Strabismus surgery for large-angle cyclotorsion after macular translocation surgery.

PURPOSE: We report the results of a new strabismus surgical procedure to address the large-angle cyclotorsion induced by macular translocation surgery for severe age-related macular degeneration. METHODS: The strabismus surgery described is a modification of earlier-described surgery(1) and was performed for symptomatic incyclotorsion measuring 20 degrees or more (by Maddox rod testing) after macular translocation. Surgery included superior oblique tenotomy and inferior oblique advancement, with transposition of the lateral and medial recti to the insertions of the superior and inferior recti, respectively, in the affected eyes. Minimum follow-up time was 6 weeks. RESULTS: Fifteen patients (15 eyes) had macular translocation surgery with incyclotorsion of 20 degrees or more. Mean incyclotorsion after macular translocation (36.1 +/- 9.4 degrees; range, 20-55) was reduced to 1.5 +/- 6.4 degrees after strabismus surgery (P <.0001), with 2 overcorrections and no surgical complications. Mean follow-up time was 24.8 +/- 13.4 weeks. All patients showed a hypertropia of the fellow eye. The mean pre-op hypertropia of 22 +/- 8 PD was reduced to 3 +/- 9 PD after strabismus surgery (P <.0001). The mean exotropia was minimally altered by strabismus surgery (21 +/- 10 PD pre vs 17 +/- 8 PD postop). All patients were symptomatic prior to strabismus surgery: 4 of 15 patients with "tilt" (objects appearing subjectively rotated with respect to their true orientation); 2 of 15 patients with diplopia; and 9 of 15 patients with both. Postoperatively, 7 patients had residual milder symptoms: tilt, 2 patients; diplopia, 3 patients; and both, 2 patients. Two patients required additional muscle surgery (on the fellow eye) for persistent symptoms. No patient showed binocular function (stereopsis or motor fusion) after macular translocation, either before or following strabismus surgery for cyclotorsion. CONCLUSION: The strabismus surgery described is effective at reducing the large degree of cyclotorsion (>or= 20 degrees) often resulting from macular translocation surgery, but does not allow reestablishment of binocular function.     

Diplopia after limited macular translocation surgery

PURPOSE: Full macular translocation surgery relocates the fovea away from choroidal neovascularization, inducing significant postoperative torsional diplopia. In "limited macular translocation," a saline-induced retinal detachment is followed by scleral imbrication with mattress sutures and spontaneous retinal reattachment. In this study, diplopia was characterized in patients treated with limited macular translocation. METHODS: Two surgeons performed retinal translocation surgery on 250 patients over an 18-month time span. The extent and direction of the retinal translocation, and the amount and location of scleral imbrication, were recorded. All patients complaining of diplopia were referred for ocular motility evaluation and treatment. RESULTS: Thirteen (5.2%) patients complained of occasional or constant diplopia. Imbricating sutures were placed supero-temporally in all cases. Inferior foveal translocation ranged from 200 to 2115 microm (median, 1750 microm). Visual acuity ranged from 20/40 to 20/400 in the operated eye. Prism-and-cover testing underestimated the strabismus when compared with subjective testing. In 3 patients, there was no shift on alternate-cover testing despite binocular diplopia. Excyclotorsion ranged from 0 degrees to 16 degrees. Diplopia resolved in 10 cases with prism; 3 required an occlusive filter for distortion or aniseikonia. One patient underwent successful strabismus surgery to eliminate dependence on prism glasses. CONCLUSIONS: Limited macular translocation only rarely produces symptomatic diplopia. Suprisingly, traditional prism-and-cover testing does not reliably quantify the misalignment. This may result from the combination of a persistent macular scotoma and a repositioned fovea relative to the peripheral retina. Prism therapy is generally satisfactory in the absence of retinal distortion or aniseikonia.     

Results of compensatory extraocular muscle surgery after macular translocation

PURPOSE: Macular translocation is an optional surgical treatment for age-related macular degeneration. However, this technique induces postoperative torsional complaints and surgical counterrotation of the globe is mandatory. The purpose of this study is to report the effect of compensatory extraocular muscle surgery upon the torsional complaints in patients who underwent a macular translocation procedure. DESIGN: The pre- and postoperative data on the first 35 patients in our department who underwent a counterrotation procedure after macular translocation surgery are reviewed. METHODS: From November 2001 to January 2005, 35 patients underwent a macular translocation procedure, with subsequent extraocular muscle surgery to counterrotate the eye. Three types of rectus muscle transposition procedures were used: full-tendon transposition of two opposite rectus muscles, "crossed" half-tendon transposition of all rectus muscles ('split & cross' procedure), and "uncrossed" half-tendon transposition of all rectus muscles ('split & neighbor cross' procedure). In the majority of patients these procedures were associated with oblique muscle surgery. RESULTS: With the selected procedures, retinal excyclodeviations are easier to correct then retinal incyclodeviations. In our hands, full-tendon transposition of two opposite rectus muscles with or without associated oblique muscle surgery, never corrects more than 30 degrees. 'Split & cross' procedures combined with oblique muscle surgery are sufficient for retinal excyclodeviations of 30-45 degrees and for incyclodeviations of up to 30 degrees; 'split & neighbor cross' procedures combined with oblique muscle surgery are sufficient for retinal excyclodeviations of 45-65 degrees and for incyclodeviations of up to 40 degrees . CONCLUSIONS: The effect of the various procedures appears to be predictable. It is possible to select a surgical procedure as a function of the amount of retinal cyclodeviation.     

