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Visual Outcomes Following Macular Translocation With 360° Peripheral Retinectomy
James C. Lai, MD;
Deborah J. Lapolice, MS;
Sandra S. Stinnett, DrPH;
Carsten H. Meyer, MD;
Luz M. Arieu, MD;
Melissa A. Keller;
Cynthia A. Toth, MD
Arch Ophthalmol. 2002;120:1317-1324.
ABSTRACT
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Objective To evaluate visual outcomes following macular translocation with 360°
peripheral retinectomy in patients with subfoveal choroidal neovascularization
secondary to age-related macular degeneration.
Methods In a prospective study, 15 consecutive patients with large subfoveal
choroidal neovascularization underwent macular translocation with 360°
peripheral retinectomy and silicone oil tamponade. Preoperative and postoperative
photographs and fluorescein angiograms were obtained to evaluate lesion size
and characteristics and translocation results. Standardized near and distance
visual acuity and reading speed were measured preoperatively and 6 and 12
months postoperatively.
Main Outcome Measures Changes in and final levels of near and distance visual acuity and reading
speed.
Results Median lesion size was 9 Macular Photocoagulation Study disc areas (range,
4-16 disc areas). In all patients, the fovea was successfully translocated
off the subfoveal lesion. The median near visual acuity logMAR score (logarithm
of the minimum angle of resolution) improved significantly from 0.54 units
to 0.40 units (Snellen equivalent, 20/70 to 20/50; P =
.02) at the 6-month follow-up and stabilized at 0.54 (12 months postoperatively;
Snellen equivalent, 20/70). Seven (54%) of 13 patients and 7 (58%) of 12 patients
achieved reading speeds of 70 words/min or greater at the 6-month and 12-month
postoperative visits, respectively. Median preoperative distance visual acuity
(20/100) was maintained at both the 6-month and 12-month examinations. No
postoperative retinal detachments occurred in this series.
Conclusion Macular translocation with 360° peripheral retinectomy and silicone
oil tamponade stabilizes and can sometimes improve near and distance visual
acuity and reading speed in patients with vision loss from subfoveal neovascular
age-related macular degeneration.
INTRODUCTION
CHOROIDAL neovascularization (CNV) secondary to age-related macular
degeneration (AMD) is a major cause of severe visual loss, including loss
of reading ability.1-3 Treatment
options for subfoveal CNV are limited. Until the recent approval of photodynamic
therapy, the only proven therapy for subfoveal CNV was focal laser photocoagulation.2, 4-5 The beneficial effect
of laser treatment was restricted to patients with small, well-demarcated
subfoveal lesions.2 Thus, the majority of patients
with subfoveal CNV were not eligible for laser treatment.6-7 Furthermore,
although laser treatment was effective in delaying large losses of visual
acuity in certain patients, it usually did not allow patients to maintain
the vision required for driving or reading.2-3 Since
its approval, photodynamic therapy has replaced laser photocoagulation as
the recommended treatment for specified patients with subfoveal CNV.8-10 Data from the Treatment
of Age-Related Macular Degeneration With Photodynamic Therapy (TAP) Study
and the Verteporfin in Photodynamic Therapy Study suggest that patients are
candidates for photodynamic therapy if the lesion is predominantly classic
or 100% occult with evidence of recent vision loss, especially if the lesion
is smaller than 4 Macular Photocoagulation Study (MPS) disc areas or if the
visual acuity is worse than 20/50.8-9,11 Photodynamic
therapy decreases the severity of vision loss but usually does not improve
vision. Furthermore, many patients are ineligible for photodynamic therapy
because of the size or characteristics of their subfoveal lesion.8-9,11
Macular translocation is a new surgical technique for the treatment
of subfoveal CNV.12-13 Originally
described by Machemer and Steinhorst,14 macular
translocation moves the neurosensory retina away from the subfoveal abnormality
to a new site of healthier retinal pigment epithelium and choriocapillaris
with the goal of maintaining or recovering visual function. A theoretical
advantage of macular translocation over current treatments is the preservation
of foveal photoreceptor function. Initial case series of limited macular translocation
and macular translocation with 360° peripheral retinectomy have demonstrated
that central vision can be preserved or even improved in certain patients
with subfoveal CNV secondary to AMD.15-22
The rate of retinal detachment and proliferative vitreoretinopathy has
significantly decreased since the first report of full macular translocation
by Machemer and Steinhorst.14 Eckardt et al16 have described a method of macular translocation
involving 360° retinotomy and simultaneous muscle surgery to reduce postoperative
torsional diplopia. Toth and Machemer19 and
Toth and Freedman20 have recently published
other modifications to the Machemer procedure.
