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Visual function after foveal translocation with 360-degree retinotomy and simultaneous torsional muscle surgery in patients with myopic neovascular maculopathy
Visual Function After Foveal Translocation With 360-Degree Retinotomy and Simultaneous Torsional Muscle Surgery in Patients With Myopic Neovascular Maculopathy TAKASHI FUJIKADO, MD, MASAHITO OHJI, MD, SHUNJI KUSAKA, MD, ATSUSHI HAYASHI, MD, MOTOHIRO KAMEI, MD, ANNABELLE A. OKADA, MD, KOICHI ODA, MA, AND YASUO TANO, MD
● PURPOSE:
To assess functional and anatomical outcomes after foveal translocation with 360-degree retinotomy and simultaneous torsional muscle surgery in patients with myopic neovascular maculopathy. ● METHODS: Foveal translocation with 360-degree retinotomy was performed in 11 eyes of 11 patients with myopic neovascular maculopathy. Ten eyes had simultaneous torsional muscle surgery with recession of the superior oblique muscle and tucking of the inferior oblique muscle. Silicone oil removal with or without intraocular lens implantation was performed 2 to 8 weeks after the primary procedure. Visual acuity, binocular function, and degree of cyclotorsion were assessed preoperatively and postoperatively. Angles of retinal and globe rotation, distance of foveal shift, and surgical complications were also investigated. ● RESULTS: With a mean postoperative follow-up of 6.2 months (range, 3 to 13 months), vision improved (greater than 0.2 logarithm of minimal angle of resolution [logMAR] units) in eight eyes, was unchanged in two eyes, and worsened (greater than 0.2 logMAR units) in 1 eye. Seven of 11 eyes (64%) had a final visual acuity of 20/50 or better. Five patients developed or maintained Accepted for publication Aug 31, 2000. From the Departments of Ophthalmology (Drs Fujikado, Ohji, Kusaka, Hayashi, and Kamei and Mr Oda) and Applied Medical Engineering (Dr Fujikado), Osaka University Medical School, Osaka; the Department of Ophthalmology (Dr Okada), Kyorin University School of Medicine, Tokyo; and the Department of Communication (Mr Oda), Tokyo Women’s Christian University, Tokyo, Japan. This work was supported in part by a grant from the Ministry of Health and Welfare, Tokyo, Japan. Reprint requests to Takashi Fujikado, MD, Department of Applied Medical Engineering, Osaka University Medical School, 2-2 Yamadaoka, Suita-shi, Osaka 565-0871 Japan; fax: ⫹81-6-6879-3458; e-mail: [email protected] 0002-9394/01/$20.00 PII S0002-9394(01)00770-4
©
2001 BY
binocular fusion, four patients continued to have suppression, and two patients developed diplopia that was managed by spectacles with Fresnel prisms. Subjective cyclotorsion was less than 8 degrees in 10 eyes. Mean retinal and globe rotations were 23.4 degrees and 19.8 degrees, respectively. Average size of the choroidal neovascular membrane was 0.8 disk diameter, whereas the average distance of foveal shift was 1.5 disk diameter. After the primary procedure, three eyes developed retinal detachment, one eye macular hole, and one eye proliferative vitreoretinopathy. These complications were successfully managed by additional surgery. ● CONCLUSION: Foveal translocation with 360-degree retinotomy is effective in restoring vision in some patients with myopic neovascular maculopathy. Although the development of torsional diplopia is generally obviated by simultaneous extraocular muscle surgery, a relatively high incidence of surgical complications should be taken into account with this procedure. (Am J Ophthalmol 2001;131:101–110. © 2001 by Elsevier Science Inc. All rights reserved.)
F
IRST DESCRIBED BY MACHEMER AND STEINHORST,1
the strategy of foveal translocation surgery is to translocate the fovea to an area with healthy retinal pigment epithelium. In the original method using a 360degree retinotomy, proliferative vitreoretinopathy and subjective image tilt were problematic. A modified method involving scleral shortening as described by de Juan and associates,2 is safer, because retinotomy is not required, although the distance of foveal shift is limited with this procedure. Choroidal neovascular membranes in myopic patients are relatively small, making these eyes possible candidates for scleral shortening. We previously reported
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RIGHTS RESERVED.
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54 54 66 73 55 64 69 68 66 62 70
Number
1 2 3 4 5 6 7 8 9 10 11
F F F F F F F F F F M
Gender
RE RE RE RE RE RE RE LE RE LE LE
Operated Eye
3 4 2 4 3 10 4 7 12 6 1
History (months)
OBL OBL ND OBL OBL OBL OBL OBL OBL OBL OBL
Muscle Surgery
2 2 4 4 2 3 2 3 3 2 2
Number of Surgeries
20/50 20/20 20/40 20/22 20/15 20/40 20/130 20/28 20/13 20/15 20/20
Visual Acuity (Fellow Eye)
20/400 20/50 20/220 20/70 20/130 20/100 20/50 20/130 20/670 20/100 20/50
Preop. Visual Acuity
20/25 20/22 20/200 20/25 20/50 20/50 20/20 20/330 20/250 20/50 20/70
Postop. Visual Acuity
1.0 0.4 0.7 0.8 1.1 0.8 0.8 1.2 0.9 1.1 0.4
Size of CNV (DD)
1.2 0.9 0.3 1.2 1.1 3 1.5 2.5 0.9 2.2 1.5
Foveal Shift (DD)
23 17 7 25 18 17 29 42 22 27 20
Retinal Rotation (degrees)
25 15 0 28 14 24 27 26 17 22 20
Globe Rotation (degrees)
3 EX 0 0 5 8 IN 5 EX 3 IN 17 IN 0 0 0
Subject. Cyclotorsion (degrees)
FU FU SU FU DIP FU SU SU SU DIP FU
Binocular Vision
N N N N Y N N N N Y N
Subject. Diplopia
1.4 ND ND 0.89 1.15 1.15 0.89 ND 1.40 1.40 ND
Preop. Critical Print Size*
0.77 0.38 ND 0.46 0.96 0.46 0.37 ND 1.40 0.57 ND
Postop. Critical Print Size*
Follow-up (months)
13 11 11 7 6 5 4 4 4 4 3
Preop. Fixation
FF⫹ E P⫹ E E⫹ FF E P FF FF⫹ ND
CNV ⫽ choroidal neovascular membrane; DD ⫽ disk diameter; DIP ⫽ diplopia; E ⫽ excellent fixation; EX ⫽ excyclotorsion; F ⫽ female; FF ⫽ fair fixation; FU ⫽ fusion; IN ⫽ incyclotorsion; M ⫽ male; N ⫽ no subjective diplopia; ND ⫽ not done; OBL ⫽ surgery of both oblique muscles; P ⫽ poor fixation; SU ⫽ suppression; Y ⫽ subjective diplopia present. *Critical print size was expressed in logMAR units. † Patients with juxtafoveal hemorrhage.
