- Email: [email protected]
Comparison of visual function after foveal translocation with 360° retinotomy and with scleral shortening in a patient with bilateral myopic neovascular maculopathy
Shields JA, Shields CL, editors. Atlas of eyelid and conjunctival tumors. Philadelphia: Lippincott Williams and Williams, 1999:324 –325. 4. Purcell JJ, Birkenkamp R, Tsai CC, Riner RN. Conjunctival involvement in primary systemic nonfamilial amyloidosis. Am J Ophthalmol 1983;95:845– 847. 5. O’Donnell B, Wuebbolt G, Collin R. Amyloidosis of the conjunctiva. Aust NZ J Ophthalmol 1995;23:207–212. 6. Patrinely JR, Koch DD. Surgical management of advanced ocular adnexal amyloidosis. Arch Ophthalmol 1992;110: 882– 885.
Comparison of Visual Function After Foveal Translocation with 360° Retinotomy and With Scleral Shortening in a Patient with Bilateral Myopic Neovascular Maculopathy Takashi Fujikado, MD, Masahito Ohji, MD, Jun Hosohata, MD, Atsushi Hayashi, MD, Koichi Oda, MA, and Yasuo Tano, MD PURPOSE:
To compare the visual outcome after foveal translocation by scleral shortening and that after 360° retinotomy with extraocular muscle surgery in a patient with bilateral myopic neovascular maculopathy. METHODS: Case report. RESULTS: A 52-year-old woman with bilateral myopic neovascular maculopathy underwent foveal translocation with scleral shortening in the left eye, and visual acuity improved from 20/70 to 20/30. However, choroidal neovascularization recurred, and the final visual acuity was 20/40 after excision of the choroidal neovascularization. Foveal translocation with 360° retinotomy was performed on the right eye, and visual acuity improved from 20/150 to 20/30. The critical print size was better, and the retinal sensitive area was larger in the right eye. CONCLUSION: The better reading ability shown by foveal translocation by a 360° retinotomy compared with scleral shortening may stem from a larger retinal sensitive area obtained by this method. (Am J Ophthalmol 2000; 130:525–527. © 2000 by Elsevier Science Inc. All rights reserved.)
Accepted for publication May 4, 2000. From the Department of Ophthalmology (T.F., M.O., J.H., A.H., Y.T.) and the Department of Applied Medical Engineering (T.F.), Osaka University Medical School, Osaka, Japan, and the Department of Communication, Tokyo Women’s Christian University, Tokyo, Japan (K.O.). Supported in part by a grant from Ministry of Health and Welfare, Japan. Inquiries to Takashi Fujikado, MD, Department of Applied Medical Engineering, Osaka University Medical School, 2-2 Yamadaoka, Suitashi Osaka, 565-0871, Japan; fax: 81-6879-3948; e-mail: fujikado@ ophthal.med.osaka-u.ac.jp
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FIGURE 1. Preoperative and postoperative fundus photographs of the left and right eyes. (Top) Preoperatively, subfoveal choroidal neovascularization and hemorrhage are present in the left eye (top right) and in the right eye (Top left). (Bottom right) Postoperative fundus photograph of the left eye 24 months after foveal translocation by scleral shortening. Tranaslocated fovea (arrow) is located just inferonasal to the border of the original choroidal neovascularization. (Bottom left) Postoperative fundus photograph of the right eye 8 months after foveal translocation by a 360° retinotomy. Translocated fovea (arrow) is located above the area of the choroidal neovascularization excision.
