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Foveal translocation with scleral imbrication in patients with myopic neovascular maculopathy
Foveal Translocation With Scleral Imbrication in Patients With Myopic Neovascular Maculopathy MIKIO ICHIBE, MD, KAZUYUKI IMAI, MD, MASAYUKI OHTA, MD, HIRUMA HASEBE, MD, TOYOHISA YOSHIZAWA, MD, AND HARUKI ABE, MD
● PURPOSE:
To report our surgical results of foveal translocation with scleral imbrication in patients with myopic neovascular maculopathy. ● DESIGN: Noncomparative, interventional, consecutive case series. ● METHODS: Ten eyes of 10 myopic patients with subfoveal neovascular membranes that had undergone foveal translocation with scleral imbrication were recruited for this retrospective study. Inclusion criteria were myopia 6.0 diopters or greater in refractive error (or axial length 26.5 mm or longer), subfoveal choroidal neovascularization, and preoperative best-corrected visual acuity of 20/100 or worse. None of these eyes had undergone prior laser photocoagulation or submacular surgery. The main outcome measures were surgical complications and postoperative visual function. ● RESULTS: Postoperatively, visual acuity had improved more than 3 lines in the logarithm of minimum angle of resolution (logMAR) measurement in all eyes. The mean preoperative, postoperative best, and final visual acuity were 0.12, 0.59, and 0.51, respectively. Of the 10 eyes, six achieved a postoperative final visual acuity of 20/40 or better. The mean postoperative foveal displacement was 0.78 disk diameter (range, 0.3–1.3 disk diameter). Two patients underwent a reoperation because of insufficient foveal displacement. Furthermore, one of these two patients required a third operation to reduce an excessive retinal fold involving the fovea induced by the second surgery. Of the 10 patients, two noted transient diplopia. This complaint, however, resolved over time as suppression developed. Although unintentional iatrogenic retinal tears formed intraoperatively in two eyes, these were successfully treated without serious complications. Postoperatively, mild retinal pigment epithelial Accepted for publication Feb 14, 2001. From the Department of Ophthalmology, Niigata University School of Medicine, Asahimachi, Niigata, Japan. Reprint requests to Mikio Ichibe, MD, Department of Ophthalmology, Niigata University School of Medicine, 1 757 Asahimachi, Niigata 951 8510, Japan; fax: ⫹ 81-25-227-0785; e-mail: [email protected]
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changes were observed in all cases, but none led to significant deterioration of visual acuity during the follow-up period. All patients but one were followed for a minimum of 6 months. ● CONCLUSIONS: In eyes with myopic neovascular maculopathy, foveal translocation with scleral imbrication may be useful in improving visual acuity. Further refinements in surgical technique and assessment of the long-term complications will be needed to make this procedure safer and more useful. (Am J Ophthalmol 2001;132:164 –171. © 2001 by Elsevier Science Inc. All rights reserved.)
D
EGENERATIVE MYOPIA IS ONE OF THE CAUSES OF
severe visual loss in adults. It has been accepted that the choroidal neovascularization in degenerative myopia is usually self-limited.1 However, subfoveal neovascularization has a generally poor visual prognosis.2,3 Laser photocoagulation treatment4 or submacular surgery5–7 for myopic neovascular maculopathy is effective in some cases in preserving or improving vision. However, expansion of a photocoagulation scar1,8,9 or retinal pigment epithelial damage after removal of neovascular membrane7 can be unfavorable complications of these treatments in degenerative myopia, sometimes with worsening of visual acuity. In 1993, Machemer and Steinhorst10 reported results, in three cases with age-related macular degeneration, of a surgical approach with a peripheral 360-degree retinotomy allowing for relocation of the fovea to a site with intact retinal pigment epithelium. In their series, one patient had a significant gain in visual function after macular translocation. However, proliferative vitreoretinopathy developed in the other two patients after initially successful rotation. Recently, in an attempt to reduce occurrences of such a serious complication, a new surgical method for translocation of the fovea without a large retinotomy was reported. Imai and associates11 and de Juan and associates12 developed a safer method with intentional retinal detachment
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0002-9394/01/$20.00 PII S0002-9394(01)00935-7
FIGURE 1. (Left) Three or four 5-0 polyester mattress sutures (asterisks) were placed 2–3 mm posterior to the rectus muscle insertion, with 5–7 mm between the anterior and posterior bites of the suture. (Right) To make a meridional scleral imbrication (asterisk), a 5-0 polyester mattress suture was placed posterior to the anteroposterior scleral imbrication (arrows), with 4 –5 mm between the both bites of the suture.
and scleral shortening. Although the distance of foveal shift is relatively small with this method, the retina can be translocated sufficiently in the eyes with smaller neovascular membranes, such as myopic choroidal neovascularization. Therefore, we performed foveal translocation with scleral imbrication in 10 patients with myopic neovascular maculopathy and investigated the functional outcomes of this surgery.
METHODS THE RECORDS OF 10 CONSECUTIVE PATIENTS WITH MYOPIC
neovascular maculopathy who underwent foveal translocation with scleral imbrication between July 1998 and May 2000 at the Department of Ophthalmology, Niigata University Hospital, Niigata, Japan, were reviewed for this study. Inclusion criteria were myopia 6.0 diopters or greater in refractive error (or axial length 26.5 mm or longer), subfoveal choroidal neovascularization, and preoperative best-corrected visual acuity of 20/100 or worse. None of these eyes had undergone prior laser photocoagulation or submacular surgery. Before the surgery, written informed consent was obtained from each patient. The surgical procedure was as follows: a standard three-port pars plana vitrectomy with dissection of the posterior hyaloid; small posterior retinotomy; injection of balanced salt solution into the subretinal space transretinally to create a subtotal retinal detachment; anteroposterior (5–7 ⫻ 18 –20 mm) scleral imbrication (with or without scleral resection) near the equator in the superotemporal or inferotemporal quadrant (Figure 1, left); meridional scleral imbrication posterior to the anteroposterior scleral imbrication (Figure 1, right); VOL. 132, NO. 2
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fluid–air exchange without draining subretinal fluid; and nonexpansive gas tamponade (10%–14% perfluoropropane). Simultaneous cataract surgery with posterior chamber intraocular lens implantation was performed on eight patients (except for patients 3 and 7). Intraocular lens power was determined by intended target refraction with additional ⫺1.0 diopter of myopic shift in consideration of hyperopic shift after scleral imbrication.13 Intraoperatively and postoperatively, choroidal neovascular membranes were not removed or photocoagulated in any case. Postoperatively, patients were positioned in a sitting or lateral position for 2 to 3 days. Surgical complications and postoperative visual function were studied. Preoperative and postoperative examination included best-corrected visual acuity, intraocular pressure, biomicroscopy of the anterior and posterior segments, color fundus photography, fluorescein and indocyanine green angiography, visual field examination (Goldmann perimeter), and orthoptic status. Additionally, the location of fixation and the presence of any scotomas were assessed by scanning laser ophthalmoscope microperimetry (Rodenstock, Germany). Final visual acuity was taken from the last available follow-up examination at least 3 months after surgery. Preoperative and postoperative fundus photographs and scanning laser ophthalmoscope microperimetry were used to evaluate the amount of objective cyclodeviation induced by surgery. All patients were followed for a minimum of 6 months, except for patient 9.