Age (years)
TABLE 1. Data of All Patients in the Study
FIGURE 1. Preoperative fundus photograph and fixation map of the right eye of patient 3. (Left) A subretinal scar (arrow) and hemorrhage (arrowhead) were present. (Right) Fixation points were scattered over and around the neovascular membrane. The red cross is a reference point for overlaying the fixation points on the fundus image. The scattered dots fit in a circle (yellow line) of radius greater than 0.8 disk diameter, and therefore this eye was classified as having poor fixation preoperatively. The postoperative visual acuity was 20/200 in this patient.
encouraging short-term results of foveal translocation by scleral shortening in myopic patients.3,4 However, some of these patients experienced recurrence of their choroidal neovascular membranes, resulting in decrease of vision to preoperative levels within a couple of years.5 More recently, Eckardt and associates6 has developed a method of foveal translocation in eyes with age-related macular degeneration involving 360-degree retinotomy and simultaneous muscle surgery. The distance of foveal shift achieved appears to be much greater by this method, with vision ultimately being less affected in cases of choroidal neovascularization membrane recurrence. In this report, we studied the functional and anatomical outcomes of foveal translocation by 360-degree retinotomy with simultaneous muscle surgery in patients with myopic choroidal neovascular membranes.
PATIENTS AND METHODS FOVEAL TRANSLOCATION WITH 360-DEGREE RETINOTOMY
was performed in 11 eyes of 11 consecutive patients with myopic choroidal neovascular membranes between February and December of 1999 in the Department of Ophthalmology, Osaka University Hospital (Table 1). Only patients with recent onset of visual loss resulting from their choroidal neovascular membranes were included in this study. Patient consent was obtained after thorough discussion of the risks and possible benefits of surgical treatment. Patient age ranged from 54 to 73 years (mean, 63.7 ⫾ 6.4 years). Ten of the patients were women. The interval of time between acute reduction in vision and surgery ranged between 1 and 12 months (mean, 5.1 months). PreoperaVOL. 131, NO. 1
tive visual acuity ranged from 20/600 to 20/50. One eye was aphakic, and two eyes were pseudophakic. The average refractive error of the eight phakic eyes was ⫺13.0 ⫾ 3.42 diopters. The operated eye was the functionally better eye in eight patients and the worse eye in three. The average size of the choroidal neovascular membrane was 0.8 ⫾ 0.25 disk diameter. Juxtafoveal hemorrhage associated with the choroidal neovascular membrane was observed in four eyes. The follow-up period ranged from 3 to 13 months (mean, 6.2 months). Measurement of best-corrected visual acuity was performed by trained ophthalmic technicians. Macular location of fixation was assessed by microperimetry using a confocal scanning laser ophthalmoscope (Rodenstock, Danbury, Connecticut) loaded with static microperimetry software. Testing conditions were as described previously.7 A cross-shaped central fixation target was chosen to determine the fixation point. Degree of fixation was estimated by the extent of scattered fixation points while stimulating 30 to 50 different points in the macula. Fixation was defined as being “excellent” when all fixation points were confined to a circle of radius 0.4 disk diameter, “fair” when points lay outside a radius of 0.4 disk diameter but still within a radius of 0.8 disk diameter, and “poor” when points lay outside a radius of 0.8 disk diameter (Figure 1). Preoperative and postoperative fundus photographs and fluorescein angiograms were used to evaluate objectively the degree of cyclodeviation induced by surgery. A choroidal vessel junction was used as a landmark in rotating the globe, and a retinal vessel junction near the fovea was used as a landmark in rotating the retina (Figure 2). The slit-light projection method8 (Figure 3) was used to assess
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FIGURE 2. Evaluation of angles of rotation of the globe and retina using preoperative and postoperative fundus photographs and fluorescein angiography (patient 2). (Top left) Preoperative fundus photograph. A junction of choroidal vessels was used as a landmark for the globe, and a line was drawn from this junction to the optic disk (green line). (Bottom left) Postoperative fundus photograph. The same junction of choroidal vessels was identified on the postoperative fundus photograph, and a line was again drawn from it to the optic disk (green line). The angle between preoperative and postoperative lines was measured, representing the angle of globe rotation (15 degrees counterclockwise rotation in this case). (Top right) Preoperative fluorescein angiography. A junction of retinal vessels near the fovea was used as a landmark for the retina, and a line was drawn from it to the optic disk (green line). (Bottom right) Postoperative fluorescein angiography. The same junction of retinal vessels was identified on postoperative fluorescein angiography, and a line was again drawn from it to the optic disk (green line). The angle between preoperative and postoperative lines was measured, representing the angle of retinal rotation (17 degrees clockwise rotation in this case).