W
E HAVE REPORTED1 GOOD SHORT-TERM RESULTS
from foveal translocation using scleral shortening2 in myopic patients. However, the quality of vision turned out to be inadequate for reading in some patients because of a limitation of the visual field. We report the visual outcome of foveal translocation using scleral shortening (left eye) and that after 360° retinotomy with extraocular muscle surgery (right eye) in a patient with myopic neovascular maculopathy. ● CASE:
The best-corrected visual acuity of a 52-year-old woman with bilateral myopic neovascular maculopathy was RE: 20/30 and LE: 20/70. After receiving informed consent, translocation of the fovea by scleral shortening was performed on the left eye, as previously described,1 and the fixation point was shifted by 0.5 disk diameter inferonasally. Visual acuity improved to 20/30 with a hard contact lens. One year later, a juxtafoveal choroidal neovascularization developed, and visual acuity decreased to 20/100 in the left eye. After excision of the choroidal neovascularization, visual acuity recovered to 20/40. However, the patient complained of difficulty in reading with the left eye because of the limitation of a clear visual field. Two years later, the subfoveal choroidal neovasculariza-
BRIEF REPORTS
525
FIGURE 2. Postoperative midphase fluorescein angiography (Top) and SLO microperimetry (Bottom). The green A’s indicate points seen by the patient, whereas the red A’s indicate scotoma points. (Top right) In the left eye, the hyperfluorescence corresponds to the original subfoveal neovascular membrane (arrow) and window defect corresponds to a retinal pigment epithelium defect at the excision site (arrowhead). (Top left) In the right eye, the window defect corresponds to a retinal pigment epithelium defect at the choroidal neovascularization excision site (arrow), and the shifted fovea is clearly seen (arrowhead). (Bottom) The retinal sensitive area around the fovea (indicated by yellow ellipsoid, in which only green A’s are included) is much larger in the right than in the left eye.
version of MNREAD reading acuity chart) showed a better critical print size5 in the right (0.4 log MAR [minimum angle of resolution]) than in the left eye (1.2 log MAR). The functional retinal area around the fovea was larger in the right than in the left eye, as determined by scanning laser ophthalmoscope microperimetry (Figure 2). We have shown that scleral shortening in the left eye shifted the fovea only 0.5 disk diameter to the border of the neovascular membrane. The visual field was restricted because the new fovea was very close to the choroidal neovascularization and the fovea was involved when there was a recurrence of the choroidal neovascularization. In comparison, a larger foveal shift and, thus, a larger retinal sensitive area were obtained by 360° retinotomy (Figure 2). Because of the large shift of the fovea, a 360° retinotomy can cause a tilt of images and diplopia. However, using simultaneous muscle surgery, the angle of retinal rotation can be neutralized, decreasing the risk of these complications. Better reading ability was obtained by foveal translocation with 360° retinotomy compared with scleral shortening in our patient; however, a longer follow-up is necessary to evaluate long-term results, including complications such
tion in the right eye enlarged, leading to a deterioration of visual acuity to 20/200. With the consent of the patient, translocation of the fovea using 360° retinotomy with simultaneous extraocular muscle surgery was performed as previously described (Figure 1).3,4 Briefly, after recession of the superior oblique muscle and tucking of the inferior oblique muscle, a 30° counterclockwise rotation of the globe was obtained. After lensectomy, vitrectomy, and an intentional retinal detachment, a 360° retinotomy was created near the ora serrata and the choroidal neovascularization was excised. A retinal clockwise rotation corresponding to the rotation of the globe was achieved with perfluorocarbon tamponade. After photocoagulation around the retinotomy site, perfluorocarbon/silicon oil exchange was performed. Two months later, a silicon/fluid exchange and intraocular lens insertion were performed. The fovea was translocated by 1.1 disk diameter upward. Transient complaints of image tilt and diplopia resolved within a month. Up to 10 months after the initial surgery, no complications, such as proliferative vitreoretinopathy, occurred and the visual acuity improved to 20/25 at the final visit. The visual acuity in the left eye remained at 20/40. She can now read a newspaper at 20 cm without a magnifier with her right eye. Her reading vision (Japanese 526
AMERICAN JOURNAL
OF
OPHTHALMOLOGY
OCTOBER 2000
as choroidal neovascularization recurrence and retinal detachment. REFERENCES
1. Fujikado T, Ohji M, Saito Y, Hayashi A, Tano Y. Visual function after foveal translocation with scleral shortening in patients with myopic neovascular maculopathy. Am J Ophthalmol 1998;125:647– 656. 2. De Juan E, Loewenstein A, Bressler NM, Alexander J. Translocation of the retina for management of subfoveal choroidal neovascularization. II. A preliminary report in humans. Am J Ophthalmol 1998;125:635– 646. 3. Machmer R, Steinhorst UH. Retinal separation, retinotomy, and macular relocation, II: surgical approach for age-related macular degeneration? Graefe’s Arch Clin Exp Ophthalmol 1993;231:635– 641. 4. Eckardt C, Eckardt U, Conraf HG. Macular rotation with and without counter-rotation of the globe in patients with agerelated macular degeneration. Graefe’s Arch Clin Exp Ophthalmol 1999;237:313–325. 5. Mansield JS, Legge GE, Bane MC. Psychophysics of reading XV: font effects in normal and low vision. Invest Ophthalmol Vis Sci 1996;37:1492–1501.