RESULTS THE AGE OF THE 10 PATIENTS IN THIS STUDY RANGED FROM
33 to 74 years (mean, 54.8 ⫾ 14.5 years). Of the 10
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FIGURE 2. Patient 8. Right eye. This patient underwent foveal translocation with scleral imbrication in the inferotemporal quadrant. Postoperatively, the fixation point had shifted in the superonasal direction by 0.8 disk diameter at an angle of 11 degrees of incyclodeviation. Three months after surgery, (left) color photograph and (right) fluorescein angiogram demonstrate the recurrent subretinal hemorrhage around the choroidal neovascularization, which is no longer subfoveal. Each arrow indicates the translocated fovea.
FIGURE 3. Patient 1. Right eye. (Left) Preoperative and (right) postoperative fixation points determined by scanning laser ophthalmoscope microperimetry. Before surgery, fixation point was located at the temporal part of the neovascular membrane. Postoperatively, the fixation shifted inferonasally. The red A’s indicate scotoma points, and blue A’s indicate stimulus points to which the patient responded.
patients, nine were female and one was male. Follow-up ranged from 3 to 28 months (mean, 15.7 ⫾ 8.2 months). Of the 10 patients, two (patients 6 and 7) required a reoperation because of insufficient foveal displacement induced by the previous surgery. The details of one of these two patients (patient 7) are described in the case reports. Postoperatively, the fovea was translocated by a distance of 0.3 to 1.3 disk diameters (average, 0.78 ⫾ 0.32 disk diameter). The amount of postoperative oblique astigmatism seen in our series ranged between 1.0 and 5.5 diopters (average, 3.15 ⫾ 1.58 diopters). Five younger patients 166
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required hard contact lenses to achieve useful vision. In the five elderly patients, refractive errors were managed with eyeglasses. The mean best-corrected visual acuity preoperatively was 0.12, and the mean postoperative best and final visual acuity were 0.59 and 0.51. Final visual acuity improved 3 or more lines in the logarithm of the minimum angle of resolution (logMAR) measurement in all 10 eyes. Of the 10 eyes, six achieved a postoperative final visual acuity of 20/40 or better. The postoperative ectopia of the macula produced a OF
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20 15 13 11 10 3 6
28 26 25
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IT ⫽ inferotemporal; PRK ⫽ photorefractive keratectomy; SR ⫽ scleral resection; SRH ⫽ subretinal hemorrhage; ST ⫽ superotemporal.
⫺9.5 ⫺6.25 ⫺8.75 ⫺18.5 ⫺7 ⫺1.75 ⫺11.5 20/20 20/20 20/20 20/200 20/200 20/20 20/200 27.2 26.7 26.9 29.6 26.5 28.9 29.5 68 51 48 35 70 42 57
female female female female female female female
right left right left right right right
1 2 6 1 2 5 4
⫺15 ⫺6.5 ⫺8 Aphakia ⫺8.5 Post-PRK ⫺10.5
1 0.2 0.3 0.3 0.7 0.2 0.5
20/40 20/20 20/70 20/25 20/40 20/50 20/30
20/40 20/20 20/100 20/30 20/50 20/50 20/40 20/200 20/200 20/200 20/200 20/200 20/100 20/200 ST,SR(⫹) ST,SR(⫹) ST,SR(⫹) ST,SR(⫹) IT,SR(⫺) ST,SR(⫺) ST,SR(⫺)
5.5 3 5 1 4 2 1
⫺7.75 ⫺5.75 ⫺4 1.5 ⫺3.25 ⫺0.25 ⫺2
0.8 0.3 1.3 0.7 0.8 0.4 0.9
None None Retinal break, Recurrent SRH None Retinal break Insufficient movement Insufficient movement Recurrent SRH None Recurrent SRH 0.8 0.5 1.3 ⫺4.5 ⫺7 ⫺10.25 ⫺4.75 ⫺0.75 ⫺10.5 5 2 3 20/20 20/300 20/20 20/300 20/40 20/50 20/100 20/25 20/30 20/100 20/25 20/25 ST,SR(⫹) ST,SR(⫹) ST,SR(⫹) 1 0.3 0.25 28.7 27 29.4 ⫺7 ⫺6 ⫺14
4 5 6 7 8 9 10
Eye Gender
female right uncertain female right 6 male right 4 70 74 33
Final Best Scleral Imbrication History (months) Patient Age No. (years)
1 2 3
Complications
Duration of Follow-up (months) Postop Final Spherical Foveal Spherical Equivalent Displacement Equivalent Fellow Eye (disc (diopters) (diopters) diameter) Postop Final Astigmatism (diopters) Fellow Eye (final) Visual Acuity Preop Axial Length Size of CNV (mm) (disc area) Refractive Error (diopters)
TABLE 1. Patient Characteristics and Surgical Results
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change in the visual axis in all patients. Of the 10 patients, two (patients 3 and 6) experienced postoperative vertical and torsional diplopia during the early follow-up period. In both of these eyes, the amount of foveal displacement was 1.3 disk diameters, which was the maximum foveal movement in this series. This complaint, however, resolved spontaneously as suppression developed in the operated eye. One patient (patient 10) who had poor visual acuity in the nonoperated eye, reported a tilting of images with the operated eye. This symptom improved but persisted in this patient to the 6-month follow-up. Intraoperatively, unintentional iatrogenic retinal breaks formed in two eyes. These were treated successfully with cryotherapy or postsurgical laser treatment. None of the 10 eyes developed proliferative vitreoretinopathy or macular pucker. Mild retinal pigment epithelial damages were observed in all cases postoperatively. None of these changes, however, has been associated with significant deterioration of visual acuity. Seven of the 10 choroidal neovascular membranes followed in this study remained stable or regressed without any hemorrhagic or exudative changes. In three eyes (patients 3, 8, and 10), recurrent subretinal hemorrhage was observed postoperatively. However, it did not extend into the subfoveal area and was not associated with loss of central vision (Figure 2). The individual data for these 10 cases are summarized in Table 1.
CASE REPORTS ● CASE 1 (PATIENT 1):
A 70-year-old woman with high myopia (RE: ⫺7.0 diopters) presented with decreased vision and metamorphopsia in her right eye. The duration of her symptoms was uncertain. Best-corrected visual acuity was RE: 20/300 and LE: 20/40. On examination, the anterior segments were normal except for cortical cataracts in both eyes. Fluorescein and indocyanine green angiography of the right eye disclosed a well-defined subfoveal choroidal neovascularization surrounded with subretinal hemorrhage. Scanning laser ophthalmoscope microperimetry showed a dense scotoma over the area of choroidal neovascularization and subretinal hemorrhage (Figure 3, left). After informed consent was obtained, this patient underwent foveal translocation with simultaneous cataract surgery in the right eye. Scleral resection, 7 mm in the radial direction, was performed superotemporally. There were no complications during surgery. Postoperatively, the fixation point had shifted in the inferonasal direction by 0.8 disk diameter at an angle of four degrees of excyclodeviation, as assessed by scanning laser ophthalmoscope microperimetry (Figure 3, right). Synoptophore testing disclosed a right hypertropia of 0.5
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degree. The patient did not notice any diplopia during binocular viewing. Six months postoperatively, she underwent cataract surgery in her left eye. Seven months after the foveal translocation surgery, the patient’s visual acuity improved to RE: 20/40 and LE: 20/20.