The goal of this study was to evaluate visual outcomes in a prospective,
standardized manner following macular translocation with 360° peripheral
retinectomy and silicone oil tamponade. Primary outcome measures were changes
in near visual acuity, reading speed, and distance visual acuity. A secondary
goal was to examine whether lesion size, lesion characteristics, or duration
of vision loss influenced final functional visual acuity.
METHODS
A prospective series of 15 consecutive patients with subfoveal CNV secondary
to AMD underwent macular translocation with 360° peripheral retinectomy
and silicone oil tamponade at the Duke University Eye Center, Durham, NC,
between July 1,1999 and August 31, 2000. During this time period, additional
patients underwent macular translocation with gas tamponade. Because of the
different possible effects of tamponade, patients receiving gas tamponade
were not included in this study and are being analyzed separately. In all
patients, the surgery was performed by one of us (C.A.T.). The study protocol
and consent were reviewed and approved by the Duke University Medical Center
Institutional Review Board. The evaluation of the macular translocation with
360° peripheral retinectomy technique in the first 16 patients treated
in the Duke study was previously reported.20 This
study summarizes the visual outcomes of the next 15 patients treated using
modifications to the surgical technique as described by Toth and Freedman.20
Patients were eligible for the study if they met the following inclusion
criteria: (1) age 55 years or older, (2) AMD with subfoveal CNV of any type,
(3) best-corrected Snellen visual acuity between 20/50 and 20/400 in the surgically
treated eye, and (4) maximum of 6 months of loss of central vision. Loss of
central vision, as reported by the patients, occurred when they could no longer
perform daily activities such as driving or reading. Patients were not excluded
if they had evidence of macular atrophy, subretinal hemorrhage, or fibrosis.
Exclusion criteria included (1) no light perception in either eye, (2) visual
acuity of better than 20/50 in the fellow eye, (3) previous laser treatment
of the center of the fovea in the surgically treated eye, (4) previous submacular
surgery in the surgically treated eye, (5) severe diabetic retinopathy or
previous laser treatment for diabetic macular edema or proliferative diabetic
retinopathy in the surgically treated eye, (6) intraocular pressure of 30
mm Hg or more in the surgically treated eye, (7) ocular disease other than
macular degeneration that would prevent the recovery of visual acuity after
surgery (eg, severe amblyopia or previous vascular occlusion), and (8) a condition
causing severe peripheral visual field loss in the fellow eye (eg, central
retinal vein occlusion, chronic retinal detachment, or severe glaucoma).
All patients underwent a complete ophthalmologic examination preoperatively
and 6 and 12 months postoperatively. At each visit, best-corrected distance
visual acuity was measured using retroilluminated Bailey-Lovey charts with
standardized refraction and visual acuity protocols adapted from the Submacular
Surgery Trials.23 Best-corrected near visual
acuity was tested using a +2.50 diopter (D) add to the distance correction
with a Rosenbaum near-vision card under standard lighting. Snellen visual
acuities were converted into logMAR (logarithm of the minimum angle of resolution)
units for statistical analysis. Evaluation of reading speed was performed
in a standardized manner using Submacular Surgery Trials reading cards.23 Subjective functional reading ability was ascertained
by questioning patients on their ability to read newsprint with and without
reading aids. Color stereo fundus photographs and fluorescein angiograms were
also obtained preoperatively and 6 and 12 months postoperatively.