A
CONGENITAL RETINAL MACROVESSEL IS A LARGE VES-
BRIEF REPORTS
527
Decompensation of a Congenital Retinal Macrovessel with Arteriovenous Communications Induced by Repetitive Rollercoaster Rides Stephen Beatty, FRCOphth, Karen Goodall, FRCOphth, Raymond Radford, FRCOphth, and Michael J. Lavin, FRCOphth PURPOSE:
To describe a congenital retinal venous macrovessel that communicates with a cilioretinal artery and a retinal artery, and to report how this vascular anomaly decompensated as a result of repetitive rollercoaster rides. METHODS: Case report with serial fundus photography and fluorescein angiography. RESULTS: After a short period of intensive rollercoaster rides, a 19-year-old woman complained of reduced vision in one eye. Funduscopy and fluorescein angiography revealed a venous congenital retinal macrovessel with arteriovenous communications, and retinal exudation was visible at the termination of the anomalous vessel. Exudation resolved, and acuity recovered after a period of avoidance of rollercoaster rides. CONCLUSION: This case represents the first report of a retinal artery and a cilioretinal artery communicating with a congenital retinal macrovessel, and it suggests that Accepted for publication May 2, 2000. From the Manchester Royal Eye Hospital, London, United Kingdom. Inquires to Stephen Beatty, FRCOphth, Manchester Royal Eye Hospital, Oxford Road, Manchester M13 9WH, U.K.
VOL. 130, NO. 4
such patients are at increased risk of retinal vascular decompensation if involved in activities associated with changes in g-forces, such as bungee jumping or rollercoaster rides. (Am J Ophthalmol 2000;130:527–528. © 2000 by Elsevier Science Inc. All rights reserved.)
sel, usually a vein, which traverses through the central macula and has large tributaries extending on both sides of the horizontal raphe.1 Typically, visual acuity is unaffected. We report a case of congenital retinal macrovessel with associated retinal arteriovenous and cilioretinal anastomoses that decompensated as a result of repetitive rollercoaster rides. A 19-year-old female was referred with a 3-month history of blurred vision in the right eye. Visual acuities were RE: 20/80, LE: 20/20. Examination of the anterior segments was unremarkable. Funduscopy revealed a congenital retinal macrovessel, originating from the inferotemporal retinal vein, which traversed the horizontal raphe and arched around the fovea. Retinal elevation and exudation were visible at the termination of the macrovessel. (Figure 1, top left). Fundus fluorescein angiography revealed the presence of a cilioretinal artery and early filling of the distal end of the venous macrovessel, indicating the presence of a ciliorioretinal shunt. (Figure 1, top right). In the venous phase, a retinal arteriovenous communication at the termination of the macrovessel was evident (Figure 1, bottom left). On further questioning, it transpired that the patient’s visual deterioration coincided with the development of her new interest in rollercoasters. She reported taking 10 to 15 rollercoaster rides per week during this period, and had traveled widely within the United Kingdom to gain access to rides with illustrious names, such as “Helter-Skelter,” “The Big Dipper,” “Nemesis,” “Oblivion,” and so on. We advised the patient to abstain from rollercoaster rides. Retinal elevation and exudation resolved, and visual acuity recovered to 20/20, over the following 6 months (Figure 1, bottom right). In Brown’s series of seven congenital retinal macrovessels, perifoveal arteriovenous communications were seen in four cases and a cilioretinal artery was present in one case.1 The retinal arteriovenous anastamosis reported here could be classified as a type I arteriovenous communication, characterized by an arterial capillary plexus bridging large communicating vessels.2 However, the communication between the cilioretinal artery and the macrovessel represents a previously undescribed finding, and it lends further credence to the view that these vascular anomalies develop from insults before the retinal vessels divide into arteries and veins.2 Congenital retinal macrovessels are typically associated with normal acuity.1 Because the intravascular pressure is increase in large retinal veins with arteriovenous communi-
Comparison of Visual Function After Foveal Translocation with 360° Retinotomy and With Scleral Shortening in a Patient with Bilateral Myopic Neovascular Maculopathy Takashi Fujikado, MD, Masahito Ohji, MD, Jun Hosohata, MD, Atsushi Hayashi, MD, Koichi Oda, MA, and Yasuo Tano, MD PURPOSE:
