Limited macular translocation for subfoveal choroidal neovascularization in age-related macular degeneration

Purpose: To examine the safety and efficacy of limited macular translocation followed by laser photocoagulation in the management of subfoveal choroidal neovascularization (CNV) in age‐related macular degeneration (AMD). Methods: A prospective study was conducted on eight consecutive patients undergoing limited macular translocation followed by laser photocoagulation for the treatment of subfoveal classic CNV form of AMD. Patients were followed up for a minimum of 12 months. The magnitude of foveal translocation, visual outcomes and complications were assessed. Results: In all cases the fovea was successfully translocated inferiorly, with a median displacement of 1.1 mm. Thermal laser photocoagulation was subsequently performed in all cases. Visual acuity improved in five eyes, remained unchanged in two eyes and worsened in one eye. The mean improvement in visual acuity was by 0.19 logMAR. At 12 months, six of the eight patients (75%) achieved Snellen visual acuity of at least 6/15, with four patients (50%) achieving Snellen visual acuity of 6/9. Conclusion: In this small case series, limited macular translocation was found to be an effective and reproducible means of treating small well‐defined subfoveal CNV.     

Full macular translocation following photodynamic therapy in neovascular age-related macular degeneration

PURPOSE: To report the long-term functional and anatomical outcome of full macular translocation (FMT) in eyes with neovascular age-related macular degeneration (AMD) following photodynamic therapy (PDT). METHODS: Twelve eyes of 12 consecutive patients with neovascular AMD who were PDT-nonresponders and underwent FMT were analysed. Best-corrected visual acuity (BCVA) measurement, fundus photography, and fluorescein angiography at baseline and at follow-up examinations in 3 months intervals were performed. Primary end point was change of BCVA from baseline to last visit. RESULTS: Totally 12 eyes of 12 patients were analysed. Mean time interval between the last PDT and FMT was 3.7 months (range 1-10 months). Mean follow-up after FMT was 25.6 months. BCVA ranged at baseline from 20/1000 to 20/80 (mean 20/230). At the last visit, mean BCVA was by 20/185. BCVA improved in 50% (6/12) of eyes by more than 1 line. Twenty five per cent (3/12) of eyes had final BCVA within +/-1 line from baseline. In 25% (3/12) of eyes the BCVA decreased by more than 1 line. One eye had recurrent CNV. In four eyes a cystoid macular oedema developed. No retinal detachment or disturbing diplopia was noted. CONCLUSIONS: In the present study, FMT in PDT-nonresponders stabilised or improved visual acuity in the majority of the eyes in a mean follow-up period of nearly 2 years. FMT can be considered as a therapeutical option in eyes who are nonresponders to the PDT in neovascular AMD.     

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.     

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.     

Iris pigment epithelial cell translocation in exudative age-related macular degeneration

Background: This prospective, non-controlled pilot study investigates the practicability of IPE translocation and functional outcome in ARMD patients. Removal of submacular choroidal neovascularization (CNV) in age-related macular degeneration (ARMD) is usually associated with RPE damage and poor visual prognosis. Homologous RPE transplants fail to preserve macular function, possibly due to immune rejection. Instead of homologous RPE, we suggest translocating autologous iris pigment epithelium (IPE), building on earlier evidence from animal and in vitro investigations that IPE can substitute RPE functions in the experimental animal. Immunological cell rejection is avoided. Methods: Four eyes with well- defined and eight eyes with ill- defined subfoveal CNV were submitted to operation and followed up for a minimum of 6 months. IPE cells were harvested from a peripheral iridectomy. A vitrectomy was performed. Submacular membranes were removed, and isolated IPE cells were injected into the subretinal space. Examinations included ETDRS visual acuity, fluorescein angiography, and SLO microperimetry. Results: All patients underwent successful surgical removal of CNV and subretinal IPE injection. Compared to preoperative visual acuity (20/400–20/100) no significant change was observed after 6 months (20/320–16/80). A change of more than two ETDRS chart lines was defined as significant. One eye with preoperative ill-defined CNV developed a recurrence, leading to reduced visual acuity. In all patients, postoperative fluorescence angiography revealed early hyperfluorescence (window defect) in the surgically denuded area. Central fixation was demonstrated in 50% of eyes. Conclusions: Preliminary data suggests that IPE translocation in submacular surgery for ARMD can preserve but not improve preoperative visual acuity over 6 months. Functional results are promising compared to submacular membrane extraction alone and RPE transplantation. Continued research on improvement of IPE translocation seems justified. Received: 19 October 1999 Revised: 22 December 1999 Accepted: 16 February 2000     

Progression of choroidal neovascularization after macular translocation in age-related macular degeneration and degenerative myopia