Macular translocation with 360° peripheral retinectomy was performed
as described by Toth and Freedman.20 After
pars plana lensectomy and posterior capsulectomy for all phakic eyes, complete
vitrectomy, posterior vitreous detachment, and shaving of the vitreous base
were performed. Fluid was injected into the subretinal space in the inferonasal
quadrant using a 36-gauge retinal needle. Detachment of the entire retina
was completed via injection of additional subretinal fluid through a rounded,
small-bore silicone cannula (Roundball; Alcon/Grieshaber, Schaffhausen, Switzerland).
A 360° retinectomy was performed at the ora serrata, the retina was reflected,
and the subfoveal lesion was removed. The neurosensory retina was then translocated
superiorly off the subfoveal abnormality with a modified diamond-dusted soft
silicone tip (surgeon-modified Tano Diamond-Dusted Membrane Scraper; Synergetics,
Inc, St Charles, Mo) that was connected via short tubing to a syringe containing
perfluorocarbon liquid. This instrument served as both a retinal manipulator
and perfluorocarbon infuser. It was used to engage the posterior retina and
slide it to its new location, followed immediately by infusion of perfluorocarbon
liquid to hold the retina in its new position. After the new location of the
fovea was confirmed, additional perfluorocarbon was added to flatten the retina
out to the margins of the retinectomy. Laser photocoagulation was applied
at the retinectomy margins while under perfluorocarbon liquid. A fluid to
air to silicone oil exchange was then performed. Silicone oil was removed
in a second operation an average of 7.5 weeks postoperatively (range, 4-10
weeks). Extraocular muscle surgery for torsional diplopia was performed at
the time of oil removal in all eyes. A secondary acrylic intraocular lens
was placed in the sulcus in aphakic eyes at the time of the oil removal.
Data were analyzed using SAS software, version 8.1 (SAS Institute, Inc,
Cary, NC). Initially, descriptive statistics (mean, median, SD, and minimum
and maximum values) were computed for continuous baseline and outcome data
(age, duration of vision loss, lesion size, preoperative and postoperative
visual acuities on logMAR derived from Snellen and on Early Treatment Diabetic
Retinopathy Study (ETDRS) scales, and preoperative and postoperative reading
speeds). Frequencies and percentages were obtained for categorical variables
(sex, lesion size, and lesion type). Variables for change from preoperatively
to 6 and 12 months postoperatively were created for ETDRS testing distance
visual acuity, near visual acuity (logMAR), and reading speed. Correlations
were obtained for selected variables.
Subsequently, the significance of the changes in visual information
(ETDRS testing, near visual acuity in logMAR units, and reading speed) was
assessed using the Wilcoxon signed rank test. This test, which uses the ranks
of the data instead of the data values themselves, assesses whether the median
change from preoperative to postoperative measurements is significantly different
from zero. This test was used instead of a paired t test
because the distributions of the changes in visual acuities were not normally
distributed.
After changes in visual acuities were evaluated, patient characteristics
were examined to determine whether they were important in predicting the changes
in acuities. Initially, selected variables were considered one by one in models
as predictors (univariable analyses). Subsequently, they were considered simultaneously
in models as predictors (multivariable analyses). Age, sex, preoperative vision,
lesion size, and duration of vision loss were examined independently and together
for their ability to predict changes in visual information. Linear models
with these variables as predictors and the ranks of the changes at (6 and
12 months) in visual information variables as the dependent variables (to
parallel the analyses of changes using ranks and described previously) were
used to assess the significance of the predictors. In addition to this assessment,
a similar analysis was carried out to assess predictors of 6-month and 12-month
values of the visual outcomes.