the degree of subjective monocular cyclodeviation. No patient had cyclodeviation preoperatively. Binocular fusion was examined by the New 4 Dot (MV 200, Nidek, Gamagohri, Japan) test,9 which is an instrument similar to the Worth four dot test except that it has less binocular dissociation. Eye position was examined using prism cover testing and synoptophore testing. Reading performance was assessed by determining the smallest character size that could be read without a reduction in reading speed (critical print size) using a Japanese version (Tokyo Women’s Christian University, Tokyo, Japan) of the MNREAD reading acuity chart.10 104
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Muscle surgery was performed as the initial step before foveal translocation in 10 eyes, using a modification of the method originally described by Fujikado et al.5 Briefly, the superior oblique muscle was recessed by 9 mm, and the inferior oblique muscle was tucked by 9 mm and sutured in a position 3 mm superior and 3 mm posterior to the upper border of the lateral rectus muscle insertion. The exact same procedure was performed in each case, and no eyes required additional muscle surgery. Muscle surgery was not performed in one eye in which only a small degree of foveal shift was intended (case 3). In the eight phakic eyes, the crystalline lens was removed OF
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FIGURE 3. Measurement of subjective angle of cyclotorsion. A slit light was projected on to the retina from a slit lamp using a ⴙ90-diopter lens. The slit light was rotated until the patient perceived the light to be horizontal, and the angle of deviation from the true horizontal was measured using a scale on the slit lamp.
by phacoemulsification by means of a corneoscleral approach (seven eyes) or a pars plana approach (one eye). A silicone posterior chamber intraocular lens was removed from one pseudophakic eye. Standard three-port pars plana vitrectomy was performed with separation of the posterior cortical vitreous from the retinal surface. Anterior or posterior lens capsule remnants were not removed during this procedure. The vitreous cavity was irrigated for 20 minutes with calcium-free and magnesium-free BSS-Part I solution (Alcon, Fort Worth, Texas) to facilitate the creation of intentional retinal detachment, followed by irrigation with BSS-Plus solution. A small retinotomy was created superior to the optic disk, just before the first bifurcation of the superotemporal vascular arcade with infusion of BSS-Plus solution into the subretinal space through this retinotomy using a 39-gauge needle to create a focal area of retinal detachment. Subsequent areas of the retina were detached by additional retinotomies in the equatorial zone with similar subretinal infusion of solution. Fluid–air exchange was performed to enlarge, connect, and reduce the height of the retinal detachment. A 360-degree retinotomy was created near the ora serrata using the vitrectomy cutter in seven eyes and using a microscissors in four eyes. Complete retinal detachment was then achieved by gently grasping the retina with an atraumatic microforceps11 and pulling the retina toward the optic disk. The subretinal choroidal neovascular membrane was removed in three eyes and left untouched in eight eyes. After placement of perfluorocarbon over the detached central retina to produce a mild tamponade effect, the retina was rotated clockwise such that the fovea was translocated to an area of healthy retinal pigment epithelium and the papillo-foveal axis was approximately horizontal (180 degrees meridian). Endolaser photocoagulation was applied to the edge of the retinotomy, followed by perfluorocarbon–silicone oil exchange. Inferior peripheral iridectomy was not performed. VOL. 131, NO. 1
Two to 8 weeks later (average, 4.4 weeks), silicone oil removal and intraocular lens implantation were performed in a secondary procedure. Insertion of a posterior chamber intraocular lens with sulcus fixation was achieved in 10 eyes; an anterior chamber lens was inserted in one eye. Postoperatively, laser photocoagulation to the choroidal neovascular membrane was not performed because of the risk of inducing a retinal scar larger in size than the original choroidal neovascular membrane in these patients with high myopia. The average duration of surgery was 210 minutes for the primary procedure involving muscle repositioning, lensectomy, and foveal translocation, and 30 minutes for the secondary procedure involving silicone oil removal and intraocular lens implantation.
RESULTS BY THE LAST EXAMINATION, VISUAL ACUITY HAD IM-
proved by greater than 0.2 logarithm of minimal angle of resolution (logMAR) unit in eight eyes, was unchanged in two eyes, and had worsened by greater than 0.2 logMAR unit in one eye (Figure 4). The visual acuity was 20/25 or better in four eyes, between 20/50 and 20/100 in four eyes, and 20/200 or worse in three eyes (Table 1). Postoperatively, the operated eye was the functionally better eye in six patients and the worse eye in five. Five patients maintained or developed binocular fusion, four patients continued to have suppression, and two patients developed diplopia. The two patients with diplopia exhibited vertical deviations of 20 and 30 prism diopters, respectively, and were successfully managed by spectacles fitted with Fresnel prisms. Subjective monocular cyclotorsion was 8 degrees or less in 10 patients. In one patient (patient 8), a 17-degree incyclotorsion was observed. However, suppression was present and the patient had no complaint of double vision. The mean degree of retinal rotation was 23.4 ⫾ 10.7 degrees and the mean degree of globe rotation was 19.8 ⫾ 7.8 degrees. Objective cyclodeviation was calculated by subtracting the angle of rotation of the retina from that of the globe. Objective cyclodeviation correlated well with subjective cyclodeviation (Figure 5, r ⫽ .85, P ⫽ .001). The average distance of foveal shift was 1.5 ⫾ 0.3 disk diameter. Because of the small size of the myopic choroidal neovascular membranes, this distance was adequate in shifting the center of the fovea to outside the area of the choroidal neovascular membrane in each case. Reading performance was evaluated in seven patients preoperatively and postoperatively (2 to 8 months after foveal translocation surgery) using a Japanese version of the MNREAD reading acuity chart. Critical print size improved more than 0.2 logMAR unit in five patients, and remained within 0.2 logMAR unit in two patients (Figure 6). Ten patients were examined preoperatively for stability
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FIGURE 5. Relationship between subjective and objective cyclotorsion. Objective cyclodeviation correlated well with subjective cyclodeviation (r ⴝ .85, P ⴝ .001).