of eyes after 2 years. Hotchkiss and Fine2 also reported a poor visual prognosis, with legal blindness in 44% of the eyes. Pece and associates4 and Bottoni and associates7 obtained similar functional results and concluded that the natural history of subfoveal choroidal neovascularization in degenerative myopia is rarely visually restorative. The management of myopic choroidal neovascularization is also controversial. Pece and associates4 found that laser treatment may be effective in preventing or limiting severe and irreversible loss of vision for extrafoveal and juxtafoveal choroidal neovascularization in degenerative myopia. However, the outcome of choroidal neovascularization (extrafoveal and juxtafoveal) laser treatment in degenerative myopia may be affected by some complications.1,8,9,14 Expansion of a photocoagulation scar is a potential complication of macular photocoagulation, especially in myopic eyes. Oshima and associates9 reported that the mean laser scar expansion ratio in eyes with degenerative myopia was 109.2%, which accords with the 103% increase reported by Brancato and associates.8 Avila and associates1 observed a progressive increase in photocoagulation scar area, sometimes with worsening of visual function. In their series, in four of 14 eyes that received laser photocoagulation, these scars eventually reached the foveal area and were directly associated with loss of central vision, although there was initial improvement or stabilization of visual acuity after laser treatment. Furthermore, in contrast to the situation for age-related macular degeneration, there are no clinical trials investigating the efficacy of laser treatment for subfoveal choroidal neovascularization in degenerative myopia. Hotchkiss and associates2 reported the neovascular membranes were inside the foveal avascular zone in 14 of 27 eyes with degenerative myopia. According to Hampton and associates,3 new vessels in degenerative myopia are located underneath the fovea in 58% of the eyes at the time of the patient’s first visit. Thus, we can treat with laser photocoagulation only the selected cases with myopic choroidal neovascularization. Whereas laser photocoagulation is destructive to both the retinal pigment epithelium and the overlying neurosensory retina, surgical removal of the subfoveal neovascular membrane has the theoretical advantage that the outer retina remains intact. This surgical approach has proven to be effective for subfoveal choroidal neovascularization in eyes with presumed ocular histoplasmosis syndrome but not in most eyes with age-related macular degeneration.5,15–17 Frequently in eyes with age-related macular degeneration, the neovascular membrane grows below as well as above the retinal pigment epithelium.5,18 Because of this, surgical removal of subfoveal choroidal neovascularization in age-related macular degeneration results in large defects of the retinal pigment epithelium and in disappointing visual prognosis. In many of the myopic choroidal neovascularization cases, subretinal pigmented halos often seen around the neovascular membranes, plaquelike elevation of the neovascular complex,
● CASE 2 (PATIENT 7): A 35-year-old woman had a history of neovascular maculopathy secondary to high myopia (RE: ⫺18.0 diopters) and poor vision in her right eye. She underwent intracapsular lens extraction in her left eye in September 1995 at another hospital because of the lens luxation resulting from ocular contusion. Postoperatively, her left visual acuity was 20/20, and posterior segment evaluation was unremarkable. She was referred to our department in November 1999 with decreased visual acuity and metamorphopsia in her left eye of 3 weeks’ duration. At the first visit, bestcorrected visual acuity was RE: 20/200 and LE: 20/200. The axial length of the left eye was 29.6 mm. Clinical and angiographic examinations of the left eye showed a classic subfoveal neovascular membrane (Figure 4, top). After giving her informed consent, this patient underwent foveal translocation in her left eye. Scleral resection, 6 mm in the radial direction, was performed superotemporally. Postoperative fluorescein angiography and scanning laser ophthalmoscope microperimetry showed an extrafoveal neovascular membrane superotemporal to the fovea (Figure 4, center). Her visual acuity, however, had not improved despite the foveal displacement of 0.4 disk diameter. Therefore, she underwent a reoperation 2 months after the initial surgery. The retina was redetached, and a partial fluid–air exchange was performed. Upright positioning was begun soon after the surgery. Postoperatively, the fovea had shifted in the inferonasal direction by 0.7 disk diameter at an angle of 8 degrees of excyclodeviation, as assessed by fluorescein angiography (Figure 4, bottom). She did not complain of diplopia or tilted vision during binocular viewing. One month postoperatively, the patient’s visual acuity improved to LE: 20/40. Finally, her visual acuity improved to LE: 20/30.
DISCUSSION SEVERAL STUDIES ATTEMPTED TO DEFINE THE NATURAL
history of choroidal neovascularization in degenerative myopia, but their results have been contradictory. It has been accepted that the choroidal neovascularization in degenerative myopia is usually self-limited. Avila and associates1 found a relatively favorable natural course of macular choroidal neovascularization. According to Hampton and associates,3 however, the natural course of choroidal neovascularization in degenerative myopia has a generally poor prognosis in that disciform degeneration may lead to a final visual acuity of 20/200 or worse in 60% 168
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and sharply defined borders shown by biomicroscopy and fluorescein angiography suggest a localization anterior to the retinal pigment epithelium but beneath the sensory retina, just as in presumed ocular histoplasmosis syndrome. In such conditions, the neovascular membranes can theoretically be extracted with preservation of the underlying retinal pigment epithelium. There are several reports of visual outcomes after surgical removal of subfoveal choroidal neovascularization secondary to degenerative myopia.5–7 According to Thomas and associates,5 the mean change in final visual acuity compared with preoperative visual acuity was a decrease of 1 line. In all of their 10 cases, final visual acuity was not better than 20/70. Their results of surgery for choroidal neovascularization secondary to degenerative myopia are similar to those seen in age-related macular degeneration. Adelberg and associates6 also reported five patients with myopic neovascular maculopathy who underwent surgical removal of subfoveal choroidal neovascularization. In their series, visual acuity improved by 2 or more lines in two of five eyes and remained unchanged in three. One of these five eyes achieved a postoperative best visual acuity of 20/80. Recently, Bottoni and associates7 reported visual outcomes after surgical excision of subfoveal choroidal neovascularization in a larger consecutive series of 65 eyes with degenerative myopia. The mean preoperative visual acuity was 0.09, and the mean postoperative visual acuity was 0.18. They reported the expansion of postsurgical retinal pigment epithelium defects. According to them, the mean postoperative retinal pigment epithelium defect was 4.6 times larger than the original choroidal neovascularization. We also retrospectively reviewed seven consecutive patients with myopic choroidal neovascularization who had been treated with submacular surgery by us between October 1996 and August 1997. The mean preoperative visual acuity, postoperative best visual acuity, and final visual acuity were 0.06, 0.15, and 0.11.19 For the laser scar expansion analysis, fundus photographs obtained soon after surgery (within 1 month) and at the last follow-up were used. Areas were estimated by one of the authors (Dr Yoshizawa) using the dedicated software of the NIH Image (National Institutes of Health, Bethesda, Maryland, USA). There was a postoperative increase in the area of retinal pigment epithelium damage in all seven eyes, with a mean expansion of 120% (range, 80% to 140%) in the
FIGURE 4. Patient 7. Left eye. (Top) Preoperative fluorescein angiography. A well-defined choroidal neovascularization was located underneath the fovea. (Middle) After the initial surgery, the fovea had shifted in the inferonasal direction by 0.4 disk diameter. Note the mild retinal pigment epithelial change, as compared with the preoperative fluorescein angiogram. (Bottom) Fluorescein angiography after the reoperation. Finally, the distance of foveal shift was 0.7 disk diameter (arrow).