Changes in focal macular ERGs after macular translocation surgery with 360 degrees retinotomy

PURPOSE: To evaluate the short- and long-term changes of focal macular electroretinograms (fmERGs) after macular translocation with 360 degrees retinotomy. METHODS: This was a retrospective study. fmERGs were recorded in 19 eyes of 19 consecutive patients who underwent macular translocation with 360 degrees retinotomy for choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD; 17 eyes) or polypoidal choroidal vasculopathy (2 eyes). The changes in the fmERGs, recorded before, shortly after (6-12 months; mean 8.3 months), and more than 18 months (18-30 months; mean 22.4 months) after surgery from 12 eyes, were analyzed. A 15 degrees stimulus centered on the fovea was used to elicit the fmERGs. RESULTS: The mean logarithm of minimum angle of resolution (logMAR) was 1.06 +/- 0.07 (20/230) before surgery, 0.78 +/- 0.08 (20/121) early after surgery (n = 19), and 0.64 +/- 0.07 (20/87) late after surgery (n = 12). These improvements in visual acuity were significant (P = 0.0074, P = 0.0050, respectively). Before surgery, the amplitudes of all components of the fmERGs were markedly reduced in all eyes. The mean b-wave amplitude in 17 AMD eyes recorded early after surgery was significantly larger (P = 0.0262), and the mean a-wave amplitude was also increased but not significantly (P = 0.1180). The mean amplitudes of the a- and b-waves in 10 AMD eyes recorded after 18 months were significantly larger than those before the surgery (P = 0.0218, and P = 0.0284). The mean implicit time of the b-wave in 17 AMD eyes decreased early after surgery, and a further decrease was detected at the later testing time. CONCLUSIONS: These results indicate that macular function is partially recoverable after macular translocation in some patients.     

Severe hypotony after macular translocation surgery with 360-degree retinotomy

PURPOSE: To report a case of severe hypotony after macular translocation with 360-degree retinotomy. DESIGN: Interventional case report. METHODS: A 50-year-old woman with myopic neovascular maculopathy underwent macular translocation with 360-degree retinotomy in her left eye. RESULTS: After the second procedure of silicone oil removal, severe hypotony developed. No clear sign of leakage was found. Pure perfluoropropane gas tamponade was then performed, which resulted in temporal resolution of severe hypotony, but the hypotony recurred as the gas bubble was absorbed. Ten weeks after the second surgery, the hypotonous eye was refilled with silicone oil. No apparent cyclitic membrane was observed intraoperatively. After this procedure, the choroidal and retinal folds regressed; intraocular pressure has been between 5 and 7 mm Hg for more than 4 months thereafter. CONCLUSION: Severe hypotony can occur as a complication of otherwise uneventful macular translocation with 360-degree retinotomy.     

Strabological findings after macular translocation surgery with 360 degrees retinotomy

PURPOSE: To examine the strabological findings after macular translocation surgery with a 360 degrees retinotomy. METHODS: Thirty-two patients who underwent macular translocation surgery were divided into three groups based on their responses to the Bagolini striated lenses test: fusion, ignoring the image, and diplopia. The relevant factors affecting binocularity were compared among the three groups. RESULTS: Five patients had peripheral fusion and three of these had gross stereopsis. Fifteen patients ignored the second image, and 12 patients had diplopia. The objective angle of macular rotation was smaller in the patients with peripheral fusion (15.0 +/- 6.1 degrees) than in those with diplopia (32.7 +/- 11.7 degrees). The subjective angle of cyclotorsion in those with peripheral fusion (6.0 +/- 4.2 degrees) was smaller than in those who ignored the image ("ignoring" group; 20.5 +/- 9.19 degrees) and the diplopia group (30.7 +/- 12.8 degrees). The amount of torsional sensory compensation in patients with diplopia (2.08 +/- 3.83 degrees) was significantly smaller than in those with peripheral fusion (9.00 +/- 7.42 degrees) and in the ignoring group (6.73 +/- 3.86 degrees). Patients with peripheral fusion were significantly younger (54.2 +/- 14.3 years) than those in the ignoring group (67.7 +/- 10.0 years) and those with diplopia (68.0 +/- 5.4 years). CONCLUSIONS: Adaptive mechanisms are activated to reduce the surgically induced objective angle of cyclotorsion, and a cyclodeviation of 15 degrees was the critical angle separating those who had peripheral fusion from those who did not. This value corresponds to the cyclofusional amplitude in normal adults.     