FIGURE 4. Visual acuity before and after foveal translocation surgery. Visual acuity had improved in eight eyes (greater than 0.2 logMAR unit), was unchanged in two eyes, and had worsened in one eye (greater than 0.2 logMAR unit).
simultaneous muscle surgery in the right eye. The choroidal neovascular membrane was neither excised nor photocoagulated in this patient. Postoperative measurements revealed the retina to be rotated clockwise by 29 degrees and the globe counterclockwise by 27 degrees (Figure 8). The horizontal axis was preserved, and the patient had no complaints of tilting or double vision. The fovea was determined to have moved 1.5 disk diameters in relation to the choroid. Postoperative fluorescein angiography showed that the translocated fovea was now located over healthyappearing retinal pigment epithelium. The patient’s fixation was excellent both preoperatively and postoperatively (Figure 9). Visual acuity in the right eye improved to 20/25 by 1 month after surgery and 20/20 by 3 months. The critical print size for the right eye improved to 20/45, and the patient can read a newspaper without a magnifying lens.
of fixation using SLO microperimetry. Fixation was excellent in four patients, fair in four patients, and poor in two patients. All four patients with excellent preoperative fixation exhibited good postoperative visual acuity (equal or better than 20/50). The two patients with poor fixation had poor visual acuity results (20/200 or worse). Patients with fair fixation had varying visual results ranging from 20/250 to 20/25 (Figure 7). After initial foveal translocation surgery, silicone oil was observed adhering to the endothelial surface of the cornea in two eyes; the silicone oil was removed and C3F8 gas injected in one of these eyes. Partial peripheral retinal detachment developed in two eyes; retinal reattachment was successfully achieved by a second surgical procedure in both eyes. One eye developed proliferative vitreoretinopathy after removal of the silicone oil; membrane peeling and gas tamponade was performed in this eye with subsequent reattachment of the retina. Persistent vitreous hemorrhage occurred in one eye that eventually cleared without surgical intervention. Finally, one eye developed a macular hole after surgery; this was closed by a second surgical procedure.
DISCUSSION THE POPULATION OF PATIENTS WITH MYOPIA IS LARGER IN
Asian countries compared with North American and European countries. Accordingly, the number of patients with pathologic myopia is also high in Asia.12 The leading cause of deterioration of vision in high myopia is the development of choroidal neovascularization.13,14 However, the results of treatment using either laser photocoagulation15 or submacular surgery have been disappointing.16 –19 Because surgical translocation of the fovea has been shown to restore reading vision in some patients with age-related macular degeneration,6 we attempted to translocate the fovea with 360-degree retinotomy and simultaneous muscle surgery in patients with myopic choroidal neovascular membranes.
CASE REPORT A 69-YEAR-OLD WOMAN WITH BILATERAL MYOPIC NEOVAS-
cular maculopathy was referred to our hospital with the complaint of difficulty reading. The best-corrected visual acuity was RE, 20/50 and LE, 20/130. Reading ability for the right eye as assessed by critical print size was 20/150. After informed consent was obtained, the patient underwent foveal translocation with 360-degree retinotomy and 106
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FIGURE 6. Reading performance evaluated by critical print size before and after foveal translocation surgery. Critical print size improved more than 0.2 logMAR unit in five patients and remained within 0.2 logMAR unit in two patients.
Visual acuity improved more than 0.2 logMAR unit in eight of 11 eyes (73%) in the present study. This is better than the improvement of vision in 13 of 30 eyes (42%) reported by Eckardt and associates for age-related macular degeneration.6 Of the 11 patients in our study, four achieved driving visual acuity (20/25 or better). Importantly, nine of the patients did not complain of diplopia, as binocular fusion developed in five patients and suppression in four patients. The two patients who did complain of diplopia resulting from vertical deviation were successfully managed by the addition of Fresnel prisms to their spectacles. The angle of retinal rotation was comparable to the degree of globe rotation achieved, and subjective cyclodeviation was within the fusional limit20 (8 degrees) in 10 patients. One patient (patient 8) with 17-degree excyclotorsion was able to adapt to the cyclodeviation by suppression.21 Because the size of the choroidal neovascular membrane is small in myopic eyes, the required angle of retinal rotation is also small. Therefore, adequate globe rotation could be achieved with manipulation of only the two oblique muscles, leaving the rectus muscles untouched. Subjective cyclodeviation as assessed by slit-light projection correlated well with objective cyclodeviation. The assessment of subjective cyclodeviation (Figure 3) can be easily performed during fundus examination even on the first postoperative day in the eye filled with silicone oil. The foveal shift was 1.5 disk diameters on average, which is large compared with the average size of the choroidal neovascular membrane (0.8 disk diameter). By the scleral shortening procedure, the foveal shift was only 0.5 disk diameter, just to the border of the neovascular membrane.3,4 With scleral shortening, the effective visual field is still limited, because the new fovea is very close to VOL. 131, NO. 1
FIGURE 7. Relationship between stability of fixation and preoperative and postoperative visual acuity. Fixation was defined as being “excellent” when all fixation points were confined to a circle of radius 0.4 disk diameter, “fair” when points lay outside a radius of 0.4 disk diameter but still within a radius of 0.8 disk diameter, and “poor” when points lay outside a radius of 0.8 disk diameter. All four patients with excellent preoperative fixation exhibited good postoperative visual acuity (equal or better than 0.4 logMAR unit, which corresponds to equal or better than 20/50). The two patients with poor fixation had poor visual acuity results (0.1 or worse logMAR unit, corresponding to 20/200 or worse). Patients with fair fixation had varying visual results ranging from 0.1 to 1.1 logMAR unit, corresponding to visual acuities of 20/25 to 20/250.
the choroidal neovascular membrane site. Furthermore, in cases of choroidal neovascular membrane recurrence or enlargement, the new fovea continues to be at risk of involvement. In contrast, the 360-degree retinotomy procedure has the advantage of being able to achieve a large foveal shift, producing a larger effective visual field and being associated with a smaller risk of involvement should the choroidal neovascular membrane recur. A reading chart was used to evaluate reading ability. A certain size of retinal area without a deep scotoma (sensitive retinal area) is necessary for reading. If the sensitive area is too small, reading speed is very slow and useful reading is not attained.5 To evaluate reading performance, critical print size10 (minimum letter size with normal reading speed) was measured. Five of seven patients showed improvement in the critical print size after surgery, showing the effectiveness of this surgery in improving reading vision. As suggested by Eckardt and associates,6 it is necessary to perform surgery early if the patient wants to recover reading acuity. Distance visual acuity does not always give an accurate assessment of the retinal status, because only a very small sensitive area is necessary to measure the minimum separable angle of a target. Disease processes occurring in the fovea, such as exudative retinal
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FIGURE 8. Preoperative and postoperative fundus photographs and fluorescein angiography of the right eye of patient 7. (Top) A subfoveal Fuchs spot (arrow) was present preoperatively (left). Midphase fluorescein angiography revealed hyperfluorescence indicative of the subfoveal neovascular membrane (right). (Bottom) Postoperatively, the subretinal neovascular membrane was located in an extrafoveal site (left). Fluorescein angiography revealed that the fovea has shifted on to healthy retinal pigment epithelium, 1.5 disk diameters superior to the neovascular membrane (right). Preoperative and postoperative foveal centers are marked by arrowheads (top left and bottom left).