To compare the visual outcome after foveal translocation by scleral shortening and that after 360° retinotomy with extraocular muscle surgery in a patient with bilateral myopic neovascular maculopathy. METHODS: Case report. RESULTS: A 52-year-old woman with bilateral myopic neovascular maculopathy underwent foveal translocation with scleral shortening in the left eye, and visual acuity improved from 20/70 to 20/30. However, choroidal neovascularization recurred, and the final visual acuity was 20/40 after excision of the choroidal neovascularization. Foveal translocation with 360° retinotomy was performed on the right eye, and visual acuity improved from 20/150 to 20/30. The critical print size was better, and the retinal sensitive area was larger in the right eye. CONCLUSION: The better reading ability shown by foveal translocation by a 360° retinotomy compared with scleral shortening may stem from a larger retinal sensitive area obtained by this method. (Am J Ophthalmol 2000; 130:525–527. © 2000 by Elsevier Science Inc. All rights reserved.)
Accepted for publication May 4, 2000. From the Department of Ophthalmology (T.F., M.O., J.H., A.H., Y.T.) and the Department of Applied Medical Engineering (T.F.), Osaka University Medical School, Osaka, Japan, and the Department of Communication, Tokyo Women’s Christian University, Tokyo, Japan (K.O.). Supported in part by a grant from Ministry of Health and Welfare, Japan. Inquiries to Takashi Fujikado, MD, Department of Applied Medical Engineering, Osaka University Medical School, 2-2 Yamadaoka, Suitashi Osaka, 565-0871, Japan; fax: 81-6879-3948; e-mail: fujikado@ ophthal.med.osaka-u.ac.jp
VOL. 130, NO. 4
FIGURE 1. Preoperative and postoperative fundus photographs of the left and right eyes. (Top) Preoperatively, subfoveal choroidal neovascularization and hemorrhage are present in the left eye (top right) and in the right eye (Top left). (Bottom right) Postoperative fundus photograph of the left eye 24 months after foveal translocation by scleral shortening. Tranaslocated fovea (arrow) is located just inferonasal to the border of the original choroidal neovascularization. (Bottom left) Postoperative fundus photograph of the right eye 8 months after foveal translocation by a 360° retinotomy. Translocated fovea (arrow) is located above the area of the choroidal neovascularization excision.
W
E HAVE REPORTED1 GOOD SHORT-TERM RESULTS
from foveal translocation using scleral shortening2 in myopic patients. However, the quality of vision turned out to be inadequate for reading in some patients because of a limitation of the visual field. We report the visual outcome of foveal translocation using scleral shortening (left eye) and that after 360° retinotomy with extraocular muscle surgery (right eye) in a patient with myopic neovascular maculopathy. ● CASE:
The best-corrected visual acuity of a 52-year-old woman with bilateral myopic neovascular maculopathy was RE: 20/30 and LE: 20/70. After receiving informed consent, translocation of the fovea by scleral shortening was performed on the left eye, as previously described,1 and the fixation point was shifted by 0.5 disk diameter inferonasally. Visual acuity improved to 20/30 with a hard contact lens. One year later, a juxtafoveal choroidal neovascularization developed, and visual acuity decreased to 20/100 in the left eye. After excision of the choroidal neovascularization, visual acuity recovered to 20/40. However, the patient complained of difficulty in reading with the left eye because of the limitation of a clear visual field. Two years later, the subfoveal choroidal neovasculariza-
BRIEF REPORTS
525
FIGURE 2. Postoperative midphase fluorescein angiography (Top) and SLO microperimetry (Bottom). The green A’s indicate points seen by the patient, whereas the red A’s indicate scotoma points. (Top right) In the left eye, the hyperfluorescence corresponds to the original subfoveal neovascular membrane (arrow) and window defect corresponds to a retinal pigment epithelium defect at the excision site (arrowhead). (Top left) In the right eye, the window defect corresponds to a retinal pigment epithelium defect at the choroidal neovascularization excision site (arrow), and the shifted fovea is clearly seen (arrowhead). (Bottom) The retinal sensitive area around the fovea (indicated by yellow ellipsoid, in which only green A’s are included) is much larger in the right than in the left eye.