RESULTS
Fifteen patients (15 eyes) participated in this study, and 8 (53%) were
men (Table 1). Their ages ranged
from 71 to 84 years (median age, 76 years). Duration of vision loss ranged
from 3 to 64 weeks. One patient was included in the study despite having had
vision loss for longer than 6 months. The smallest lesion measured 4 MPS disc
areas,1 and the largest was 16 MPS disc areas
(median, 9 MPS disc areas). Most lesions (10 [67%] of 15) measured 6 MPS disc
areas or larger (Figure 1). Of 15
eyes, 8 (53%) had a component of classic CNV (Figure 2), and 4 (27%) contained purely occult lesions. The fovea
was successfully translocated off the subfoveal lesion in all 15 eyes (Figure 3). None of the patients in this series
had undergone previous laser treatment or photodynamic therapy at the time
of the translocation. All 15 patients had subfoveal CNV or a disciform scar
in the fellow eye. Median visual acuity of the fellow eye was 20/400 (range,
20/64 to 20/1280). Ten eyes (67%) were phakic and underwent pars plana lensectomy
at the time of the macular translocation.
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Table 1. Patient Demographics*
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Figure 1. Choroidal neovascularization lesion
size. The median lesion size was 9 Macular Photocoagulation Study (MPS) disc
areas. Most lesions (10/15 [67%]) measured 6 MPS disc areas or larger.
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Figure 2. Type of lesion by relative size
of components. Eight (53%) of 15 eyes had a component of classic (C) choroidal
neovascularization, and 4 (27%) contained purely occult (O) lesions. B indicates
subretinal hemorrhage.
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Figure 3. Patient 7, an 81-year-old woman,
had preoperative near and distance visual acuities of 20/64 and 20/70, respectively.
Reading speed was 11 words/min. A, Preoperative examination revealed a subfoveal
neovascular membrane with surrounding subretinal hemorrhage. B, A midphase
fluorescein angiogram revealed a subfoveal classic membrane with areas of
hypofluorescence corresponding with subretinal hemorrhage. C, One year after
macular translocation with 360° peripheral retinectomy and subsequent
muscle rotation, near and distance visual acuities had both improved to 20/40.
Reading speed had improved to 120 words/min. There is no evidence of subretinal
fluid or hemorrhage. Retinal pigment epithelium atrophy from the original
site of choroidal neovascularization (CNV) removal is present along the inferotemporal
arcade. D, A fluorescein angiogram reveals translocation of the fovea away
from the site of the original CNV. There is no evidence of CNV.
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Median preoperative best-corrected near visual acuity was 0.54 logMAR
units (range, 0.30 logMAR units to 1.6 logMAR units). One patient did not
return for the 6-month follow-up. This patient's visual acuity was recorded
by an outside ophthalmologist and was not used in the data analysis. Six months
postoperatively, the median best-corrected logMAR score improved to 0.40 (P = .02) (Figure 4).
Of 14 patients, 5 (36%) remained within 0.2 logMAR units of their preoperative
near visual acuity, and 8 (57%) improved more than 0.2 logMAR units. Of 14
patients, 13 (93%) achieved near visual acuity of 20/100 or better at 6 months,
and 3 (21%) achieved near visual acuity of 20/40 or better (Table 2).
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Figure 4. Preoperative and 6-month postoperative
near visual acuity (NVA), measured in logMAR (logarithm of the minimum angle
of resolution) units.
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Table 2. Preoperative and Postoperative Near Visual Acuity*
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One-year follow-up data were available on 13 patients. Two patients
died before their 1-year follow-up date. The median 12-month near visual acuity
was 0.54 logMAR units. No statistical difference existed between the median
preoperative and 12-month near visual acuity nor between the median 6-month
and 12-month near visual acuities. At 12 months, 5 (38%) of 13 patients remained
within 0.2 logMAR units of their preoperative score, 5 (38%) improved more
than 0.2 logMAR units, and 3 (23%) worsened more than 0.2 logMAR units compared
with their preoperative score (Figure 5). One year postoperatively, 11 (85%) of 13 patients achieved near visual acuity
of at least 20/100, and 4 patients (31%) achieved near acuity of at least
20/40.
