula relative to the underlying tissues. Effective macular translocation may be defined as successful intraoperative or postoperative relocation of the fovea overlying a subfoveal lesion to an area outside the border of the lesion. The concepts of minimum desired translocation and median postoperative foveal displacement can give some useful idea of the likelihood of effective macular translocation before surgery.

CONCLUSIONS

Use of a common standardized terminology for macular translocation will facilitate communication within the scientific community and enhance further research in this area. However, the definitions, terms, classification, and concepts concerning macular translocation are likely to continue to evolve as macular translocation undergoes further modifications and refinements.

Correction of cyclovertical strabismus induced by limited macular translocation in a case of age-related macular degeneration

PURPOSE

To report a case of strabismus surgery performed to treat cyclovertical strabismus induced by limited macular translocation.

METHODS

Case report.

RESULTS

A 62-year-old man suffering with age-related macular degeneration and subfoveal choroidal neovascularization, RE, underwent limited macular translocation surgery. The fovea was rotated downward, and his visual acuity improved from 20/100 to 20/25 postoperatively. Cyclovertical diplopia persisted for 6 months after the operation. A Hess screen test revealed a pattern that simulated an underaction of the superior oblique muscle and inferior rectus muscle with an overaction of the ipsilateral inferior oblique muscle. To treat the diplopia, advancement of the superior oblique muscle tendon and resection of the ipsilateral inferior rectus muscle were performed. Binocular single vision with 140 seconds of arc for stereopsis was obtained.

CONCLUSION

Cyclovertical strabismus after limited macular translocation is corrective with conventional surgery on the treated eye.

Initial experience of inferior limited macular translocation for subfoveal choroidal neovascularization resulting from causes other than age-related macular degeneration

PURPOSE

To report our initial experience of inferior limited macular translocation in patients with subfoveal choroidal neovascularization resulting from causes other than age-related macular degeneration.

METHODS

We conducted a retrospective study of 23 eyes of 22 patients with choroidal neovascularization involving the foveal center secondary to pathologic myopia (11 eyes), ocular histoplasmosis syndrome (four eyes), angioid streaks (four eyes), idiopathic neovascularization (three eyes), and multifocal choroiditis (one eye), in which the fovea was moved inferiorly by means of limited macular translocation surgery. The mean preoperative best-corrected visual acuity was 20/150, and in five of 23 eyes (21.7%) the visual acuity was 20/80 or better. The major outcome measures were preoperative and postoperative visual acuity, postoperative foveal displacement, and complications related to the surgery.

RESULTS

The mean postoperative follow-up was 10.82 months (range, 6 to 18 months). Postoperative best-corrected visual acuity improved by 2 or more Snellen lines of visual acuity in 11 of 23 eyes (47.82%), remained within 1 line in seven of 23 eyes (30.43%), and worsened 2 or more lines of vision in five of 23 eyes (21.74%). The mean postoperative best-corrected visual acuity was 20/100, and in 12 of the 23 eyes (52.17%) the visual acuity achieved was 20/80 or better. Retinal detachment was the most frequent complication and occurred in six eyes (26%).

CONCLUSIONS

Our initial experience with limited macular translocation shows that this treatment modality offers the potential to improve visual function in some eyes with subfoveal choroidal neovascularization secondary to myopia, ocular histoplasmosis syndrome, angioid streaks, idiopathic neovascularization, and multifocal choroiditis. Although longer and more complete follow-up is needed, the results of this initial series warrant further studies to define the precise role of macular translocation in the management of these conditions.

Visual function after foveal translocation with 360-degree retinotomy and simultaneous torsional muscle surgery in patients with myopic neovascular maculopathy

PURPOSE

To assess functional and anatomical outcomes after foveal translocation with 360-degree retinotomy and simultaneous torsional muscle surgery in patients with myopic neovascular maculopathy.

METHODS

Foveal translocation with 360-degree retinotomy was performed in 11 eyes of 11 patients with myopic neovascular maculopathy. Ten eyes had simultaneous torsional muscle surgery with recession of the superior oblique muscle and tucking of the inferior oblique muscle. Silicone oil removal with or without intraocular lens implantation was performed 2 to 8 weeks after the primary procedure. Visual acuity, binocular function, and degree of cyclotorsion were assessed preoperatively and postoperatively. Angles of retinal and globe rotation, distance of foveal shift, and surgical complications were also investigated.