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first year after surgery (Yoshizawa T, unpublished data, 2000). This increase in the size of the retinal pigment epithelial damage can result in loss of central vision as observed in laser treatment. Retinal pigment epithelium defects during surgery and their expansion may be responsible for the limited success in these studies. Because of the mechanical tissue strain induced by excessive axial elongation, the retinal pigment epithelium– choroid complex may become thin and atrophic in eyes with degenerative myopia. Therefore, the retinal pigment epithelium and choroid in highly myopic eyes may be more easily affected by the thermal burn of photocoagulation or surgical excision of choroidal neovascularization. Recently, foveal translocation with various techniques has been suggested to improve central vision by shifting the fovea to an area of healthy retinal pigment epithelium in eyes with subfoveal choroidal neovascularization.10 – 13,20,21 A new surgical approach, using a scleral imbrication with intentional retinal detachment, has the advantage of being less invasive, because it does not require a large retinotomy. This technique allows small translocations, but these are often large enough to move the fovea outside neovascular membranes in myopic neovascular maculopathy. Fujikado and associates13 describe two highly myopic patients whose visual acuity improved from 20/150 to 20/20 and from 20/70 to 20/30, 4 to 6 months after translocation of the fovea. Their results are very impressive, with remarkable gains in visual acuity. For these reasons, surgeries for myopic neovascular maculopathy by means of foveal translocation with scleral imbrication were performed in our clinic. None of the patients in this study underwent simultaneous excision of choroidal neovascularization or postsurgical laser treatment to avoid a scar expansion, which may cause significant, delayed visual loss after successful treatment. We made meridional scleral imbrications in all cases of this study. We suppose that this additional procedure may have been of some help in producing redundant retina. Postoperatively, all of the eyes achieved an effective foveal translocation and had a significant increase in visual acuity. As we had expected, serious complications, such as proliferative vitreoretinopathy or deterioration of visual acuity resulting from retinal pigment epithelium damage, were not observed in any of our cases. Although postoperative changes in spherical correction and astigmatism are unavoidable complications of this technique, these are not problematic in younger patients who already wear hard contact lenses. In elderly patients, who are likely to require cataract surgery, astigmatic and anisometropic changes can be controlled to some extent with the cataract surgery itself, and residual refractive error can be managed with eyeglasses. This technique also produces vertical, horizontal, and rotatory deviation of the visual axis in the treated eye. 170
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Large amounts of foveal displacement induce the development of suppression in the operated eye if the other eye has good visual function. Some degree of cyclodeviations, however, can be handled by some compensatory mechanisms.22–24 One of the important compensatory mechanisms for cyclodeviations is sensory cyclofusion, which is fortunately well developed in humans. Using this ability, the normal person can fuse up to 10 to 15 degrees of cyclodeviation.22 The early results of our study indicate that, for eyes with subfoveal choroidal neovascularization resulting from myopic degeneration, the prognosis for improvement of visual acuity after translocation with scleral imbrication is better than that for any other treatments. There are several problems, however, that need to be solved in the future. One unsolved problem is that the amount of foveal movement is difficult to control, as described in case report 2, because no attempt is made to drain the subretinal fluid during surgery. Thus, an adequate amount of scleral imbrication, which may be different for myopic neovascular maculopathy and for age-related macular degeneration, should be estimated to move the fovea enough without excessive corneal astigmatism, retinal folding, or orthoptical changes.25 Another problem is whether the retinal pigment epithelium damage induced by intentional retinal detachment will be accompanied by a decrease in visual function in the long term. A longer follow-up time is needed to confirm and to assess this problem. In summary, the surgical procedure described here has the potential to improve visual function in patients with myopic choroidal neovascularization. Further refinements in surgical technique and assessment of the long-term complications will be needed to make this procedure safer and more useful.
REFERENCES 1. Avila MP, Weiter JJ, Jalkh AE, Trempe CL, Pruett RC, Schepens CL. Natural history of choroidal neovascularization in degenerative myopia. Ophthalmology 1984;91:1573– 1581. 2. Hotchkiss ML, Fine SL. Pathologic myopia and choroidal neovascularization. Am J Ophthalmol 1981;91:177–183. 3. Hampton GR, Kohen D, Bird AC. Visual prognosis of disciform degeneration in myopia. Ophthalmology 1983;90: 923–926. 4. Pece A, Brancato R, Avanza P, Camesasca F, Galli L. Laser photocoagulation of choroidal neovascularization in pathologic myopia: long-term results. Int Ophthalmol 1995;18: 339 –344. 5. Thomas MA, Dickinson JD, Melberg NS, Ibanez HE, Dhaliwal RS. Visual results after surgical removal of subfoveal choroidal neovascular membranes. Ophthalmology 1994; 101:1384 –1396. 6. Adelberg DA, Del Priore LV, Kaplan HJ. Surgery for subfoveal membranes in myopia, angioid streaks, and other disorders. Retina 1995;15:198 –205. OF
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7. Bottoni F, Perego E, Airaghi P, et al. Surgical removal of subfoveal choroidal neovascular membranes in high myopia. Graefe’s Arch Clin Exp Ophthalmol 1999;237:573–582. 8. Brancato R, Pece A, Avanza P, Radrizzani E. Photocoagulation scar expansion after laser therapy for choroidal neovascularization in degenerative myopia. Retina 1990;10:239 – 243. 9. Oshima Y, Harino S, Tano Y. Scanning laser ophthalmoscope microperimetric assessment in patients with successful laser treatment for juxtafoveal choroidal neovascularization. Retina 1998;18:109 –117. 10. Machemer R, Steinhorst UH. Retinal separation, retinotomy, and macular relocation II: a surgical approach for age-related macular degeneration? Graefe’s Arch Clin Exp Ophthalmol 1993;231:635– 641. 11. Imai K, Loewenstein A, de Juan E Jr. Translocation of the retina for management of subfoveal choroidal neovascularization I: experimental studies in the rabbit eye. Am J Ophthalmol 1998;125:627– 634. 12. de Juan E Jr, 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. 13. 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. 14. Johnson DA, Yannuzzi LA, Shakin JL, Lightman DA. Lacquer cracks following laser treatment of choroidal neovascularization in pathologic myopia. Retina 1998;18:118 – 124. 15. Berger AS, Kaplan HJ. Clinical experience with the surgical removal of subfoveal neovascular membranes. Short-term postoperative results. Ophthalmology 1992;99:969 –976. 16. Submacular Surgery Trials Pilot Study Investigators. Submacular surgery trials randomized pilot trial of laser photocoagulation versus surgery for recurrent choroidal
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neovascularization secondary to age-related macular degeneration: I. Ophthalmic outcomes: Submacular Surgery Trials Pilot Study Report Number 1. Am J Ophthalmol 2000;130: 387– 407. Submacular Surgery Trials Pilot Study Investigators. Submacular surgery trials randomized pilot trial of laser photocoagulation versus surgery for recurrent choroidal neovascularization secondary to age-related macular degeneration: II. quality of life outcomes: Submacular Surgery Trials Pilot Study Report Number 2. Am J Ophthalmol 2000;130:408 – 418. Gass JD. Biomicroscopic and histopathologic considerations regarding the feasibility of surgical excision of subfoveal neovascular membranes. Am J Ophthalmol 1994;118:285– 298. Yoshizawa T. Results of submacular surgery for myopic choroidal neovascular membranes. Folia Ophthalmol Jpn 1999;50:699 –706. Ninomiya Y, Lewis JM, Hasegawa T, Tano Y. Retinotomy and foveal translocation for surgical management of subfoveal choroidal neovascular membranes. Am J Ophthalmol 1996;122:613– 621. Pieramici DJ, de Juan E Jr, Fujii GY, et al. Limited inferior macular translocation for the treatment of subfoveal choroidal neovascularization secondary to age-related macular degeneration. Am J Ophthalmol 2000;130:419 – 428. Guyton DL, von Noorden GK. Sensory adaptations to cyclodeviations. In: Reinecke RD, editor. Strabismus. New York: Grune & Stratton, 1978:399 – 403. von Noorden GK. Clinical observations in cyclodeviations. Ophthalmology 1979;86:1451–1461. Seaber JH, Machemer R. Adaptation to monocular torsion after macular translocation. Graefe’s Arch Clin Exp Ophthalmol 1997;235:76 – 81. de Juan E Jr, Vander JF. Effective macular translocation without scleral imbrication. Am J Ophthalmol 1999;128: 380 –382.