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Figure 5. Preoperative and 1-year postoperative
near visual acuity (NVA), measured in logMAR (logarithm of the minimum angle
of resolution) units.
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Median preoperative reading speed was 70 words/min. Patient 3 had a
postoperative reading speed that could not be accurately measured because
she developed Alzheimer disease, and her data were excluded from further reading
speed analyses (her 12-month distance and near visual acuities were 20/32
and 20/25 Snellen equivalents, respectively). Six months postoperatively,
the median reading speed improved to 74 words/min (P =
.85). Five (38%) of 13 patients remained within 25 words/min of their original
starting reading speed (Table 3),
and 4 patients (31%) gained more than 25 words/min in their reading speed;
7 (54%) of 13 patients had a 6-month reading speed of 70 words/min or greater.
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Table 3. Preoperative and Postoperative Reading Speed*
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The median reading speed at the 1-year follow-up increased from the
preoperative median speed of 70 words/min to 95 words/min (P = .37). Seven (58%) of 12 patients had a 12-month reading speed of
70 words/min or greater.
In terms of functional reading ability, 8 (67%) of 12 patients reported
the ability to read standard-sized newsprint at the 1-year follow-up. Although
not all patients were tested with low vision aids prior to surgery, none of
these patients were able to read preoperatively with their reading glasses;
5 patients were able to read with the use of low-add (< +4.00 D) reading
correction, and 3 patients required the use of high-add ( +4.00 D) reading
correction.
The preoperative median best-corrected distance visual acuity was 65
letters on ETDRS testing (range, 45 to 86 letters). Converted to Snellen visual
acuity, this corresponded to a median best-corrected distance acuity of 20/100
(range, 20/32 to 20/320) (Table 4).
The 6-month postoperative median best-corrected visual acuity was also 65
letters on ETDRS testing (range, 48 to 86 letters; Snellen equivalent, 20/100).
Distance visual acuity remained within 10 letters on ETDRS testing in 10 (71%)
of 14 patients and improved by 11 or more letters in 3 patients (21%). It
decreased by 11 or more letters in 1 (7%) of 14 patients. At 6 months postoperatively,
10 (71%) of 14 patients achieved a best-corrected distance visual acuity of
20/100 or better, and 3 (21%) achieved a distance visual acuity of at least
20/40.
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Table 4. Distance Visual Acuity 6 and 12 Months Postoperatively*
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The distance visual acuity remained stable through 1 year of follow-up.
The median 1-year postoperative distance visual acuity was 64 letters by ETDRS
testing (range, 48-87 letters). There was no statistical difference between
median preoperative and 1-year postoperative distance visual acuity (65 letters
vs 64 letters). One year postoperatively, 10 (77%) of 13 patients achieved
best-corrected ETDRS testing distance visual acuity of at least 20/100, and
4 (31%) achieved a distance acuity of at least 20/40 (Table 4).
Age, sex, preoperative visual acuity, size of lesion, and duration of
loss of vision were not predictive of 6-month or 12-month postoperative distance
visual acuity, near visual acuity, or reading speed.
Four patients (27%) developed recurrent extrafoveal CNV, with a range
of onset from 1 to 9 months postoperatively. These recurrences were treated
with standard focal laser photocoagulation. Patients with recurrent CNV were
more likely to develop worsened distance visual acuity at the 6-month (P = .04) and 12-month (P = .05)
postoperative visits. Recurrent CNV was not correlated with worsened near
vision or reading speed.
A subgroup analysis of patients without CNV recurrence (n = 11) revealed
a median lesion size of 6 MPS disc areas. For this group, the median 6-month
near visual acuity was significantly better than the preoperative acuity (0.35
logMAR units vs 0.70 logMAR units respectively; P =
.02). The difference between preoperative and 12-month near visual acuity
was not statistically significant. Although the median reading speed improved
from 66 words/min preoperatively to 75 words/min at 6 months and 96 words/min
at 12 months postoperatively, the differences were not statistically significant.
