To report the long-term (>5 years) results of full macular translocation in patients with choroidal neovascularization (CNV).
Retrospective, interventional case series.
This study involved 32 eyes of 32 patients who had undergone full macular translocation for CNV. The median follow-up was 6.5 years (range, 5.2 to 7.7 years). We evaluated the best-corrected visual acuity, fundus examination results obtained before and 1 and 5 years after operation, and postoperative complications.
At the 1-year follow-up, foveal retinal pigment epithelium atrophy was observed in only 3 eyes (12%), and the mean logarithm of the minimal angle of resolution (logMAR) visual acuity (VA) at that time (1.39 ± 0.67) was not significantly changed from that before surgery (logMAR, 1.31 ± 0.66) in 25 eyes with age-related macular degeneration (AMD). However, at 5-year follow-up, foveal retinal pigment epithelium atrophy increased (18 eyes; 72%), and final mean logMAR VA (1.88 ± 0.76) was significantly lower ( P < .01). Five eyes with myopic CNV maintained their VA from before operation (mean logMAR, 0.88 ± 0.35) until final follow-up (mean logMAR, 0.73 ± 0.31). The final VA was significantly better in myopic CNV than in exudative age-related macular degeneration on multiple regression analysis ( P = .019).
Long-term follow-up of full macular translocation showed that the final VA was poor in age-related macular degeneration, but relatively better in myopic CNV.
Age-related macular degeneration (AMD) is the leading cause of legal blindness among the elderly in industrialized countries, and there has been a recent trend for the number of such patients to increase in Japan. Full macular translocation has been performed to treat exudative AMD. Recently, however, the main treatments for choroidal neovascularization (CNV), including exudative AMD, have become anti–vascular endothelial growth factor (VEGF) therapy and photodynamic therapy (PDT), because long-term follow-up has shown that macular translocation is not effective and has a high rate of postoperative complications, such as proliferative vitreoretinopathy and retinal detachment.
Most studies have reported a favorable outcome with 2 years of follow-up after full macular translocation. However, there are a few reports with follow-up of 3 years or longer, and their results were poor. In this report, the long-term results (at least 5 years of follow-up) are reported for patients who underwent full macular translocation.
Full macular translocation was performed for CNV in 45 eyes of 45 patients from November 1999 through June 2002 at Nagasaki University. The study involved 32 eyes of 32 patients with follow-up of 5 years or more. CNV was classified, and CNV lesion sizes were measured by fluorescein angiography before surgery. The best-corrected visual acuity (BCVA), fundus examination results before and 1 and 5 years after surgery, and postoperative complications were reviewed retrospectively using the patients’ clinical records.
The surgical procedure included phacoemulsification and implantation of an intraocular lens in phakic eyes. Then, 3-port pars plana vitrectomy was performed, posterior vitreous detachment was induced, and the vitrectomy was completed to the vitreous base. Balanced saline solution was injected to induce total retinal detachment, and 360-degree retinotomy was performed at the posterior edge of the vitreous base. Then, CNV was removed, a small amount of perfluorocarbon liquid was injected onto the retinal surface, and the retina was rotated to move the fovea to the normal area of retinal pigment epithelium (RPE). Perfluorocarbon liquid was added up to the edge of the retinotomy site, and peripheral laser retinopexy was performed at the edge of the retinotomy sites in all quadrants after retinal reattachment. Silicone oil tamponade was performed at the end of the procedure. The mean duration of silicone oil tamponade was 5 months.
Results are expressed as mean ± standard deviation. Analysis of variance with the Tukey test was used to compare BCVA before and after surgery. Multiple regression analysis was used to evaluate final BCVA, which is known to be related to age, cause of CNV (AMD, myopic), and preoperative BCVA. Logistic regression analysis was used to evaluate the relationships between CNV recurrences and age, sex, cause of CNV (AMD, myopic), type of CNV (classic, occult), lesion size, preoperative BCVA, final BCVA, and tobacco use. Statistical analysis was performed using Statflex software version 5.0 (Artech Corporation, Osaka, Japan).