version of MNREAD reading acuity chart) showed a better critical print size5 in the right (0.4 log MAR [minimum angle of resolution]) than in the left eye (1.2 log MAR). The functional retinal area around the fovea was larger in the right than in the left eye, as determined by scanning laser ophthalmoscope microperimetry (Figure 2). We have shown that scleral shortening in the left eye shifted the fovea only 0.5 disk diameter to the border of the neovascular membrane. The visual field was restricted because the new fovea was very close to the choroidal neovascularization and the fovea was involved when there was a recurrence of the choroidal neovascularization. In comparison, a larger foveal shift and, thus, a larger retinal sensitive area were obtained by 360° retinotomy (Figure 2). Because of the large shift of the fovea, a 360° retinotomy can cause a tilt of images and diplopia. However, using simultaneous muscle surgery, the angle of retinal rotation can be neutralized, decreasing the risk of these complications. Better reading ability was obtained by foveal translocation with 360° retinotomy compared with scleral shortening in our patient; however, a longer follow-up is necessary to evaluate long-term results, including complications such
tion in the right eye enlarged, leading to a deterioration of visual acuity to 20/200. With the consent of the patient, translocation of the fovea using 360° retinotomy with simultaneous extraocular muscle surgery was performed as previously described (Figure 1).3,4 Briefly, after recession of the superior oblique muscle and tucking of the inferior oblique muscle, a 30° counterclockwise rotation of the globe was obtained. After lensectomy, vitrectomy, and an intentional retinal detachment, a 360° retinotomy was created near the ora serrata and the choroidal neovascularization was excised. A retinal clockwise rotation corresponding to the rotation of the globe was achieved with perfluorocarbon tamponade. After photocoagulation around the retinotomy site, perfluorocarbon/silicon oil exchange was performed. Two months later, a silicon/fluid exchange and intraocular lens insertion were performed. The fovea was translocated by 1.1 disk diameter upward. Transient complaints of image tilt and diplopia resolved within a month. Up to 10 months after the initial surgery, no complications, such as proliferative vitreoretinopathy, occurred and the visual acuity improved to 20/25 at the final visit. The visual acuity in the left eye remained at 20/40. She can now read a newspaper at 20 cm without a magnifier with her right eye. Her reading vision (Japanese 526
AMERICAN JOURNAL
OF
OPHTHALMOLOGY
OCTOBER 2000
as choroidal neovascularization recurrence and retinal detachment. REFERENCES
1. Fujikado T, Ohji M, Saito Y, Hayashi A, Tano Y. Visual function after foveal translocation with scleral shortening in patients with myopic neovascular maculopathy. Am J Ophthalmol 1998;125:647– 656. 2. De Juan E, Loewenstein A, Bressler NM, Alexander J. Translocation of the retina for management of subfoveal choroidal neovascularization. II. A preliminary report in humans. Am J Ophthalmol 1998;125:635– 646. 3. Machmer R, Steinhorst UH. Retinal separation, retinotomy, and macular relocation, II: surgical approach for age-related macular degeneration? Graefe’s Arch Clin Exp Ophthalmol 1993;231:635– 641. 4. Eckardt C, Eckardt U, Conraf HG. Macular rotation with and without counter-rotation of the globe in patients with agerelated macular degeneration. Graefe’s Arch Clin Exp Ophthalmol 1999;237:313–325. 5. Mansield JS, Legge GE, Bane MC. Psychophysics of reading XV: font effects in normal and low vision. Invest Ophthalmol Vis Sci 1996;37:1492–1501.