The median distance acuity improved significantly after surgery. For patients
who had measurements of distance visual acuity at 6 and 12 months postoperatively,
median preoperative distance acuity was 54 ETDRS letters. Distance acuity
improved to 65 letters at 6 months postoperatively (P =
.03) and to 67 letters at 12 months postoperatively (P =
.03).
No retinal detachments, proliferative vitreoretinopathy, or macular
folds developed in this series of patients. The most common postoperative
complications were the development of cystoid macular edema in 3 patients
(20%) and epiretinal membrane in 3 patients (20%).
COMMENT
Macular translocation with 360° peripheral retinectomy is a promising
new surgical technique for the treatment of large subfoveal CNV. Earlier studies
have demonstrated that certain patients with subfoveal CNV can recover good
central vision following macular translocation.15-22 Macular
translocation with 360° peripheral retinectomy offers the potential benefit
of relocating the fovea away from the CNV site and of removing the CNV, which
in turn may halt membrane growth. Furthermore, macular translocation with
360° peripheral retinectomy is not limited by potential obscuration of
the lesion by blood nor by the nature of CNV within the lesion.
Our preliminary study indicates that macular translocation with 360°
peripheral retinectomy can stabilize, and sometimes improve, central visual
function in patients with subfoveal CNV. At the 6-month postoperative follow-up,
a statistically significant number of patients experienced an improvement
in their near visual acuity. Of 14 patients, 13 (93%) achieved a near visual
acuity of 20/100 or better and 7 (54%) achieved a reading speed of at least
70 words/min. At 6 months postoperatively, 10 patients (71%) achieved a best-corrected
distance visual acuity of at least 20/100, and 3 (21%) achieved a distance
acuity of at least 20/40. One-year follow-up data revealed stable near and
distance visual acuity and reading speed compared with the preoperative and
6-month measurements. At 1 year, the majority of patients (11 [85%] of 13)
achieved near acuity of at least 20/100, and 4 (31%) achieved near acuity
of at least 20/40. A majority of patients (10 [77%] of 13) also achieved best-corrected
distance visual acuity of at least 20/100, and 4 (31%) achieved a distance
acuity of at least 20/40. Seven (58%) of 12 patients had a 12-month reading
speed of 70 words/min or greater. When asked about reading function, 8 (67%)
of 12 patients reported being able to read the newspaper postoperatively with
standard reading glasses. None of these patients could read newsprint preoperatively.
Although the functional results are promising, a cautionary note should
be raised for those patients with good baseline visual acuity. Seven of the
8 patients with a preoperative visual acuity of at least 20/100 and with follow-up
at 1 year maintained 20/100 or better visual acuity 1 year postoperatively.
One patient improved by 20 letters on ETDRS testing, 6 patients remained within
10 letters, and 1 patient worsened by 38 letters. This last patient's visual
acuity worsening from 20/32 preoperatively to 20/200 postoperatively illustrates
the point that visual acuity can worsen after macular translocation with 360°
peripheral retinectomy.
Our visual outcomes compared favorably with published series of macular
translocation with 360° peripheral retinectomy for the treatment of subfoveal
CNV secondary to AMD. Eckardt et al16 report
that 22 of 30 patients had the same or better distance visual acuity postoperatively,
with an average follow-up of 10.5 months. Four eyes had an improvement of
3 or more lines, and 2 eyes lost 3 or more lines. In their study, 18 of 30
eyes had near visual acuity of at least 20/50 at the last reported follow-up.
With the same technique, Wolf et al24 report
a significant gain in visual acuity in only 1 of 7 operated eyes. More recently,
Ohji et al21 report their results of 36 patients
who had undergone macular translocation with 360° peripheral retinectomy.