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● PURPOSE:
To report our surgical results of foveal translocation with scleral imbrication in patients with myopic neovascular maculopathy. ● DESIGN: Noncomparative, interventional, consecutive case series. ● METHODS: Ten eyes of 10 myopic patients with subfoveal neovascular membranes that had undergone foveal translocation with scleral imbrication were recruited for this retrospective study. Inclusion criteria were myopia 6.0 diopters or greater in refractive error (or axial length 26.5 mm or longer), subfoveal choroidal neovascularization, and preoperative best-corrected visual acuity of 20/100 or worse. None of these eyes had undergone prior laser photocoagulation or submacular surgery. The main outcome measures were surgical complications and postoperative visual function. ● RESULTS: Postoperatively, visual acuity had improved more than 3 lines in the logarithm of minimum angle of resolution (logMAR) measurement in all eyes. The mean preoperative, postoperative best, and final visual acuity were 0.12, 0.59, and 0.51, respectively. Of the 10 eyes, six achieved a postoperative final visual acuity of 20/40 or better. The mean postoperative foveal displacement was 0.78 disk diameter (range, 0.3–1.3 disk diameter). Two patients underwent a reoperation because of insufficient foveal displacement. Furthermore, one of these two patients required a third operation to reduce an excessive retinal fold involving the fovea induced by the second surgery. Of the 10 patients, two noted transient diplopia. This complaint, however, resolved over time as suppression developed. Although unintentional iatrogenic retinal tears formed intraoperatively in two eyes, these were successfully treated without serious complications. Postoperatively, mild retinal pigment epithelial Accepted for publication Feb 14, 2001. From the Department of Ophthalmology, Niigata University School of Medicine, Asahimachi, Niigata, Japan. Reprint requests to Mikio Ichibe, MD, Department of Ophthalmology, Niigata University School of Medicine, 1 757 Asahimachi, Niigata 951 8510, Japan; fax: ⫹ 81-25-227-0785; e-mail: [email protected]
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changes were observed in all cases, but none led to significant deterioration of visual acuity during the follow-up period. All patients but one were followed for a minimum of 6 months. ● CONCLUSIONS: In eyes with myopic neovascular maculopathy, foveal translocation with scleral imbrication may be useful in improving visual acuity. Further refinements in surgical technique and assessment of the long-term complications will be needed to make this procedure safer and more useful. (Am J Ophthalmol 2001;132:164 –171. © 2001 by Elsevier Science Inc. All rights reserved.)
D
EGENERATIVE MYOPIA IS ONE OF THE CAUSES OF
severe visual loss in adults. It has been accepted that the choroidal neovascularization in degenerative myopia is usually self-limited.1 However, subfoveal neovascularization has a generally poor visual prognosis.2,3 Laser photocoagulation treatment4 or submacular surgery5–7 for myopic neovascular maculopathy is effective in some cases in preserving or improving vision. However, expansion of a photocoagulation scar1,8,9 or retinal pigment epithelial damage after removal of neovascular membrane7 can be unfavorable complications of these treatments in degenerative myopia, sometimes with worsening of visual acuity. In 1993, Machemer and Steinhorst10 reported results, in three cases with age-related macular degeneration, of a surgical approach with a peripheral 360-degree retinotomy allowing for relocation of the fovea to a site with intact retinal pigment epithelium. In their series, one patient had a significant gain in visual function after macular translocation. However, proliferative vitreoretinopathy developed in the other two patients after initially successful rotation. Recently, in an attempt to reduce occurrences of such a serious complication, a new surgical method for translocation of the fovea without a large retinotomy was reported. Imai and associates11 and de Juan and associates12 developed a safer method with intentional retinal detachment
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0002-9394/01/$20.00 PII S0002-9394(01)00935-7
FIGURE 1. (Left) Three or four 5-0 polyester mattress sutures (asterisks) were placed 2–3 mm posterior to the rectus muscle insertion, with 5–7 mm between the anterior and posterior bites of the suture. (Right) To make a meridional scleral imbrication (asterisk), a 5-0 polyester mattress suture was placed posterior to the anteroposterior scleral imbrication (arrows), with 4 –5 mm between the both bites of the suture.
and scleral shortening. Although the distance of foveal shift is relatively small with this method, the retina can be translocated sufficiently in the eyes with smaller neovascular membranes, such as myopic choroidal neovascularization. Therefore, we performed foveal translocation with scleral imbrication in 10 patients with myopic neovascular maculopathy and investigated the functional outcomes of this surgery.
METHODS THE RECORDS OF 10 CONSECUTIVE PATIENTS WITH MYOPIC
neovascular maculopathy who underwent foveal translocation with scleral imbrication between July 1998 and May 2000 at the Department of Ophthalmology, Niigata University Hospital, Niigata, Japan, were reviewed for this study. Inclusion criteria were myopia 6.0 diopters or greater in refractive error (or axial length 26.5 mm or longer), subfoveal choroidal neovascularization, and preoperative best-corrected visual acuity of 20/100 or worse. None of these eyes had undergone prior laser photocoagulation or submacular surgery. Before the surgery, written informed consent was obtained from each patient. The surgical procedure was as follows: a standard three-port pars plana vitrectomy with dissection of the posterior hyaloid; small posterior retinotomy; injection of balanced salt solution into the subretinal space transretinally to create a subtotal retinal detachment; anteroposterior (5–7 ⫻ 18 –20 mm) scleral imbrication (with or without scleral resection) near the equator in the superotemporal or inferotemporal quadrant (Figure 1, left); meridional scleral imbrication posterior to the anteroposterior scleral imbrication (Figure 1, right); VOL. 132, NO. 2
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fluid–air exchange without draining subretinal fluid; and nonexpansive gas tamponade (10%–14% perfluoropropane). Simultaneous cataract surgery with posterior chamber intraocular lens implantation was performed on eight patients (except for patients 3 and 7). Intraocular lens power was determined by intended target refraction with additional ⫺1.0 diopter of myopic shift in consideration of hyperopic shift after scleral imbrication.13 Intraoperatively and postoperatively, choroidal neovascular membranes were not removed or photocoagulated in any case. Postoperatively, patients were positioned in a sitting or lateral position for 2 to 3 days. Surgical complications and postoperative visual function were studied. Preoperative and postoperative examination included best-corrected visual acuity, intraocular pressure, biomicroscopy of the anterior and posterior segments, color fundus photography, fluorescein and indocyanine green angiography, visual field examination (Goldmann perimeter), and orthoptic status. Additionally, the location of fixation and the presence of any scotomas were assessed by scanning laser ophthalmoscope microperimetry (Rodenstock, Germany). Final visual acuity was taken from the last available follow-up examination at least 3 months after surgery. Preoperative and postoperative fundus photographs and scanning laser ophthalmoscope microperimetry were used to evaluate the amount of objective cyclodeviation induced by surgery. All patients were followed for a minimum of 6 months, except for patient 9.
RESULTS THE AGE OF THE 10 PATIENTS IN THIS STUDY RANGED FROM
33 to 74 years (mean, 54.8 ⫾ 14.5 years). Of the 10
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FIGURE 2. Patient 8. Right eye. This patient underwent foveal translocation with scleral imbrication in the inferotemporal quadrant. Postoperatively, the fixation point had shifted in the superonasal direction by 0.8 disk diameter at an angle of 11 degrees of incyclodeviation. Three months after surgery, (left) color photograph and (right) fluorescein angiogram demonstrate the recurrent subretinal hemorrhage around the choroidal neovascularization, which is no longer subfoveal. Each arrow indicates the translocated fovea.