detachment, often cause metamorphopsia. Because reading efficiency can be strongly affected by metamorphopsia, reading ability may be a good index to use in deciding the appropriateness of surgery. To evaluate the function of the fovea overlying the choroidal neovascular membrane, we examined stability of fixation using scanning laser ophthalmoscope (SLO) microperimetry. Although it is only a semiquantitative evaluation compared with the quantitative original method,22 we found that good visual results were obtained in patients with excellent fixation preoperatively. Two patients (patients 1 and 10) who had good postoperative vision but only fair fixation preoperatively had juxtafoveal hemorrhage observed before surgery. It is possible that this subretinal hemorrhage may have interfered in accurate 108
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preoperative assessment of foveal function. Therefore, except in cases of choroidal neovascular membranes associated with hemorrhage, we found stability of fixation to be a useful parameter in predicting existing foveal function as well as the chance for improvement in vision with surgery (Figure 7). Retinal detachment occurred postoperatively in three eyes, one of which was associated with proliferative vitreoretinopathy. The retina was reattached by a second surgical procedure in all cases. In addition, macular hole developed in one eye that was closed after repeat surgery. Eyes required frequent examination in the first several months of the postoperative period. Although the complications of foveal translocation surgery appear to be manageable, the potential gain in visual acuity with such OF
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FIGURE 9. Preoperative and postoperative fixation map of the right eye of patient 7. (Top) Preoperatively, fixation points (arrow) were confined to the area of the neovascular membrane. The extent of scattered dots was within a radius of 0.4 disk diameter, and therefore this eye was classified as having excellent fixation. The preoperative visual acuity was 20/50. (Bottom) Postoperatively, fixation points (arrow) were identified in the translocated fovea, and visual acuity improved to 20/20.
surgery clearly needs to be weighed against the high rate of complications, in particular, retinal detachment. Photodynamic therapy may be another option available for eyes with myopic choroidal neovascular membranes, although choroidal neovascular membrane recurrence appears to be almost inevitable by this therapy23 and visual recovery may not be satisfactory. In conclusion, foveal translocation with 360-degree VOL. 131, NO. 1
retinotomy achieved improvement in visual acuity in some patients with myopic choroidal neovascular membranes. However, this study was based on a small number of patients with relatively short follow-up. Furthermore, although the development of torsional diplopia can be avoided in most eyes with simultaneous muscle surgery, the surgical complication rate is high. A randomized study with longer follow-up is necessary to evaluate properly the
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11. Ohji M, Tano Y, Scheller GD, Chang S. New soft-tipped instruments for foveal translocation surgery with 360-degree retinotomy. Arch Ophthalmol 2000;118:1422–1428. 12. Curtin BJ. The myopias, Philadelphia: Harper & Row, 1985:39 –59. 13. Tokoro T. Atlas of posterior fundus changes in pathologic myopia. Tokyo: Springer, 1998:59 – 61. 14. Tabandeh H, Flynn HW, Scott IU, et al. Visual acuity outcomes of patients 50 years of age and older with high myopia and untreated choroidal neovascularization. Ophthalmology 1999:2063–2067. 15. Macular Photocoagulation Study Group. Laser photocoagulation of subfoveal neovascular lesions in age-related macular degeneration: results of a randomized clinical trial. Arch Ophthalmol 1991;109:1220 –1231. 16. Berger AS, Kaplan HJ. Clinical experience with the surgical removal of subfoveal neovascular membranes: short-term postoperative results. Ophthalmology 1992;99:969 –976. 17. de Juan E Jr, Machemer R. Vitreous surgery for hemorrhagic and fibrous complication of age-related macular degeneration. Am J Ophthalmol 1988;105:25–29. 18. Lambert HM, Capone A Jr, Aaberg TM, Sternberg P Jr, Mandell BA, Lopez PF. Surgical excision of subfoveal neovascular membranes in age-related macular degeneration. Am J Ophthalmol 1992;113:257–262. 19. Bottoni F, Airaghi P, Perego E, Ortolina S, Carlevaro G, Molfetta VD. Surgical removal of ideopathic, myopic and age-related subfoveal neovascularization. Graefes Arch Clin Exp Ophthalmol 1996;234:S42–S50. 20. Guyton DL, von Noorden GK. Sensory adaptation to cyclodeviation in strabismus. In: Reinecke RD, editor. Strabismus. New York: Grune & Stratton, 1978:399 – 403. 21. Seaber JH, Machemer R. Adaptation to monocular torsion after macular translocation. Graefes Arch Clin Exp Ophthalmol 1997;235:76 – 81 22. Rohrshneider K, Bultmann S, Gluck R, Kruse FE, Fendrich T, Volcker HE. Scanning laser ophthalmoscope fundus perimetry before and after laser photocoagulation for clinically significant deabetic macular edema. Am J Ophthalmol 2000;129:27–32. 23. Sickenberg M, Schmidt-Erfurth U, Miller JW, et al. A preliminary study of photodynamic therapy using verteporfin for choroidal neovascularization in pathologic myopia, ocular histoplasmosis syndrome, angioid streaks, and idiopathic causes. Arch Ophthalmol 2000;118:327–336.
efficacy of this procedure, including an assessment of the long-term risk of choroidal neovascular membrane recurrence or enlargement.