RESULTS

With a mean postoperative follow-up of 6.2 months (range, 3 to 13 months), vision improved (greater than 0.2 logarithm of minimal angle of resolution [logMAR] units) in eight eyes, was unchanged in two eyes, and worsened (greater than 0.2 logMAR units) in 1 eye. Seven of 11 eyes (64%) had a final visual acuity of 20/50 or better. Five patients developed or maintained binocular fusion, four patients continued to have suppression, and two patients developed diplopia that was managed by spectacles with Fresnel prisms. Subjective cyclotorsion was less than 8 degrees in 10 eyes. Mean retinal and globe rotations were 23.4 degrees and 19.8 degrees, respectively. Average size of the choroidal neovascular membrane was 0.8 disk diameter, whereas the average distance of foveal shift was 1.5 disk diameter. After the primary procedure, three eyes developed retinal detachment, one eye macular hole, and one eye proliferative vitreoretinopathy. These complications were successfully managed by additional surgery.

CONCLUSION

Foveal translocation with 360-degree retinotomy is effective in restoring vision in some patients with myopic neovascular maculopathy. Although the development of torsional diplopia is generally obviated by simultaneous extraocular muscle surgery, a relatively high incidence of surgical complications should be taken into account with this procedure.

Complications associated with limited macular translocation

PURPOSE

To report the ocular complications associated with the limited macular translocation procedure.

METHODS

Retrospective review of 153 consecutive eyes of 151 patients that had the limited macular translocation procedure for subfoveal choroidal neovascularization between April 1996 and February 1999. The major study variables investigated included the incidence of specific ocular complications and their impact on visual acuity at 3 months after the surgery. In addition, baseline patient characteristics and operative factors were evaluated to determine whether they were significant risk factors for the development of an ocular complication. The existence of a surgical procedure learning process was investigated.

RESULTS

One hundred forty-one (92.15%) of 153 eyes achieved at least 3-month follow-up. At least one complication occurred in 53 of 153 eyes (34.6%) and in 51 of these 53 eyes (96. 22%) the complications occurred before 3 months of postoperative follow-up. The intraoperative and postoperative complications included retinal detachment (17.4%), retinal breaks (13.4%), macular holes (7.8%), macular fold (4.6%), and intraocular hemorrhage (vitreous, subretinal, or choroidal; 9.2%). Eyes that developed retinal detachment, subretinal hemorrhage, and macular fold had significantly more loss of visual acuity than eyes without each of these complications (P =.0001, P =.038, and P =.027, respectively). The presence of predominantly classic choroidal neovascularization, the occurrence of an intraoperative retinal break, any intraocular hemorrhage, or macular fold formation were significantly associated with retinal detachment (P =.021, P =.025, P =.013, and P =.014, respectively). The incidence of any complication, retinal detachment, and hemorrhage significantly decreased during the study period, suggesting a learning process (P =.03, P =.006, P =.027, respectively).

CONCLUSIONS

A variety of ocular complications can occur during or after limited macular translocation, and some are associated with reduced postoperative visual acuity. Improved surgical techniques and experience may significantly reduce the incidence of these complications.

Macular translocation: histopathologic findings in swine eyes

PURPOSE

Macular translocation has been proposed as an alternative technique in the treatment of some cases of choroidal neovascularization. The purpose of the paper is to report the histopathologic findings in the retina of swine eyes undergone macular translocation.

METHODS

Ten eyes of ten Yucatan pigs underwent posterior pars plana vitrectomy and scleral imbrication to achieve macular translocation. Mattress sutures were preplaced at the equator of the eyes. After a pars plana vitrectomy, balanced saline solution was injected under the temporal retina to produce a retinal detachment. Scleral imbrication was achieved by tightening the mattress sutures. An air-fluid exchange was performed and the eye was filled with sulfur hexafluoride 18%. The eyes were enucleated 2, 4, 8 and 12 weeks after surgery and analyzed under light and electron microscopy.

RESULTS

Macular translocation was achieved in all cases. The major findings consist of a minimal decrease in the number of photoreceptors outer segments; also a change in the morphology was noted. This included some degree of loss of vertical alignment and an increase in the interphotoreceptor space. There was a recovery in the morphology of the photoreceptors over time.

CONCLUSIONS

Minimal changes in the photoreceptors and retinal pigment epithelium are observed when macular translocation is performed with recovery of these changes over time. Scleral imbrication is an effective technique to achieve translocation of the fovea.