Reading ability after macular translocation surgery with 360-degree retinotomy

PURPOSE: To report reading ability using a standardized reading chart after macular translocation with 360-degree retinotomy in eyes with age-related macular degeneration (AMD) or with myopic choroidal neovascularization (mCNV). DESIGN: Interventional case series. METHODS: In 34 eyes of 34 patients with subfoveal choroidal neovascular membrane (AMD, 23; mCNV, 11), macular translocation surgery with 360-degree retinotomy and simultaneous extraocular muscle surgery were performed. The average age was 67.4 +/- 7.9 years, and the average follow-up period was 7.6 +/- 3.3 months. The best-corrected far visual acuity (FVA) was measured with a standardized visual acuity chart using Landolt Cs, and the critical print size (CPS) was determined with the Japanese version of the Minnesota reading chart (MNREAD-J Chart) preoperatively and postoperatively. Preoperative and postoperative change in the CPS was compared with the subjective visual improvement as assessed by a questionnaire. RESULTS: The postoperative improvement of FVA was statistically significant in eyes with mCNV (P =.010) but not significant in eyes with AMD (P =.495). The postoperative improvement of CPS was statistically significant both in eyes with AMD (P =.027) and in eyes with mCNV (P =.004). The subjective visual improvement was significantly correlated with the change of CPS in patients after a second better eye surgery. CONCLUSIONS: After macular translocation with 360-degree retinotomy, the improvement of reading ability was significant in eyes with both AMD and mCNV. We conclude that this surgical method is well suited to improve reading ability of patients with AMD or mCNV.     

Fixation switch and diplopia after full macular translocation surgery.

PURPOSE: We sought to identify and evaluate treatment of patients who switched fixation to the poorer-seeing eye and complained of persistent diplopia 6 to 12 months after full macular translocation surgery (MT360) and extraocular muscle surgery. METHODS: All patients enrolled in a prospective study undergoing MT360 and extraocular muscle surgery were included. All patients had sensorimotor examinations. Visual acuity and fixation preference between 6 and 12 months after MT360 and extraocular muscle surgery were analyzed. RESULTS: Preoperative median visual acuity was 20/100 in operated vs 20/640 in fellow eyes; after MT360, the values were similar to the preoperative values (n = 67). After MT360 but before extraocular muscle surgery, all patients preferred the fellow eye for ambulation. Six to 12 months after MT360, 58 of 67 (86%) patients fixated with the better-seeing eye (52 operated vs 6 fellow eyes); 4/67 (6%) fixated with the operated eye despite its poorer or equal visual acuity; 5 of 67 (8%) fixated with the poorer-seeing fellow eye, all 5 of whom experienced diplopia (ie, fixation switch and diplopia). Treatment of diplopia included Fresnel prism, additional extraocular muscle surgery, and occlusion. CONCLUSIONS: Fixation switch to the poorer-seeing eye can occur after MT360, despite a successful visual outcome in the operated eye and the diplopia is difficult to treat.     

Strabismus presenting after cataract surgery

Strabismus presenting after cataract surgery is etiologically related to a heterogenous group of disorders. Clinical data from 63 patients so affected revealed four broad etiologic categories: 1) pre-existing disorders that preceded the cataract surgery, but were rendered asymptomatic by the occluding cataract (e.g., thyroid eye disease, cranial nerve palsy, myasthenia); 2) disorders precipitated by prolonged occlusion by a cataract (e.g., sensory deviations, decompensation of heterophorias, and central disruption of binocular vision); 3) disorders resulting from surgical trauma to extraocular muscles and orbital soft tissues. Traumatic injury to the inferior rectus muscle secondary to retrobulbar anesthesia injection, a specific subset, is postulated to result from a Volkmann's type ischemic contracture, a well-known osseofascial compartment syndrome occurring in peripheral skeletal muscles. 4) Disorders related to resulting aphakia/pseudophakia and associated optical aberrations (e.g.; anisophoria, ocular dominance reversal, and color/brightness disparity). The diagnostic and therapeutic implications of these findings are discussed.     

Strabismus after retinal detachment surgery

Strabismus after retinal detachment surgery is temporary in most cases. Long-term diplopia, however, is seen in 5% to 25% of patients. In most cases the cause is restrictive strabismus due to adhesions, muscle fibrosis, or scarring involving the buckling material. Deviations due to direct muscle injury and "sensory" deviations due to poor vision also occur. Nonsurgical treatments include prisms and botulinum toxin injections. Surgical intervention using adjustable sutures is successful in most cases.     