A
CONGENITAL RETINAL MACROVESSEL IS A LARGE VES-
BRIEF REPORTS
527
Decompensation of a Congenital Retinal Macrovessel with Arteriovenous Communications Induced by Repetitive Rollercoaster Rides Stephen Beatty, FRCOphth, Karen Goodall, FRCOphth, Raymond Radford, FRCOphth, and Michael J. Lavin, FRCOphth PURPOSE:
To describe a congenital retinal venous macrovessel that communicates with a cilioretinal artery and a retinal artery, and to report how this vascular anomaly decompensated as a result of repetitive rollercoaster rides. METHODS: Case report with serial fundus photography and fluorescein angiography. RESULTS: After a short period of intensive rollercoaster rides, a 19-year-old woman complained of reduced vision in one eye. Funduscopy and fluorescein angiography revealed a venous congenital retinal macrovessel with arteriovenous communications, and retinal exudation was visible at the termination of the anomalous vessel. Exudation resolved, and acuity recovered after a period of avoidance of rollercoaster rides. CONCLUSION: This case represents the first report of a retinal artery and a cilioretinal artery communicating with a congenital retinal macrovessel, and it suggests that Accepted for publication May 2, 2000. From the Manchester Royal Eye Hospital, London, United Kingdom. Inquires to Stephen Beatty, FRCOphth, Manchester Royal Eye Hospital, Oxford Road, Manchester M13 9WH, U.K.
VOL. 130, NO. 4
such patients are at increased risk of retinal vascular decompensation if involved in activities associated with changes in g-forces, such as bungee jumping or rollercoaster rides. (Am J Ophthalmol 2000;130:527–528. © 2000 by Elsevier Science Inc. All rights reserved.)
sel, usually a vein, which traverses through the central macula and has large tributaries extending on both sides of the horizontal raphe.1 Typically, visual acuity is unaffected. We report a case of congenital retinal macrovessel with associated retinal arteriovenous and cilioretinal anastomoses that decompensated as a result of repetitive rollercoaster rides. A 19-year-old female was referred with a 3-month history of blurred vision in the right eye. Visual acuities were RE: 20/80, LE: 20/20. Examination of the anterior segments was unremarkable. Funduscopy revealed a congenital retinal macrovessel, originating from the inferotemporal retinal vein, which traversed the horizontal raphe and arched around the fovea. Retinal elevation and exudation were visible at the termination of the macrovessel. (Figure 1, top left). Fundus fluorescein angiography revealed the presence of a cilioretinal artery and early filling of the distal end of the venous macrovessel, indicating the presence of a ciliorioretinal shunt. (Figure 1, top right). In the venous phase, a retinal arteriovenous communication at the termination of the macrovessel was evident (Figure 1, bottom left). On further questioning, it transpired that the patient’s visual deterioration coincided with the development of her new interest in rollercoasters. She reported taking 10 to 15 rollercoaster rides per week during this period, and had traveled widely within the United Kingdom to gain access to rides with illustrious names, such as “Helter-Skelter,” “The Big Dipper,” “Nemesis,” “Oblivion,” and so on. We advised the patient to abstain from rollercoaster rides. Retinal elevation and exudation resolved, and visual acuity recovered to 20/20, over the following 6 months (Figure 1, bottom right). In Brown’s series of seven congenital retinal macrovessels, perifoveal arteriovenous communications were seen in four cases and a cilioretinal artery was present in one case.1 The retinal arteriovenous anastamosis reported here could be classified as a type I arteriovenous communication, characterized by an arterial capillary plexus bridging large communicating vessels.2 However, the communication between the cilioretinal artery and the macrovessel represents a previously undescribed finding, and it lends further credence to the view that these vascular anomalies develop from insults before the retinal vessels divide into arteries and veins.2 Congenital retinal macrovessels are typically associated with normal acuity.1 Because the intravascular pressure is increase in large retinal veins with arteriovenous communi-