PURPOSE: To study the progression of choroidal neovascularization (CNV) after macular translocation in age-related macular degeneration (AMD) and degenerative myopia. PATIENTS AND METHODS: The data from 42 consecutive eyes (28 AMD, and 14 degenerative myopia) operated on by limited macular translocation (DeJuan technique), with a follow-up of 6 months or more, were prospectively analyzed. In the AMD group, neovascularization was classic in 54% of eyes and classic and occult in 46% of eyes. Previous laser treatment was applied on extra- or juxtafoveal CNV in 3 eyes. The major outcome measures were visual acuity, fluorescein and indocyanine green angiographies. RESULTS: After translocation, foveal displacement was greater in AMD than in myopic eyes (mean: 1 260 and 812 micro m, respectively). Laser photocoagulation was applied postoperatively onto extra-or juxtafoveal CNV in 26 (93%) AMD eyes and 12 myopic eyes (86%). Mean follow-up was 10 months (range, 6-18 months). Recurrence of CNV occurred in 14 AMD eyes (50%) and 2 myopic eyes (14%) an average of 5.6 months after surgery (range, 1-18 months). Recurrence was more frequent in AMD eyes with preoperative occult CNV (66%) than without (36%). Recurrence reached the new fovea in 69% of cases. Supplementary laser treatment was possible and successful on extra- or juxtafoveal recurrence in 3 eyes. Recurrence was significantly correlated with a poor visual prognosis: eyes without recurrence or with extra- or juxtafoveal recurrence had a final gain in visual acuity of 2.4 lines, eyes with subfoveal recurrence had a loss of 1.3 lines, and eyes with diffuse recurrence had a loss of 4.2 lines. CNV appeared in a new area at a BSS injection site in one eye. Occult CNV seemed to fade relatively within the first postoperative weeks, but were unchanged at the end of follow-up. In one eye, a small polypoidal lesion near the disc noted preoperatively disappeared after surgery. CONCLUSION: Our results suggest that the surgical procedure does not affect the course of classic or occult CNV. The rate of recurrence of CNV after macular translocation seemed similar to that observed after conventional laser treatment for extrafoveal CNV in AMD. Neovascular recurrence is the most frequent postoperative complication and was frequently directed at the new fovea. Despite these complications, macular translocation moves CNV outside of the subfoveolar zone so the eyes can be treated with conventional laser, leading to a favorable outcome at the last follow-up in 57% of cases. Further studies are required to confirm these findings and to define the best criteria for treatment.     

Inferior limited macular translocation for subfoveal choroidal neovascularization secondary to age-related macular degeneration: 1-year visual outcome and recurrence report

PURPOSE: To report the 1-year visual outcomes and incidence of persistent and recurrent choroidal neovascularization (CNV) after limited macular translocation (LMT) for subfoveal CNV in patients with age-related macular degeneration (ARMD). DESIGN: Interventional case series. METHODS: Retrospective review of 102 consecutive eyes of 101 patients that had the inferior limited macular translocation procedure for subfoveal choroidal neovascularization secondary to ARMD. The outcome measures were visual acuity at 12 months after surgery, change in visual acuity from baseline, the proportion of eyes with moderate (3 or more lines) or severe (6 or more lines) visual acuity loss, and cumulative incidence of persistent or recurrent CNV and its impact on visual acuity. Cumulative incidence was estimated using Kaplan-Meier survival analysis methods. Association between persistence and recurrence of CNV and the Snellen visual acuity recorded at each follow-up visit was evaluated using the Wilcoxon rank-sum test. RESULTS: Eighty-six (84.3%) of 102 eyes completed the 1-year follow-up. By 12 months postoperatively, 35 (40.7%) of the 86 eyes achieved visual acuity of 20/100 or better while 34 (39.5%) of the 86 eyes experienced 2 or more Snellen lines of visual improvement. In the 52 eyes with effective translocation and complete laser photocoagulation of the CNV complex with sparing of the sensory fovea, the estimated incidence of recurrence was 34.6% at 12 months (95% confidence interval of 21%-48%). Sixty-five percent of the recurrences were subfoveal and caused a decrease in visual acuity. There was a trend toward worse median change in visual acuity in eyes with persistent or recurrent CNV. CONCLUSIONS: Limited macular translocation for the treatment of subfoveal CNV secondary to ARMD is associated with improvement in visual acuity in approximately 39.5% of eyes and enables complete laser photocoagulation of the neovascular complex with sparing of the sensory macula in approximately 60.4% of eyes that complete 1 year follow-up. Persistence and recurrence of CNV are common after LMT and are important causes of vision loss. Further studies are warranted to more precisely evaluate the risks and benefits of LMT in ARMD.     