Limited inferior macular translocation for the treatment of subfoveal choroidal neovascularization secondary to age-related macular degeneration

PURPOSE

To review a series of patients with age-related macular degeneration undergoing limited macular translocation for the treatment of subfoveal choroidal neovascularization, to determine short-term visual acuity outcomes, to measure amounts of attainable retinal movement, and to identify prognostic factors.

METHODS

A retrospective review was conducted on a consecutive series of patients undergoing inferior limited macular translocation with scleral imbrication for the treatment of subfoveal choroidal neovascularization secondary to age-related macular degeneration. The main outcome measures investigated were distance of macular translocation, visual acuity at 3 and 6 months after surgery, change in visual acuity from baseline, and the development of intraoperative and postoperative complications. Univariate and multivariate analyses of a number of potential prognostic factors were undertaken.

RESULTS

Macular translocation was achieved in all 102 eyes (101 patients) included in this study. The range of movement varied from 200 to 2,800 microm with a median movement of 1, 200 microm. Nearly 33% of the study group achieved a visual acuity better than 20/100 at 3 months, and 49% achieved this vision at 6 months. At 3 and 6 months, 37% and 48% of the study group, respectively, experienced 2 or more lines of improvement on visual acuity testing, and by 6 months 16% experienced greater than 6 lines of visual improvement. Good baseline vision, achieving the desired amount of macular translocation, a greater amount of macular translocation, and recurrent choroidal neovascularization at baseline were associated with better visual acuities at 3 and 6 months. Poor preoperative vision and the development of complications were associated with worse vision at 3 and 6 months.

CONCLUSIONS

Limited macular translocation is a technically feasible procedure that can lead to significant visual improvement and good visual acuity in some patients presenting with subfoveal choroidal neovascularization associated with age-related macular degeneration. A randomized prospective clinical trial of this surgical technique is warranted.

Comparison of visual function after foveal translocation with 360 degrees retinotomy and with scleral shortening in a patient with bilateral myopic neovascular maculopathy

PURPOSE

To compare the visual outcome after foveal translocation by scleral shortening and that after 360 degrees retinotomy with extraocular muscle surgery in a patient with bilateral myopic neovascular maculopathy.

METHODS

Case report.

RESULTS

A 52-year-old woman with bilateral myopic neovascular maculopathy underwent foveal translocation with scleral shortening in the left eye, and visual acuity improved from 20/70 to 20/30. However, choroidal neovascularization recurred, and the final visual acuity was 20/40 after excision of the choroidal neovascularization. Foveal translocation with 360 degrees retinotomy was performed on the right eye, and visual acuity improved from 20/150 to 20/30. The critical print size was better, and the retinal sensitive area was larger in the right eye.

CONCLUSION

The better reading ability shown by foveal translocation by a 360 degrees retinotomy compared with scleral shortening may stem from a larger retinal sensitive area obtained by this method.

Macular translocation

Macular translocation is a term used to describe any surgical procedure that involves the deliberate detachment of the retina with subsequent repositioning of the macula to a new location relative to the underlying retinal pigment epithelium. By moving the fovea away from abnormal pigment epithelium and/or choroid and repositioning it over more normal tissue, macular function can be stabilized or improved. Various techniques have been developed to accomplish this movement. Although this approach holds great promise for selected conditions (in particular, subfoveal choroidal neovascularization), the optimal technique to be used and the long-term prognosis are uncertain.

Foveal relocation by redistribution of the neurosensory retina

AIM

To describe a new surgical technique for foveal relocation, and to report the outcome in nine patients treated with this procedure.

METHODS

Nine consecutive patients with subfoveal choroidal neovascular membranes (CNVMs) secondary to age related macular degeneration underwent foveal relocation surgery by redistribution of the neurosensory retina (RNR). The technique involved induction of a retinal detachment via a single retinotomy, relocation of the fovea by "sweeping" the retinal tissue with a retinal brush, and stabilisation of the retina in its new location using perfluorocarbon liquid peroperatively and silicone oil postoperatively.

RESULTS

In eight of nine eyes successful relocation of the fovea was achieved; in one eye the CNVM remained in a subfoveal location postoperatively. Visual acuity improved in two eyes, remained unchanged in three, and decreased in four eyes after a median follow up of 4 months (range 2.5-6 months). Complications included rupture of a foveal cyst with the development of a macular hole in one eye and epimacular membrane formation in another eye. In two eyes, macular retinal vessel closure occurred at the time of laser photocoagulation; one of these eyes later developed cystoid macular oedema and the other an epiretinal membrane. Recurrence of the CNVM was observed in one eye, but was controlled with further laser treatment.