Three patients (8%) achieved a final visual acuity greater than 20/40, and
23 patients (64%) achieved a visual acuity of at least 20/200 at the last
follow-up. Aisenbrey et al22 report stabilization
of baseline vision at the 1-year follow-up in their series of 90 consecutive
patients with a heterogeneous composition of CNV. Visual acuity improved in
24 patients (27%), remained stable in 37 patients (41%), and worsened in 29
patients (32%) 12 months postoperatively. Near visual acuity and reading speed
were not reported in these 2 later papers.21-22
Similar visual results are reported in studies of limited macular translocation
treating smaller subfoveal lesions. Pieramici et al18 report
their experience with limited translocations (median lesion size, 3 MPS disc
areas) in a consecutive series of 102 eyes. Data on 31 eyes were available
at the 6-month follow-up. A distance visual acuity of 20/40 to 20/80 was achieved
in 12 of 31 eyes, and visual acuity better than 20/40 was achieved in 3 of
31 eyes. Lewis et al17 report their experience
using a similar technique for macular translocation. In their series of 10
patients (median lesion size, 2 MPS disc areas), preoperative median visual
acuity was 20/111. No patients had a postoperative visual acuity better than
20/80. However, comparing results between limited and full macular translocations
should be done cautiously. Because of their larger sizes, many of the lesions
treated by full macular translocation could not have been treated successfully
with the shorter foveal displacement of limited translocations. As a result,
the difference in macular lesion characteristics of patients undergoing full
vs those undergoing limited macular translocation must be recognized in any
comparison of visual outcomes.
Another difference between the full and limited macular translocation
techniques is the pars plana lensectomy and insertion of an intraocular lens
at the time of the macular translocation for all phakic patients. In our series,
5 patients were pseudophakic prior to undergoing full macular translocation
with 360° peripheral retinectomy. Comparisons between the pseudophakic
and phakic groups revealed no statistical differences in preoperative visual
acuity and final visual outcomes. Although the sample sizes were small, the
lack of a difference in visual outcomes between the 2 groups suggests that
the cataract extraction was not the major reason for the observed improvement
in visual function.
One limitation of this study is the absence of a control group with
which to compare visual outcomes. The Macular Photocoagulation Study subfoveal
laser study4 and the TAP Study8-9 have
demonstrated that most patients with untreated subfoveal CNV develop severe
visual loss and that only a few patients experience an improvement in vision.
For example, in the control group of the MPS subfoveal trial, at 6 months,
only 12 (7%) of 171 patients attained distance visual acuity better than 20/100,
and only 1 (0.05%) attained a visual acuity better than 20/40. Those patients,
however, did not necessarily have CNV and poor vision in the fellow eye as
did our patients. Poor vision in the fellow eye can impact the visual acuity
in the treated eye, making it difficult to compare the results of our study
with others. Thus, a randomized trial of macular translocation with 360°
peripheral retinectomy vs observation is warranted to evaluate these outcomes.
Proven treatment options available to the patients in our series were
limited. No patients would have qualified for standard MPS laser treatment
given the large sizes of their lesions (median, 9 MPS disc areas; range, 4-16
MPS disc areas). Although 3 of the patients in our series (No. 2, 7, and 8)
would have been eligible for photodynamic therapy, this treatment option was
not available at the time of their enrollment in our trial. The remaining
12 eyes would not have qualified for photodynamic therapy secondary to their
lesion characteristics. Comparisons between our visual outcomes and those
of the TAP studies are not possible. In our series, 13 (93%) of 14 patients
at 6 months and 12 (92%) of 13 at 1 year had lost fewer than 15 letters of
visual acuity. One year postoperatively, 10 (77%) of 13 patients achieved
visual acuity of at least 20/100, and 4 (31%) achieved visual acuity of 20/40.
Our data suggest that macular translocation with 360° peripheral retinectomy
can provide a reasonable opportunity for preservation of vision. Furthermore,
macular translocation with 360° peripheral retinectomy may also offer
a chance of visual improvement in a mixed group of large subfoveal lesions
that may not be eligible for any other treatment.