FIGURE 3. Patient 1. Right eye. (Left) Preoperative and (right) postoperative fixation points determined by scanning laser ophthalmoscope microperimetry. Before surgery, fixation point was located at the temporal part of the neovascular membrane. Postoperatively, the fixation shifted inferonasally. The red A’s indicate scotoma points, and blue A’s indicate stimulus points to which the patient responded.
patients, nine were female and one was male. Follow-up ranged from 3 to 28 months (mean, 15.7 ⫾ 8.2 months). Of the 10 patients, two (patients 6 and 7) required a reoperation because of insufficient foveal displacement induced by the previous surgery. The details of one of these two patients (patient 7) are described in the case reports. Postoperatively, the fovea was translocated by a distance of 0.3 to 1.3 disk diameters (average, 0.78 ⫾ 0.32 disk diameter). The amount of postoperative oblique astigmatism seen in our series ranged between 1.0 and 5.5 diopters (average, 3.15 ⫾ 1.58 diopters). Five younger patients 166
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required hard contact lenses to achieve useful vision. In the five elderly patients, refractive errors were managed with eyeglasses. The mean best-corrected visual acuity preoperatively was 0.12, and the mean postoperative best and final visual acuity were 0.59 and 0.51. Final visual acuity improved 3 or more lines in the logarithm of the minimum angle of resolution (logMAR) measurement in all 10 eyes. Of the 10 eyes, six achieved a postoperative final visual acuity of 20/40 or better. The postoperative ectopia of the macula produced a OF
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20 15 13 11 10 3 6
28 26 25
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IT ⫽ inferotemporal; PRK ⫽ photorefractive keratectomy; SR ⫽ scleral resection; SRH ⫽ subretinal hemorrhage; ST ⫽ superotemporal.
⫺9.5 ⫺6.25 ⫺8.75 ⫺18.5 ⫺7 ⫺1.75 ⫺11.5 20/20 20/20 20/20 20/200 20/200 20/20 20/200 27.2 26.7 26.9 29.6 26.5 28.9 29.5 68 51 48 35 70 42 57
female female female female female female female
right left right left right right right
1 2 6 1 2 5 4
⫺15 ⫺6.5 ⫺8 Aphakia ⫺8.5 Post-PRK ⫺10.5
1 0.2 0.3 0.3 0.7 0.2 0.5
20/40 20/20 20/70 20/25 20/40 20/50 20/30
20/40 20/20 20/100 20/30 20/50 20/50 20/40 20/200 20/200 20/200 20/200 20/200 20/100 20/200 ST,SR(⫹) ST,SR(⫹) ST,SR(⫹) ST,SR(⫹) IT,SR(⫺) ST,SR(⫺) ST,SR(⫺)
5.5 3 5 1 4 2 1
⫺7.75 ⫺5.75 ⫺4 1.5 ⫺3.25 ⫺0.25 ⫺2
0.8 0.3 1.3 0.7 0.8 0.4 0.9
None None Retinal break, Recurrent SRH None Retinal break Insufficient movement Insufficient movement Recurrent SRH None Recurrent SRH 0.8 0.5 1.3 ⫺4.5 ⫺7 ⫺10.25 ⫺4.75 ⫺0.75 ⫺10.5 5 2 3 20/20 20/300 20/20 20/300 20/40 20/50 20/100 20/25 20/30 20/100 20/25 20/25 ST,SR(⫹) ST,SR(⫹) ST,SR(⫹) 1 0.3 0.25 28.7 27 29.4 ⫺7 ⫺6 ⫺14
4 5 6 7 8 9 10
Eye Gender
female right uncertain female right 6 male right 4 70 74 33
Final Best Scleral Imbrication History (months) Patient Age No. (years)
1 2 3
Complications
Duration of Follow-up (months) Postop Final Spherical Foveal Spherical Equivalent Displacement Equivalent Fellow Eye (disc (diopters) (diopters) diameter) Postop Final Astigmatism (diopters) Fellow Eye (final) Visual Acuity Preop Axial Length Size of CNV (mm) (disc area) Refractive Error (diopters)
TABLE 1. Patient Characteristics and Surgical Results
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change in the visual axis in all patients. Of the 10 patients, two (patients 3 and 6) experienced postoperative vertical and torsional diplopia during the early follow-up period. In both of these eyes, the amount of foveal displacement was 1.3 disk diameters, which was the maximum foveal movement in this series. This complaint, however, resolved spontaneously as suppression developed in the operated eye. One patient (patient 10) who had poor visual acuity in the nonoperated eye, reported a tilting of images with the operated eye. This symptom improved but persisted in this patient to the 6-month follow-up. Intraoperatively, unintentional iatrogenic retinal breaks formed in two eyes. These were treated successfully with cryotherapy or postsurgical laser treatment. None of the 10 eyes developed proliferative vitreoretinopathy or macular pucker. Mild retinal pigment epithelial damages were observed in all cases postoperatively. None of these changes, however, has been associated with significant deterioration of visual acuity. Seven of the 10 choroidal neovascular membranes followed in this study remained stable or regressed without any hemorrhagic or exudative changes. In three eyes (patients 3, 8, and 10), recurrent subretinal hemorrhage was observed postoperatively. However, it did not extend into the subfoveal area and was not associated with loss of central vision (Figure 2). The individual data for these 10 cases are summarized in Table 1.
CASE REPORTS ● CASE 1 (PATIENT 1):
A 70-year-old woman with high myopia (RE: ⫺7.0 diopters) presented with decreased vision and metamorphopsia in her right eye. The duration of her symptoms was uncertain. Best-corrected visual acuity was RE: 20/300 and LE: 20/40. On examination, the anterior segments were normal except for cortical cataracts in both eyes. Fluorescein and indocyanine green angiography of the right eye disclosed a well-defined subfoveal choroidal neovascularization surrounded with subretinal hemorrhage. Scanning laser ophthalmoscope microperimetry showed a dense scotoma over the area of choroidal neovascularization and subretinal hemorrhage (Figure 3, left). After informed consent was obtained, this patient underwent foveal translocation with simultaneous cataract surgery in the right eye. Scleral resection, 7 mm in the radial direction, was performed superotemporally. There were no complications during surgery. Postoperatively, the fixation point had shifted in the inferonasal direction by 0.8 disk diameter at an angle of four degrees of excyclodeviation, as assessed by scanning laser ophthalmoscope microperimetry (Figure 3, right). Synoptophore testing disclosed a right hypertropia of 0.5
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degree. The patient did not notice any diplopia during binocular viewing. Six months postoperatively, she underwent cataract surgery in her left eye. Seven months after the foveal translocation surgery, the patient’s visual acuity improved to RE: 20/40 and LE: 20/20.