REFERENCES 1. Machemer R, Steinhorst UH. Retinal separation, retinotomy, and macular relocation, II: surgical approach for age-related macular degeneration? Graefes Arch Clin Exp Ophthalmol 1993;231:635– 641. 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. 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. 4. Fujikado T, Ohji M, Hayashi A, Tano Y. Foveal translocation with scleral shortening in patients with myopic neovascular maculopathy. In: Lin LLK, Shih YF, Hung PT, editors. Myopia updates II. Tokyo: Springer, 2000:149 –150. 5. Fujikado T, Ohji M, Hosohata J, Hayashi A, Tano Y. Oda K. Comparison of visual function after foveal translocation with 360° retinotomy and with scleral shortening in a patient with bilateral myopic neovascular maculopathy. Am J Ophthalmol 2000;135:525–527. 6. Eckardt C, Eckardt U, Conraf HG. Macular rotation with and without counter-rotation of the globe in patients with age-related macular degeneration. Graefe’s Arch Clin Exp Ophthalmol 1999;237:313–325. 7. Tsujikawa M, Ohji M, Fujikado T, Saito Y, Motokura M, Ishimoto I, Tano Y. Differentiating full thickness macular holes from impending macular holes and macular pseudoholes. Br J Ophthalmol 1997;81:117–122 8. Spierer A. Measurement of cyclotorsion. Am J Ophthalmol 1996;122:911–912. 9. Fujikado T, Matsuda I, Hosohata J, Ohmi G. A development of a new four dot test to assess suppression scotoma without glasses. In: Lennerstrand G, editor. Advances in strabismology. Buren: Aeolus, 1999:65– 68. 10. 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.
The full-text of AJO is now available online at www.ajo.com. Authors Interactive威, currently available in limited form, is undergoing an upgrade.
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● PURPOSE:
To assess functional and anatomical outcomes after foveal translocation with 360-degree retinotomy and simultaneous torsional muscle surgery in patients with myopic neovascular maculopathy. ● METHODS: Foveal translocation with 360-degree retinotomy was performed in 11 eyes of 11 patients with myopic neovascular maculopathy. Ten eyes had simultaneous torsional muscle surgery with recession of the superior oblique muscle and tucking of the inferior oblique muscle. Silicone oil removal with or without intraocular lens implantation was performed 2 to 8 weeks after the primary procedure. Visual acuity, binocular function, and degree of cyclotorsion were assessed preoperatively and postoperatively. Angles of retinal and globe rotation, distance of foveal shift, and surgical complications were also investigated. ● RESULTS: With a mean postoperative follow-up of 6.2 months (range, 3 to 13 months), vision improved (greater than 0.2 logarithm of minimal angle of resolution [logMAR] units) in eight eyes, was unchanged in two eyes, and worsened (greater than 0.2 logMAR units) in 1 eye. Seven of 11 eyes (64%) had a final visual acuity of 20/50 or better. Five patients developed or maintained Accepted for publication Aug 31, 2000. From the Departments of Ophthalmology (Drs Fujikado, Ohji, Kusaka, Hayashi, and Kamei and Mr Oda) and Applied Medical Engineering (Dr Fujikado), Osaka University Medical School, Osaka; the Department of Ophthalmology (Dr Okada), Kyorin University School of Medicine, Tokyo; and the Department of Communication (Mr Oda), Tokyo Women’s Christian University, Tokyo, Japan. This work was supported in part by a grant from the Ministry of Health and Welfare, Tokyo, Japan. Reprint requests to Takashi Fujikado, MD, Department of Applied Medical Engineering, Osaka University Medical School, 2-2 Yamadaoka, Suita-shi, Osaka 565-0871 Japan; fax: ⫹81-6-6879-3458; e-mail: [email protected] 0002-9394/01/$20.00 PII S0002-9394(01)00770-4
©
2001 BY
binocular fusion, four patients continued to have suppression, and two patients developed diplopia that was managed by spectacles with Fresnel prisms. Subjective cyclotorsion was less than 8 degrees in 10 eyes. Mean retinal and globe rotations were 23.4 degrees and 19.8 degrees, respectively. Average size of the choroidal neovascular membrane was 0.8 disk diameter, whereas the average distance of foveal shift was 1.5 disk diameter. After the primary procedure, three eyes developed retinal detachment, one eye macular hole, and one eye proliferative vitreoretinopathy. These complications were successfully managed by additional surgery. ● CONCLUSION: Foveal translocation with 360-degree retinotomy is effective in restoring vision in some patients with myopic neovascular maculopathy. Although the development of torsional diplopia is generally obviated by simultaneous extraocular muscle surgery, a relatively high incidence of surgical complications should be taken into account with this procedure. (Am J Ophthalmol 2001;131:101–110. © 2001 by Elsevier Science Inc. All rights reserved.)
F
IRST DESCRIBED BY MACHEMER AND STEINHORST,1
the strategy of foveal translocation surgery is to translocate the fovea to an area with healthy retinal pigment epithelium. In the original method using a 360degree retinotomy, proliferative vitreoretinopathy and subjective image tilt were problematic. A modified method involving scleral shortening as described by de Juan and associates,2 is safer, because retinotomy is not required, although the distance of foveal shift is limited with this procedure. Choroidal neovascular membranes in myopic patients are relatively small, making these eyes possible candidates for scleral shortening. We previously reported
ELSEVIER SCIENCE INC. ALL
RIGHTS RESERVED.