CONCLUSIONS

Foveal relocation by RNR appears to be feasible, obviating the need for extensive retinotomies or scleral shortening.

Macular translocation for subfoveal choroidal neovascularization in age-related macular degeneration: a prospective study

PURPOSE

To conduct a prospective study of macular translocation in patients with subfoveal choroidal neovascularization secondary to age-related macular degeneration.

METHODS

In 10 eyes of 10 patients with subfoveal choroidal neovascularization and best-corrected visual acuity ranging from 20/50 to 20/800 (median, 20/111), the fovea was relocated by means of scleral imbrication, intentional retinal detachment with small posterior retinotomies, and partial fluid-air exchange. In two eyes, the choroidal neovascular membranes were removed at the time of macular translocation; in seven eyes they were photocoagulated in the postoperative period; and in one eye the membrane was removed during reoperation to unfold a macular fold.

RESULTS

All 10 eyes were followed up for 6 months. The median postoperative foveal displacement was 1286 microm (range, 114 to 1,919 microm). In three eyes (30%), a foveal fold formed postoperatively requiring reoperation, with one of these eyes requiring a second reoperation for a rhegmatogenous retinal detachment. Best-corrected visual acuity improved in four eyes (median, 10.5 letters) and decreased in six eyes (median, 14.5 letters). The median change in visual acuity was a decrease of 5 letters. The final best-corrected visual acuity was 20/80 in two eyes, 20/126 in one eye, 20/160 in four eyes, 20/200 in one eye, 20/250 in one eye, and 20/640 in one eye.

CONCLUSIONS

Our initial experience with limited macular translocation suggests that this surgical technique is unpredictable. However, in patients with subfoveal choroidal neovascularization from age-related macular degeneration, it offers the potential for improving visual function and may be associated with less loss of vision than the disease itself, if allowed to progress. Further refinements in surgical indications and technique are needed to make this procedure safer, more predictable, and more beneficial.

Randomized trial of radiation for age-related macular degeneration

PURPOSE

To assess external beam radiation efficacy for subfoveal neovascularization associated with age-related macular degeneration.

METHODS

All patients were evaluated in the same institution. In this prospective trial, 27 eyes (27 patients) with subfoveal neovascularization associated with age-related macular degeneration were randomized to either single fraction radiation (750 centigray) or observation. Endpoints were assessed by fluorescein angiography and Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity. Examiners were masked to patient treatment status. Parametric and nonparametric statistical analyses were performed.

RESULTS

Twenty-seven patients were entered into the trial with a mean age of 76 years (range, 64 to 89) and a mean follow-up of 17 months (range, 7 to 32). The visual acuity loss was slightly less in the irradiated group, a finding of borderline significance (P < .046). There was no significant difference in fluorescein angiographic evidence of subretinal neovascular membrane change in the control group vs the irradiated group.

CONCLUSIONS

External beam radiation, at this dose and fractionation, did not appear harmful. There was slightly less visual loss in irradiated eyes. No difference in fluorescein angiographic characteristics of subfoveal neovascularization size or progression in eyes with age-related macular degeneration was noted.

Anatomic and functional recovery of the fovea after foveal translocation surgery without large retinotomy and simultaneous excision of a neovascular membrane

PURPOSE

To document the anatomic and functional recovery of the fovea after foveal translocation surgery with scleral shortening and simultaneous excision of a neovascular membrane in a patient with age-related macular degeneration.

METHOD

Case report.

RESULTS

The visual acuity of a 54-year-old woman with age-related macular degeneration improved from 20/200 to 20/50 after excision of subretinal neovascular membrane and foveal translocation surgery in the right eye. Fixation shifted inferonasally 0.6 disk diameters, corresponding to the direction of foveal translocation, as shown by scanning laser ophthalmoscope microperimetry. Postoperative optical coherence tomography through fixation disclosed normal foveal concavity and intact retinal pigment epithelium.

CONCLUSION

Anatomic and functional recovery of the fovea was confirmed in a patient with age-related macular degeneration after foveal translocation surgery with scleral shortening and simultaneous excision of a neovascular membrane.