ARMD: Outcomes After Full Macular Translocation Surgery
ARMD: Outcomes After Full Macular Translocation Surgery
Background/aims Long-term data of macular translocation for choroidal neovascularisation (CNV) secondary to age-related macular degeneration is lacking. Therefore, we describe the 3-year acuity outcomes.
Methods This is a retrospective, interventional case series consisting of 40 consecutive patients who underwent translocation between 2003 and 2008. Best-corrected visual acuity (BCVA) at the most recent follow-up visit was compared to that of the 1 year and pre-operative visits. Delayed post-operative complications were recorded, as diagnosed by clinical examination, spectral-domain optical coherence tomography, fundus autofluorescence imaging and angiography.
Results The mean (range) follow-up duration was 37.6 months (range 12.4–67.4 months). Median BCVA values were 0.80, 0.70 and 0.78 log(MAR) at the baseline, 1 year and most recent visits (p=0.13). A three-line gain in BCVA was seen in 12 (30%) patients at 1 year and 10 (25%) patients at the last observation. Twenty-seven (68%) patients achieved a BCVA of 6/60 or better and six (15%) patients, 6/12 or better at the final visit. In the subset of the cohort followed for two or more years, 24 of 32 patients (75%) achieved a BCVA of 6/60 at 1 year but six of these (25%) lost two lines of BCVA thereafter due to recurrent CNV, idiopathic macular oedema, macular hole or macular pucker. Recurrent CNV developed in nine patients (23%) within the first 2 years and their final mean VA was 6/30.
Conclusions With close post-operative monitoring and early treatment of delayed complications, 25% of this cohort maintained a three-line gain in acuity at 3 years after macular translocation.
Neovascular age-related macular degeneration (AMD) is characterised by the formation of choroidal neovascularisation (CNV). In this process, the new vessels may leak or bleed resulting in serous or haemorrhagic pigment epithelial detachment (PED), retinal pigment epithelium (RPE) rip, formation of subretinal fluid and haemorrhage, macular oedema and, ultimately, disciform scar with chorioretinal atrophy. In those with more than 50% of the lesions being CNV, intravitreal ranibizumab has been shown to reverse visual loss with an average of between 1- to 2-line gain in best-corrected visual acuity (BCVA) and up to 40% of eyes gaining 3 lines of acuity at 12 months which was maintained at 24 months. However, the use of these agents in patients with large submacular haemorrhage, serous or haemorrhagic PED and RPE rip remains controversial. Although surgical removal of submacular haemorrhage or CNV alone did not restore vision in large randomised trials, macular translocation surgery, which reconstructs the RPE defects that accompany removal of CNV and blood, has been shown to rescue visual acuity and reading ability with up to a 2-line gain in VA and 40% gaining 3 lines of VA at 1 year in several case series and one pilot randomised trial.
The aim of macular translocation in AMD is to reposition the macula onto a healthier RPE and choroid after removal of the CNV and blood which invariably damage the underlying supporting tissues. The source of the healthier RPE-choroid in translocation is located near the supra-temporal vascular arcade (paramacular region, about 10° eccentricity) when the macula is supra-rotated 45° around the disc. Since the RPE in this region predominantly interact with rods, it is not known if these RPE can also provide long-term support for macular cone survival and function. Furthermore, the extrafoveal atrophy created by the removal of CNV and subsequent foveal rotation may expand with time or allow recurrence of CNV to threaten foveal function. The purpose of this study was therefore to report the long-term acuity and macular structural outcome in a cohort of patients who have undergone translocation surgery and examine the causes for late visual acuity decline.
Abstract and Introduction
Abstract
Background/aims Long-term data of macular translocation for choroidal neovascularisation (CNV) secondary to age-related macular degeneration is lacking. Therefore, we describe the 3-year acuity outcomes.
Methods This is a retrospective, interventional case series consisting of 40 consecutive patients who underwent translocation between 2003 and 2008. Best-corrected visual acuity (BCVA) at the most recent follow-up visit was compared to that of the 1 year and pre-operative visits. Delayed post-operative complications were recorded, as diagnosed by clinical examination, spectral-domain optical coherence tomography, fundus autofluorescence imaging and angiography.
Results The mean (range) follow-up duration was 37.6 months (range 12.4–67.4 months). Median BCVA values were 0.80, 0.70 and 0.78 log(MAR) at the baseline, 1 year and most recent visits (p=0.13). A three-line gain in BCVA was seen in 12 (30%) patients at 1 year and 10 (25%) patients at the last observation. Twenty-seven (68%) patients achieved a BCVA of 6/60 or better and six (15%) patients, 6/12 or better at the final visit. In the subset of the cohort followed for two or more years, 24 of 32 patients (75%) achieved a BCVA of 6/60 at 1 year but six of these (25%) lost two lines of BCVA thereafter due to recurrent CNV, idiopathic macular oedema, macular hole or macular pucker. Recurrent CNV developed in nine patients (23%) within the first 2 years and their final mean VA was 6/30.
Conclusions With close post-operative monitoring and early treatment of delayed complications, 25% of this cohort maintained a three-line gain in acuity at 3 years after macular translocation.
Introduction
Neovascular age-related macular degeneration (AMD) is characterised by the formation of choroidal neovascularisation (CNV). In this process, the new vessels may leak or bleed resulting in serous or haemorrhagic pigment epithelial detachment (PED), retinal pigment epithelium (RPE) rip, formation of subretinal fluid and haemorrhage, macular oedema and, ultimately, disciform scar with chorioretinal atrophy. In those with more than 50% of the lesions being CNV, intravitreal ranibizumab has been shown to reverse visual loss with an average of between 1- to 2-line gain in best-corrected visual acuity (BCVA) and up to 40% of eyes gaining 3 lines of acuity at 12 months which was maintained at 24 months. However, the use of these agents in patients with large submacular haemorrhage, serous or haemorrhagic PED and RPE rip remains controversial. Although surgical removal of submacular haemorrhage or CNV alone did not restore vision in large randomised trials, macular translocation surgery, which reconstructs the RPE defects that accompany removal of CNV and blood, has been shown to rescue visual acuity and reading ability with up to a 2-line gain in VA and 40% gaining 3 lines of VA at 1 year in several case series and one pilot randomised trial.
The aim of macular translocation in AMD is to reposition the macula onto a healthier RPE and choroid after removal of the CNV and blood which invariably damage the underlying supporting tissues. The source of the healthier RPE-choroid in translocation is located near the supra-temporal vascular arcade (paramacular region, about 10° eccentricity) when the macula is supra-rotated 45° around the disc. Since the RPE in this region predominantly interact with rods, it is not known if these RPE can also provide long-term support for macular cone survival and function. Furthermore, the extrafoveal atrophy created by the removal of CNV and subsequent foveal rotation may expand with time or allow recurrence of CNV to threaten foveal function. The purpose of this study was therefore to report the long-term acuity and macular structural outcome in a cohort of patients who have undergone translocation surgery and examine the causes for late visual acuity decline.
Source...