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54 54 66 73 55 64 69 68 66 62 70
Number
1 2 3 4 5 6 7 8 9 10 11
F F F F F F F F F F M
Gender
RE RE RE RE RE RE RE LE RE LE LE
Operated Eye
3 4 2 4 3 10 4 7 12 6 1
History (months)
OBL OBL ND OBL OBL OBL OBL OBL OBL OBL OBL
Muscle Surgery
2 2 4 4 2 3 2 3 3 2 2
Number of Surgeries
20/50 20/20 20/40 20/22 20/15 20/40 20/130 20/28 20/13 20/15 20/20
Visual Acuity (Fellow Eye)
20/400 20/50 20/220 20/70 20/130 20/100 20/50 20/130 20/670 20/100 20/50
Preop. Visual Acuity
20/25 20/22 20/200 20/25 20/50 20/50 20/20 20/330 20/250 20/50 20/70
Postop. Visual Acuity
1.0 0.4 0.7 0.8 1.1 0.8 0.8 1.2 0.9 1.1 0.4
Size of CNV (DD)
1.2 0.9 0.3 1.2 1.1 3 1.5 2.5 0.9 2.2 1.5
Foveal Shift (DD)
23 17 7 25 18 17 29 42 22 27 20
Retinal Rotation (degrees)
25 15 0 28 14 24 27 26 17 22 20
Globe Rotation (degrees)
3 EX 0 0 5 8 IN 5 EX 3 IN 17 IN 0 0 0
Subject. Cyclotorsion (degrees)
FU FU SU FU DIP FU SU SU SU DIP FU
Binocular Vision
N N N N Y N N N N Y N
Subject. Diplopia
1.4 ND ND 0.89 1.15 1.15 0.89 ND 1.40 1.40 ND
Preop. Critical Print Size*
0.77 0.38 ND 0.46 0.96 0.46 0.37 ND 1.40 0.57 ND
Postop. Critical Print Size*
Follow-up (months)
13 11 11 7 6 5 4 4 4 4 3
Preop. Fixation
FF⫹ E P⫹ E E⫹ FF E P FF FF⫹ ND
CNV ⫽ choroidal neovascular membrane; DD ⫽ disk diameter; DIP ⫽ diplopia; E ⫽ excellent fixation; EX ⫽ excyclotorsion; F ⫽ female; FF ⫽ fair fixation; FU ⫽ fusion; IN ⫽ incyclotorsion; M ⫽ male; N ⫽ no subjective diplopia; ND ⫽ not done; OBL ⫽ surgery of both oblique muscles; P ⫽ poor fixation; SU ⫽ suppression; Y ⫽ subjective diplopia present. *Critical print size was expressed in logMAR units. † Patients with juxtafoveal hemorrhage.
Age (years)
TABLE 1. Data of All Patients in the Study
FIGURE 1. Preoperative fundus photograph and fixation map of the right eye of patient 3. (Left) A subretinal scar (arrow) and hemorrhage (arrowhead) were present. (Right) Fixation points were scattered over and around the neovascular membrane. The red cross is a reference point for overlaying the fixation points on the fundus image. The scattered dots fit in a circle (yellow line) of radius greater than 0.8 disk diameter, and therefore this eye was classified as having poor fixation preoperatively. The postoperative visual acuity was 20/200 in this patient.
encouraging short-term results of foveal translocation by scleral shortening in myopic patients.3,4 However, some of these patients experienced recurrence of their choroidal neovascular membranes, resulting in decrease of vision to preoperative levels within a couple of years.5 More recently, Eckardt and associates6 has developed a method of foveal translocation in eyes with age-related macular degeneration involving 360-degree retinotomy and simultaneous muscle surgery. The distance of foveal shift achieved appears to be much greater by this method, with vision ultimately being less affected in cases of choroidal neovascularization membrane recurrence. In this report, we studied the functional and anatomical outcomes of foveal translocation by 360-degree retinotomy with simultaneous muscle surgery in patients with myopic choroidal neovascular membranes.
PATIENTS AND METHODS FOVEAL TRANSLOCATION WITH 360-DEGREE RETINOTOMY
was performed in 11 eyes of 11 consecutive patients with myopic choroidal neovascular membranes between February and December of 1999 in the Department of Ophthalmology, Osaka University Hospital (Table 1). Only patients with recent onset of visual loss resulting from their choroidal neovascular membranes were included in this study. Patient consent was obtained after thorough discussion of the risks and possible benefits of surgical treatment. Patient age ranged from 54 to 73 years (mean, 63.7 ⫾ 6.4 years). Ten of the patients were women. The interval of time between acute reduction in vision and surgery ranged between 1 and 12 months (mean, 5.1 months). PreoperaVOL. 131, NO. 1
tive visual acuity ranged from 20/600 to 20/50. One eye was aphakic, and two eyes were pseudophakic. The average refractive error of the eight phakic eyes was ⫺13.0 ⫾ 3.42 diopters. The operated eye was the functionally better eye in eight patients and the worse eye in three. The average size of the choroidal neovascular membrane was 0.8 ⫾ 0.25 disk diameter. Juxtafoveal hemorrhage associated with the choroidal neovascular membrane was observed in four eyes. The follow-up period ranged from 3 to 13 months (mean, 6.2 months). Measurement of best-corrected visual acuity was performed by trained ophthalmic technicians. Macular location of fixation was assessed by microperimetry using a confocal scanning laser ophthalmoscope (Rodenstock, Danbury, Connecticut) loaded with static microperimetry software. Testing conditions were as described previously.7 A cross-shaped central fixation target was chosen to determine the fixation point. Degree of fixation was estimated by the extent of scattered fixation points while stimulating 30 to 50 different points in the macula. Fixation was defined as being “excellent” when all fixation points were confined to a circle of radius 0.4 disk diameter, “fair” when points lay outside a radius of 0.4 disk diameter but still within a radius of 0.8 disk diameter, and “poor” when points lay outside a radius of 0.8 disk diameter (Figure 1). Preoperative and postoperative fundus photographs and fluorescein angiograms were used to evaluate objectively the degree of cyclodeviation induced by surgery. A choroidal vessel junction was used as a landmark in rotating the globe, and a retinal vessel junction near the fovea was used as a landmark in rotating the retina (Figure 2). The slit-light projection method8 (Figure 3) was used to assess
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FIGURE 2. Evaluation of angles of rotation of the globe and retina using preoperative and postoperative fundus photographs and fluorescein angiography (patient 2). (Top left) Preoperative fundus photograph. A junction of choroidal vessels was used as a landmark for the globe, and a line was drawn from this junction to the optic disk (green line). (Bottom left) Postoperative fundus photograph. The same junction of choroidal vessels was identified on the postoperative fundus photograph, and a line was again drawn from it to the optic disk (green line). The angle between preoperative and postoperative lines was measured, representing the angle of globe rotation (15 degrees counterclockwise rotation in this case). (Top right) Preoperative fluorescein angiography. A junction of retinal vessels near the fovea was used as a landmark for the retina, and a line was drawn from it to the optic disk (green line). (Bottom right) Postoperative fluorescein angiography. The same junction of retinal vessels was identified on postoperative fluorescein angiography, and a line was again drawn from it to the optic disk (green line). The angle between preoperative and postoperative lines was measured, representing the angle of retinal rotation (17 degrees clockwise rotation in this case).