Fundus autofluorescence after full macular translocation surgery for myopic choroidal neovascularization

BACKGROUND: To investigate fundus autofluorescence (FAF) findings in patients who underwent full macular translocation surgery with 360-degree retinotomy (MT360) for myopic choroidal neovascularization (CNV). METHODS: Observational case series. Thirty-one eyes of 31 patients who underwent MT360 for myopic CNV from February 1999 through September 2005 were included. We measured the best-corrected visual acuity and obtained color fundus photographs, optical coherence tomography (OCT) images, and fluorescein angiography images. FAF imaging by confocal scanning laser ophthalmoscope was obtained postoperatively in all study eyes and preoperatively in two study participants. FAF features at the new macula were qualitatively evaluated and compared with preoperative lesions associated with CNV. The FAF features at the retinal pigment epithelial (RPE) area with preoperative CNV also were evaluated. RESULTS: The mean interval between MT360 and the final FAF examination was 58 months (range, 8-94 months). FAF imaging was almost normal in five eyes (16%), the increased FAF was well defined at the new macula area in 23 eyes (74%), and the FAF was decreased in three eyes (10%). Neither newly developed CNV nor subretinal fluid was seen at the new macular region in any eyes on fluorescein angiography or OCT imaging. The configurations of well-defined increased FAF in 23 eyes corresponded with the preoperative CNV in two eyes (9%) and subretinal hemorrhages in five eyes (22%). Well-defined increased FAF larger than the CNV or subretinal hemorrhage was seen in 16 eyes (69%). The RPE area located at the area of the preoperative CNV had a FAF defect or decreased FAF in 30 eyes (97%) on postoperative FAF imaging; there were no increased FAF changes. CONCLUSIONS: Well-defined increased FAF at the new macula after MT360 suggests that FAF reflects not only fluorophores in the RPE but also in the neurosensory retina. These fluorophores may result from interactions between the retina and CNV/pathologic RPE.     

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.     

Improvement in macular function after retinal translocation surgery in a patient with age-related macular degeneration

PURPOSE: To assess focal electroretinographic findings before and after retinal translocation surgery in a patient with age-related macular degeneration. METHOD: Case report. A 79-year-old man with a well-defined subfoveal choroidal neovascular membrane from age-related macular degeneration underwent preoperative and postoperative focal electroretinography. RESULTS: After retinal translocation surgery, best-corrected Snellen visual acuity improved from 9/200 to 20/60. A significant increase in mean foveal amplitude, from 0.08 microV to 0.16 microV (P = 0.008) was recorded. CONCLUSION: Age-related macular degenerative changes in visual acuity and foveal electroretinogram amplitude may be reversible after retinal translocation surgery.     

Change in full-field ERGs after macular translocation surgery with 360 degrees retinotomy

PURPOSE: One of the methods used in macular translocation (MT) surgery for subfoveal neovascularization is to create a temporary total retinal detachment followed by a 360 degrees retinotomy. The whole retina is then shifted from the original surface of the retinal pigment epithelium (RPE), resulting in an unusual retina and RPE complex. The purpose of this study was to assess retinal function after MT surgery. METHODS: Full-field electroretinograms (ERGs) were recorded before and 4 to 8 months (mean, 5.4 months) after MT surgery with a 360 degrees retinotomy in 15 consecutive patients with age-related macular degeneration (10 eyes), high myopia (4 eyes), and polypoidal choroidal vasculopathy (1 eye). Their ages ranged from 57 to 74 years. The angle of rotation of the retina ranged from 18 degrees to 45 degrees (mean +/- SE, 30 +/- 2 degrees). In addition to the recording of the standard rod and mixed rod-cone ERGs after 30 minutes of dark adaptation, the cone single flash and 30-Hz flicker ERGs were recorded immediately after a light-adapting background was turned on (LA(0)) and also after 10 minutes of light adaptation (LA(10)). RESULTS: The mean amplitude of the full-field ERGs was reduced after surgery by 44% for the rod response, by 24% for the mixed rod-cone b-wave, by 12% and 35% for the cone single-flash b-wave at LA(0) and 30-Hz flicker ERGs at LA(0), respectively. The mean implicit times were delayed by 8 msec for the rod response, by 2 msec for the mixed rod-cone oscillatory potential (OP1), by 4 msec for the cone single-flash b-wave at LA(0), and by 6 msec for the 30-Hz flicker at LA(0). CONCLUSIONS: These results demonstrated a functional alteration in both the rod and cone components of the ERGs for the entire retina after MT surgery.