of eyes after 2 years. Hotchkiss and Fine2 also reported a poor visual prognosis, with legal blindness in 44% of the eyes. Pece and associates4 and Bottoni and associates7 obtained similar functional results and concluded that the natural history of subfoveal choroidal neovascularization in degenerative myopia is rarely visually restorative. The management of myopic choroidal neovascularization is also controversial. Pece and associates4 found that laser treatment may be effective in preventing or limiting severe and irreversible loss of vision for extrafoveal and juxtafoveal choroidal neovascularization in degenerative myopia. However, the outcome of choroidal neovascularization (extrafoveal and juxtafoveal) laser treatment in degenerative myopia may be affected by some complications.1,8,9,14 Expansion of a photocoagulation scar is a potential complication of macular photocoagulation, especially in myopic eyes. Oshima and associates9 reported that the mean laser scar expansion ratio in eyes with degenerative myopia was 109.2%, which accords with the 103% increase reported by Brancato and associates.8 Avila and associates1 observed a progressive increase in photocoagulation scar area, sometimes with worsening of visual function. In their series, in four of 14 eyes that received laser photocoagulation, these scars eventually reached the foveal area and were directly associated with loss of central vision, although there was initial improvement or stabilization of visual acuity after laser treatment. Furthermore, in contrast to the situation for age-related macular degeneration, there are no clinical trials investigating the efficacy of laser treatment for subfoveal choroidal neovascularization in degenerative myopia. Hotchkiss and associates2 reported the neovascular membranes were inside the foveal avascular zone in 14 of 27 eyes with degenerative myopia. According to Hampton and associates,3 new vessels in degenerative myopia are located underneath the fovea in 58% of the eyes at the time of the patient’s first visit. Thus, we can treat with laser photocoagulation only the selected cases with myopic choroidal neovascularization. Whereas laser photocoagulation is destructive to both the retinal pigment epithelium and the overlying neurosensory retina, surgical removal of the subfoveal neovascular membrane has the theoretical advantage that the outer retina remains intact. This surgical approach has proven to be effective for subfoveal choroidal neovascularization in eyes with presumed ocular histoplasmosis syndrome but not in most eyes with age-related macular degeneration.5,15–17 Frequently in eyes with age-related macular degeneration, the neovascular membrane grows below as well as above the retinal pigment epithelium.5,18 Because of this, surgical removal of subfoveal choroidal neovascularization in age-related macular degeneration results in large defects of the retinal pigment epithelium and in disappointing visual prognosis. In many of the myopic choroidal neovascularization cases, subretinal pigmented halos often seen around the neovascular membranes, plaquelike elevation of the neovascular complex,
● CASE 2 (PATIENT 7): A 35-year-old woman had a history of neovascular maculopathy secondary to high myopia (RE: ⫺18.0 diopters) and poor vision in her right eye. She underwent intracapsular lens extraction in her left eye in September 1995 at another hospital because of the lens luxation resulting from ocular contusion. Postoperatively, her left visual acuity was 20/20, and posterior segment evaluation was unremarkable. She was referred to our department in November 1999 with decreased visual acuity and metamorphopsia in her left eye of 3 weeks’ duration. At the first visit, bestcorrected visual acuity was RE: 20/200 and LE: 20/200. The axial length of the left eye was 29.6 mm. Clinical and angiographic examinations of the left eye showed a classic subfoveal neovascular membrane (Figure 4, top). After giving her informed consent, this patient underwent foveal translocation in her left eye. Scleral resection, 6 mm in the radial direction, was performed superotemporally. Postoperative fluorescein angiography and scanning laser ophthalmoscope microperimetry showed an extrafoveal neovascular membrane superotemporal to the fovea (Figure 4, center). Her visual acuity, however, had not improved despite the foveal displacement of 0.4 disk diameter. Therefore, she underwent a reoperation 2 months after the initial surgery. The retina was redetached, and a partial fluid–air exchange was performed. Upright positioning was begun soon after the surgery. Postoperatively, the fovea had shifted in the inferonasal direction by 0.7 disk diameter at an angle of 8 degrees of excyclodeviation, as assessed by fluorescein angiography (Figure 4, bottom). She did not complain of diplopia or tilted vision during binocular viewing. One month postoperatively, the patient’s visual acuity improved to LE: 20/40. Finally, her visual acuity improved to LE: 20/30.
DISCUSSION SEVERAL STUDIES ATTEMPTED TO DEFINE THE NATURAL
history of choroidal neovascularization in degenerative myopia, but their results have been contradictory. It has been accepted that the choroidal neovascularization in degenerative myopia is usually self-limited. Avila and associates1 found a relatively favorable natural course of macular choroidal neovascularization. According to Hampton and associates,3 however, the natural course of choroidal neovascularization in degenerative myopia has a generally poor prognosis in that disciform degeneration may lead to a final visual acuity of 20/200 or worse in 60% 168
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and sharply defined borders shown by biomicroscopy and fluorescein angiography suggest a localization anterior to the retinal pigment epithelium but beneath the sensory retina, just as in presumed ocular histoplasmosis syndrome. In such conditions, the neovascular membranes can theoretically be extracted with preservation of the underlying retinal pigment epithelium. There are several reports of visual outcomes after surgical removal of subfoveal choroidal neovascularization secondary to degenerative myopia.5–7 According to Thomas and associates,5 the mean change in final visual acuity compared with preoperative visual acuity was a decrease of 1 line. In all of their 10 cases, final visual acuity was not better than 20/70. Their results of surgery for choroidal neovascularization secondary to degenerative myopia are similar to those seen in age-related macular degeneration. Adelberg and associates6 also reported five patients with myopic neovascular maculopathy who underwent surgical removal of subfoveal choroidal neovascularization. In their series, visual acuity improved by 2 or more lines in two of five eyes and remained unchanged in three. One of these five eyes achieved a postoperative best visual acuity of 20/80. Recently, Bottoni and associates7 reported visual outcomes after surgical excision of subfoveal choroidal neovascularization in a larger consecutive series of 65 eyes with degenerative myopia. The mean preoperative visual acuity was 0.09, and the mean postoperative visual acuity was 0.18. They reported the expansion of postsurgical retinal pigment epithelium defects. According to them, the mean postoperative retinal pigment epithelium defect was 4.6 times larger than the original choroidal neovascularization. We also retrospectively reviewed seven consecutive patients with myopic choroidal neovascularization who had been treated with submacular surgery by us between October 1996 and August 1997. The mean preoperative visual acuity, postoperative best visual acuity, and final visual acuity were 0.06, 0.15, and 0.11.19 For the laser scar expansion analysis, fundus photographs obtained soon after surgery (within 1 month) and at the last follow-up were used. Areas were estimated by one of the authors (Dr Yoshizawa) using the dedicated software of the NIH Image (National Institutes of Health, Bethesda, Maryland, USA). There was a postoperative increase in the area of retinal pigment epithelium damage in all seven eyes, with a mean expansion of 120% (range, 80% to 140%) in the
FIGURE 4. Patient 7. Left eye. (Top) Preoperative fluorescein angiography. A well-defined choroidal neovascularization was located underneath the fovea. (Middle) After the initial surgery, the fovea had shifted in the inferonasal direction by 0.4 disk diameter. Note the mild retinal pigment epithelial change, as compared with the preoperative fluorescein angiogram. (Bottom) Fluorescein angiography after the reoperation. Finally, the distance of foveal shift was 0.7 disk diameter (arrow).