The study included 32 eyes of 32 patients (8 females, 24 males; mean age at operation, 66.6 years) who underwent full macular translocation. All patients were Japanese. The causes of CNV were exudative AMD in 25 eyes, myopia in 5 eyes, idiopathic cause in 1 eye, and angioid streaks in 1 eye. The mean duration of follow-up was 6.5 years (range, 5.2 to 7.7 years). A clear intraocular lens was used in all patients. Fourteen patients were tobacco users.
The exudative AMD group included 5 female and 20 male patients, with a mean age at operation of 70.5 years ( Table ). On fluorescein angiography, 18 eyes had classic CNV, and 7 eyes had occult CNV. The mean lesion size was 5.6 ± 3.1 Macular Photocoagulation Study (MPS) disc areas (range, 2 to 16 MPS disc areas). Operative complications included iatrogenic retinal break, macular hole, subretinal perfluorocarbon liquid, and subretinal hemorrhage in 1 eye each. The subretinal perfluorocarbon liquid was removed at the silicone oil removal operation if the perfluorocarbon liquid was located in the posterior pole. Macular holes and subretinal hemorrhages were likely to affect the visual acuity (VA), but the others had no effect on the VA because the complications were unrelated to the macular lesion. Postoperative complications within 1 year after operation were: proliferative vitreoretinopathy in 5 eyes; epiretinal membrane (ERM) in 5 eyes; superficial punctate keratitis in 3 eyes; and secondary glaucoma in 3 eyes. All cases of proliferative vitreoretinopathy were resected successfully by reoperation, and ERMs were removed at the silicone oil removal operation in 4 cases. It took more than 1 month for superficial punctate keratitis to be cured by topical hyaluronate sodium treatment after operation. With respect to secondary glaucoma, silicone oil-induced glaucoma occurred in 2 eyes, but ocular tension improved when the silicone oil was removed. Neovascular glaucoma complicated with diabetic retinopathy occurred in 1 eye 3 years after full macular translocation, but ocular tension improved with topical β-blocker therapy after panretinal photocoagulation and cyclophotocoagulation. These postoperative complications also were likely to affect the VA. However, the mean logarithm of the minimal angle of resolution (logMAR) was not significantly different between the 13 cases with operative or postoperative complications and the 12 cases with no complications ( P = .77). CNV recurrence developed in 5 (20%) of 25 eyes. Two cases were under observation because of lower CNV activity. PDT was performed in 2 cases, after which the activity decreased. CNV removal was performed in 1 case by reoperation.
|No. of Eyes||Mean Age at Operation (yrs)||Preoperative Mean logMAR Visual Acuity a||Final Mean logMAR Visual Acuity a||Fovea at 1 Year after Operation, No. (%) of Eyes||Fovea at Final Follow-up, No. (%) of Eyes|
|AMD||25||70.5||1.31 ± 0.66||1.88 ± 0.76|
|Myopic CNV||5||51.0||0.88 ± 0.35||0.73 ± 0.31|
VA before operation, VA 1 year after operation, and final VA were compared in AMD ( Figures 1 through 4 ). A normal fovea was defined as one without edema or RPE atrophy on ophthalmoscopic examination. At the 1-year follow-up, mean logMAR VA was 1.39 ± 0.67, which was not significantly changed from the VA before operation (mean logMAR, 1.31 ± 0.66) in AMD. However, at the 5-year follow-up, final VA (mean logMAR, 1.88 ± 0.76) was significantly lower than that before operation ( P < .01; Figure 4 ). One year after operation, a normal fovea was observed in 18 eyes (72%), and RPE atrophy was observed in 3 eyes (12%). However, 5 years or longer after operation, a normal fovea was observed in only 4 eyes (16%), whereas RPE atrophy was observed in 18 eyes (72%) because of progressive degeneration ( Table ). VA was worse in the abnormal fovea group than in the normal fovea group 5 years or more after operation, but the difference was not statistically significant ( P = .051). In the 4 eyes with a normal fovea at 5 years, VA was good in 3 eyes, but progressive visual loss from an unknown cause occurred in 1 eye. At the final observation, VA was worse than before operation in 18 eyes (72%), there were no changes in 3 eyes (12%), and VA was improved in 4 eyes (16%).