氢醌诱导小鼠年龄相关性黄斑变性模型的建立

目的　观察氢醌诱导小鼠年龄相关性黄斑变性（ａｇｅ-ｒｅｌａｔｅｄｍａｃｕｌａｒｄｅｇｅｎｅｒａｔｉｏｎ,ＡＭＤ）动物模型的病理特征及超微结构改变,为ＡＭＤ发病机制及防治研究提供模型选择和依据。方法　６～７个月龄Ｃ５７ＢＬ／６小鼠１６只随机分为模型组和正常组,每组８只。模型组小鼠被喂以基于基础纯净合成的含８ｇ·Ｌ－１氢醌的饮食,正常组小鼠被喂以不含氢醌的同配方饮食,饲养５个月。采用组织病理学、ＴＵＮＥＬ方法和８-ＯＨｄＧ免疫荧光法观察两组小鼠视网膜的结构改变、视网膜色素上皮（ｒｅｔｉｎａｌｐｉｇｍｅｎｔｅｐｉｔｈｅｌｉｕｍ,ＲＰＥ）细胞的凋亡和ＤＮＡ损伤情况,透射电镜观察超微结构的改变。结果　正常组ＲＰＥ细胞数目为（７．０５±１．５４）个,模型组ＲＰＥ细胞数目为（３．９０±１．２１）个,模型组ＲＰＥ细胞数量较正常组显著减少（Ｐ＜０．０１）。透射电子显微镜显示,正常组ＲＰＥ细胞质中含有丰富的线粒体,较多的色素颗粒,细胞顶部微绒毛数目多且较长;Ｂｒｕｃｈ膜结构规整,厚度均匀。模型组ＲＰＥ细胞微绒毛变短,Ｂｒｕｃｈ膜不规则增厚,外胶原层见层状沉积物,呈纤丝状及无定形状。ＴＵＮＥＬ结果显示,模型组可见较多ＲＰＥ细胞凋亡,凋亡率为（７．７５±３．７６）％,内、外核层散在细胞凋亡,正常组未见细胞凋亡,两组差异有显著统计学意义（Ｐ＜０．０１）。８-ＯＨｄＧ结果显示,模型组ＲＰＥ细胞可见较多的８-ＯＨｄＧ阳性染色,ＲＰＥ细胞ＤＮＡ损伤率为（３３．３５±１１．１６）％,内、外核层散在阳性染色,正常组ＲＰＥ细胞散在微弱的８-ＯＨｄＧ表达,ＤＮＡ损伤率为（０．８４±１．７８）％,内、外核层未见阳性染色,２组比较差异有显著统计学意义（Ｐ＜０．０１）。结论　含氢醌饲料喂养的小鼠具有早、中期ＡＭＤ的病变特征,可为进一步防治早、中期ＡＭＤ研究提供可靠的动物模型。     

炎症与年龄相关性黄斑变性

近年来炎症与年龄相关性黄斑变性（AMD）的关系受到关注，主要包括与炎症相关的免疫分子与AMD的关系，如补体系统和炎症相关基因、单核细胞趋化蛋白（MCP）、C反应蛋白（CRP）等，以及炎症与AMD病理改变的关系如视网膜色素上皮细胞（RPE）损伤、玻璃膜疣以及脉络膜新生血管形成（CNV）等。     

老年黄斑变性中感光细胞的凋亡

目的 探讨细胞凋亡在老年黄斑病变性感光细胞死亡中的作用。方法 对１６只老年黄斑变性眼的黄斑部视网膜组织进行ＴＵＮＥＬ技术（ＴＤＴ－ｍｅｄｉａｔｅｄｂｉｏｔｉｎ－ｄＵＴＰｎｉｃｋ－ｅｎｄｌａｂｅｌｌｉｎｇ）和病理组织学研究。结果 本组中６只眼的黄斑病有细胞凋亡的特征性改变,分散排列的感光细胞核ＤＮＡ片断化。结论 细胞凋亡是老年黄斑变性中感光细胞死亡的一个重要机理。     

Autologous translocation of large retinal pigment epithelium choroid patches in age-related macular degeneration

BACKGROUND: The latest development in ARMD surgery is the translocation of an autologeous pigment epithelium choroid patch. The method has technical shortcomings: The transplant is excised including the overlaying retina and inserted through a retinotomy near the posterior pole thus causing iatrogenic field defects. For the same reasons the size of the transplant is limited. MATERIALS AND METHODS: The technique was modified as follows: lens surgery using a special PCL with equal power in water and silicone oil, 180 degrees retinotomy just at the temporal ora serrata, subretinal surgery including patch transplantation with the retina folded over nasally and fixed by PFCL, complete silicone oil tamponade without any water remaining. PATIENTS: 12 consecutive cases, age 79 (70 - 86) years, 4 RPE detachments and rips, 8 subretinal hemorrhages from wet ARMD, follow-up in 10 eyes over 15.3 (3 - 23) months. Time courses for visual acuity, depth of central scotoma, OCT and FAG. RESULTS: The mean diameter of the transplants was 16.5 (9 - 33) degrees . Silicone explantation in 7 / 10. Complications in 3 / 10: 1 macula puckering, 1 peripheral detachment, 1 PVR detachment. According to FAG the transplant vascularises in 4 - 6 weeks. 4 / 10 eyes reached visual acuity > 0.2 with limited reading capability. Central scotoma depth remained constant at -11 dB. Function deteriorated again after 6 - 9 months with cystoid degeneration and retinal thickening. 8 / 11 patients estimated the operated eye to be superior to the untreated partner eye. CONCLUSIONS: Patch transplantation is able to restore limited reading capability in eyes having minor damage of the central retina. The best cases for this type of operation are RPE rips and recent sub-RPE haemorrhages. The functional success lasts 5 to 9 months, then the retina over the transplant begins to degenerate.