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first year after surgery (Yoshizawa T, unpublished data, 2000). This increase in the size of the retinal pigment epithelial damage can result in loss of central vision as observed in laser treatment. Retinal pigment epithelium defects during surgery and their expansion may be responsible for the limited success in these studies. Because of the mechanical tissue strain induced by excessive axial elongation, the retinal pigment epithelium– choroid complex may become thin and atrophic in eyes with degenerative myopia. Therefore, the retinal pigment epithelium and choroid in highly myopic eyes may be more easily affected by the thermal burn of photocoagulation or surgical excision of choroidal neovascularization. Recently, foveal translocation with various techniques has been suggested to improve central vision by shifting the fovea to an area of healthy retinal pigment epithelium in eyes with subfoveal choroidal neovascularization.10 – 13,20,21 A new surgical approach, using a scleral imbrication with intentional retinal detachment, has the advantage of being less invasive, because it does not require a large retinotomy. This technique allows small translocations, but these are often large enough to move the fovea outside neovascular membranes in myopic neovascular maculopathy. Fujikado and associates13 describe two highly myopic patients whose visual acuity improved from 20/150 to 20/20 and from 20/70 to 20/30, 4 to 6 months after translocation of the fovea. Their results are very impressive, with remarkable gains in visual acuity. For these reasons, surgeries for myopic neovascular maculopathy by means of foveal translocation with scleral imbrication were performed in our clinic. None of the patients in this study underwent simultaneous excision of choroidal neovascularization or postsurgical laser treatment to avoid a scar expansion, which may cause significant, delayed visual loss after successful treatment. We made meridional scleral imbrications in all cases of this study. We suppose that this additional procedure may have been of some help in producing redundant retina. Postoperatively, all of the eyes achieved an effective foveal translocation and had a significant increase in visual acuity. As we had expected, serious complications, such as proliferative vitreoretinopathy or deterioration of visual acuity resulting from retinal pigment epithelium damage, were not observed in any of our cases. Although postoperative changes in spherical correction and astigmatism are unavoidable complications of this technique, these are not problematic in younger patients who already wear hard contact lenses. In elderly patients, who are likely to require cataract surgery, astigmatic and anisometropic changes can be controlled to some extent with the cataract surgery itself, and residual refractive error can be managed with eyeglasses. This technique also produces vertical, horizontal, and rotatory deviation of the visual axis in the treated eye. 170
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Large amounts of foveal displacement induce the development of suppression in the operated eye if the other eye has good visual function. Some degree of cyclodeviations, however, can be handled by some compensatory mechanisms.22–24 One of the important compensatory mechanisms for cyclodeviations is sensory cyclofusion, which is fortunately well developed in humans. Using this ability, the normal person can fuse up to 10 to 15 degrees of cyclodeviation.22 The early results of our study indicate that, for eyes with subfoveal choroidal neovascularization resulting from myopic degeneration, the prognosis for improvement of visual acuity after translocation with scleral imbrication is better than that for any other treatments. There are several problems, however, that need to be solved in the future. One unsolved problem is that the amount of foveal movement is difficult to control, as described in case report 2, because no attempt is made to drain the subretinal fluid during surgery. Thus, an adequate amount of scleral imbrication, which may be different for myopic neovascular maculopathy and for age-related macular degeneration, should be estimated to move the fovea enough without excessive corneal astigmatism, retinal folding, or orthoptical changes.25 Another problem is whether the retinal pigment epithelium damage induced by intentional retinal detachment will be accompanied by a decrease in visual function in the long term. A longer follow-up time is needed to confirm and to assess this problem. In summary, the surgical procedure described here has the potential to improve visual function in patients with myopic choroidal neovascularization. Further refinements in surgical technique and assessment of the long-term complications will be needed to make this procedure safer and more useful.
REFERENCES 1. Avila MP, Weiter JJ, Jalkh AE, Trempe CL, Pruett RC, Schepens CL. Natural history of choroidal neovascularization in degenerative myopia. Ophthalmology 1984;91:1573– 1581. 2. Hotchkiss ML, Fine SL. Pathologic myopia and choroidal neovascularization. Am J Ophthalmol 1981;91:177–183. 3. Hampton GR, Kohen D, Bird AC. Visual prognosis of disciform degeneration in myopia. Ophthalmology 1983;90: 923–926. 4. Pece A, Brancato R, Avanza P, Camesasca F, Galli L. Laser photocoagulation of choroidal neovascularization in pathologic myopia: long-term results. Int Ophthalmol 1995;18: 339 –344. 5. Thomas MA, Dickinson JD, Melberg NS, Ibanez HE, Dhaliwal RS. Visual results after surgical removal of subfoveal choroidal neovascular membranes. Ophthalmology 1994; 101:1384 –1396. 6. Adelberg DA, Del Priore LV, Kaplan HJ. Surgery for subfoveal membranes in myopia, angioid streaks, and other disorders. Retina 1995;15:198 –205. OF
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7. Bottoni F, Perego E, Airaghi P, et al. Surgical removal of subfoveal choroidal neovascular membranes in high myopia. Graefe’s Arch Clin Exp Ophthalmol 1999;237:573–582. 8. Brancato R, Pece A, Avanza P, Radrizzani E. Photocoagulation scar expansion after laser therapy for choroidal neovascularization in degenerative myopia. Retina 1990;10:239 – 243. 9. Oshima Y, Harino S, Tano Y. Scanning laser ophthalmoscope microperimetric assessment in patients with successful laser treatment for juxtafoveal choroidal neovascularization. Retina 1998;18:109 –117. 10. Machemer R, Steinhorst UH. Retinal separation, retinotomy, and macular relocation II: a surgical approach for age-related macular degeneration? Graefe’s Arch Clin Exp Ophthalmol 1993;231:635– 641. 11. Imai K, Loewenstein A, de Juan E Jr. Translocation of the retina for management of subfoveal choroidal neovascularization I: experimental studies in the rabbit eye. Am J Ophthalmol 1998;125:627– 634. 12. de Juan E Jr, 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. 13. 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. 14. Johnson DA, Yannuzzi LA, Shakin JL, Lightman DA. Lacquer cracks following laser treatment of choroidal neovascularization in pathologic myopia. Retina 1998;18:118 – 124. 15. Berger AS, Kaplan HJ. Clinical experience with the surgical removal of subfoveal neovascular membranes. Short-term postoperative results. Ophthalmology 1992;99:969 –976. 16. Submacular Surgery Trials Pilot Study Investigators. Submacular surgery trials randomized pilot trial of laser photocoagulation versus surgery for recurrent choroidal
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neovascularization secondary to age-related macular degeneration: I. Ophthalmic outcomes: Submacular Surgery Trials Pilot Study Report Number 1. Am J Ophthalmol 2000;130: 387– 407. Submacular Surgery Trials Pilot Study Investigators. Submacular surgery trials randomized pilot trial of laser photocoagulation versus surgery for recurrent choroidal neovascularization secondary to age-related macular degeneration: II. quality of life outcomes: Submacular Surgery Trials Pilot Study Report Number 2. Am J Ophthalmol 2000;130:408 – 418. Gass JD. Biomicroscopic and histopathologic considerations regarding the feasibility of surgical excision of subfoveal neovascular membranes. Am J Ophthalmol 1994;118:285– 298. Yoshizawa T. Results of submacular surgery for myopic choroidal neovascular membranes. Folia Ophthalmol Jpn 1999;50:699 –706. Ninomiya Y, Lewis JM, Hasegawa T, Tano Y. Retinotomy and foveal translocation for surgical management of subfoveal choroidal neovascular membranes. Am J Ophthalmol 1996;122:613– 621. Pieramici DJ, de Juan E Jr, Fujii GY, et al. Limited inferior macular translocation for the treatment of subfoveal choroidal neovascularization secondary to age-related macular degeneration. Am J Ophthalmol 2000;130:419 – 428. Guyton DL, von Noorden GK. Sensory adaptations to cyclodeviations. In: Reinecke RD, editor. Strabismus. New York: Grune & Stratton, 1978:399 – 403. von Noorden GK. Clinical observations in cyclodeviations. Ophthalmology 1979;86:1451–1461. Seaber JH, Machemer R. Adaptation to monocular torsion after macular translocation. Graefe’s Arch Clin Exp Ophthalmol 1997;235:76 – 81. de Juan E Jr, Vander JF. Effective macular translocation without scleral imbrication. Am J Ophthalmol 1999;128: 380 –382.
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