To date, the impact of various treatments on reading ability and near
visual acuity in patients with AMD has not been well studied. Distance visual
acuity and contrast thresholds were tested in the MPS5 and
the TAP study.8-9 Although the
MPS tested reading speeds, near visual acuities were not specifically measured
in the MPS or the TAP study. From a quality of life standpoint, near visual
function is important to patients.25 Eckardt
et al16 reported encouraging outcomes for near
visual acuity following macular translocation. In this study, we measured
in a standardized manner not only the near acuity but also the reading speed
following macular translocation with 360° peripheral retinectomy. Studies
have indicated that patients with an absolute scotoma covering part or all
of the central 5° of the visual field have a median reading speed of 25
words/min with a maximum speed never exceeding 70 words/min.25 Following
macular translocation, more than half our patients (7 [58%] of 12) achieved
a reading speed of 70 words/min or greater. A majority of patients (8 [67%]
of 12) were able to read standard newsprint using reading glasses. These results
suggest that successful translocation can preserve central foveal photoreceptor
function.
Outcomes after full macular translocation have been limited by complications,
including retinal detachment with proliferative vitreoretinopathy, cystoid
macular edema, and CNV recurrence.16, 24 However,
with new instrumentation and techniques, the rate of complications has dramatically
decreased. In our small series, there were no retinal detachments or cases
of proliferative vitreoretinopathy. The most common postoperative complications
were recurrence of CNV, development of cystoid macular edema, and development
of epiretinal membrane. Although the recurrences of CNV were treated with
standard laser photocoagulation, it is not surprising that the presence of
CNV recurrence was associated with a worsened visual outcome.
Modifications to the original inclusion criteria were made during this
trial. Many of our patients were enrolled in the study despite having a history
of more than 6 months of loss of vision. One patient had visual loss for 64
weeks before surgery. Yet, surprisingly, duration of vision loss was not correlated
with a worsened visual outcome. It is possible that visual outcomes may be
even better if surgery is performed before irreversible foveal damage has
occurred. It would be useful to have an objective measure of the extent of
irreversible vision loss preoperatively.
In conclusion, our preliminary study indicates that full macular translocation
with 360° peripheral retinectomy can stabilize and sometimes improve the
visual prognosis in patients with subfoveal CNV secondary to AMD. Macular
translocation with 360° peripheral retinectomy has the potential to restore
the ability to read. The results of this study with heterogeneous composition
of the neovascular AMD, including 3 cases in which hemorrhage was a predominant
component, should be interpreted carefully. Longer follow-up is necessary
to confirm these findings and to monitor for any long-term complications.
The impact of macular translocation with 360° peripheral retinectomy on
quality of life measures is currently being studied. The early data support
the establishment of a prospective, randomized clinical trial to examine the
benefit of this treatment and to define the best criteria for treatment eligibility.
AUTHOR INFORMATION
Submitted for publication November 13, 2001; final revision received
May 15, 2002; accepted May 29, 2002.
This study was supported in part by the Andrew Family Foundation (Boston,
Mass), the Adler Foundation (Scarsdale, NY), and Euan and Angelique Baird
(New York, NY). Dr Lai received support from the Heed and AOS-Knapp Ophthalmic
Foundation and the Ronald G. Michels Fellowship Foundation.
We thank Katrina P. Winter, BS, for her assistance in preparing the
tables and graphs.
Corresponding author and reprints: Cynthia A. Toth, MD, PO Box 3802,
Durham, NC 27710 (e-mail: cynthia.toth{at}duke.edu).
From the Department of Ophthalmology, Vitreoretinal Service, Duke University
Medical Center, Durham, NC. Dr Toth and the Duke University Eye Center Biophysics
Laboratory developed the 36-gauge retinal needle and the Roundball cannula
described in this article and receive research support and royalties from
Alcon Laboratories (Fort Worth, Tex). The authors have no financial interest
in other products mentioned in this article.
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