the degree of subjective monocular cyclodeviation. No patient had cyclodeviation preoperatively. Binocular fusion was examined by the New 4 Dot (MV 200, Nidek, Gamagohri, Japan) test,9 which is an instrument similar to the Worth four dot test except that it has less binocular dissociation. Eye position was examined using prism cover testing and synoptophore testing. Reading performance was assessed by determining the smallest character size that could be read without a reduction in reading speed (critical print size) using a Japanese version (Tokyo Women’s Christian University, Tokyo, Japan) of the MNREAD reading acuity chart.10 104
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Muscle surgery was performed as the initial step before foveal translocation in 10 eyes, using a modification of the method originally described by Fujikado et al.5 Briefly, the superior oblique muscle was recessed by 9 mm, and the inferior oblique muscle was tucked by 9 mm and sutured in a position 3 mm superior and 3 mm posterior to the upper border of the lateral rectus muscle insertion. The exact same procedure was performed in each case, and no eyes required additional muscle surgery. Muscle surgery was not performed in one eye in which only a small degree of foveal shift was intended (case 3). In the eight phakic eyes, the crystalline lens was removed OF
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FIGURE 3. Measurement of subjective angle of cyclotorsion. A slit light was projected on to the retina from a slit lamp using a ⴙ90-diopter lens. The slit light was rotated until the patient perceived the light to be horizontal, and the angle of deviation from the true horizontal was measured using a scale on the slit lamp.
by phacoemulsification by means of a corneoscleral approach (seven eyes) or a pars plana approach (one eye). A silicone posterior chamber intraocular lens was removed from one pseudophakic eye. Standard three-port pars plana vitrectomy was performed with separation of the posterior cortical vitreous from the retinal surface. Anterior or posterior lens capsule remnants were not removed during this procedure. The vitreous cavity was irrigated for 20 minutes with calcium-free and magnesium-free BSS-Part I solution (Alcon, Fort Worth, Texas) to facilitate the creation of intentional retinal detachment, followed by irrigation with BSS-Plus solution. A small retinotomy was created superior to the optic disk, just before the first bifurcation of the superotemporal vascular arcade with infusion of BSS-Plus solution into the subretinal space through this retinotomy using a 39-gauge needle to create a focal area of retinal detachment. Subsequent areas of the retina were detached by additional retinotomies in the equatorial zone with similar subretinal infusion of solution. Fluid–air exchange was performed to enlarge, connect, and reduce the height of the retinal detachment. A 360-degree retinotomy was created near the ora serrata using the vitrectomy cutter in seven eyes and using a microscissors in four eyes. Complete retinal detachment was then achieved by gently grasping the retina with an atraumatic microforceps11 and pulling the retina toward the optic disk. The subretinal choroidal neovascular membrane was removed in three eyes and left untouched in eight eyes. After placement of perfluorocarbon over the detached central retina to produce a mild tamponade effect, the retina was rotated clockwise such that the fovea was translocated to an area of healthy retinal pigment epithelium and the papillo-foveal axis was approximately horizontal (180 degrees meridian). Endolaser photocoagulation was applied to the edge of the retinotomy, followed by perfluorocarbon–silicone oil exchange. Inferior peripheral iridectomy was not performed. VOL. 131, NO. 1
Two to 8 weeks later (average, 4.4 weeks), silicone oil removal and intraocular lens implantation were performed in a secondary procedure. Insertion of a posterior chamber intraocular lens with sulcus fixation was achieved in 10 eyes; an anterior chamber lens was inserted in one eye. Postoperatively, laser photocoagulation to the choroidal neovascular membrane was not performed because of the risk of inducing a retinal scar larger in size than the original choroidal neovascular membrane in these patients with high myopia. The average duration of surgery was 210 minutes for the primary procedure involving muscle repositioning, lensectomy, and foveal translocation, and 30 minutes for the secondary procedure involving silicone oil removal and intraocular lens implantation.
RESULTS BY THE LAST EXAMINATION, VISUAL ACUITY HAD IM-
proved by greater than 0.2 logarithm of minimal angle of resolution (logMAR) unit in eight eyes, was unchanged in two eyes, and had worsened by greater than 0.2 logMAR unit in one eye (Figure 4). The visual acuity was 20/25 or better in four eyes, between 20/50 and 20/100 in four eyes, and 20/200 or worse in three eyes (Table 1). Postoperatively, the operated eye was the functionally better eye in six patients and the worse eye in five. Five patients maintained or developed binocular fusion, four patients continued to have suppression, and two patients developed diplopia. The two patients with diplopia exhibited vertical deviations of 20 and 30 prism diopters, respectively, and were successfully managed by spectacles fitted with Fresnel prisms. Subjective monocular cyclotorsion was 8 degrees or less in 10 patients. In one patient (patient 8), a 17-degree incyclotorsion was observed. However, suppression was present and the patient had no complaint of double vision. The mean degree of retinal rotation was 23.4 ⫾ 10.7 degrees and the mean degree of globe rotation was 19.8 ⫾ 7.8 degrees. Objective cyclodeviation was calculated by subtracting the angle of rotation of the retina from that of the globe. Objective cyclodeviation correlated well with subjective cyclodeviation (Figure 5, r ⫽ .85, P ⫽ .001). The average distance of foveal shift was 1.5 ⫾ 0.3 disk diameter. Because of the small size of the myopic choroidal neovascular membranes, this distance was adequate in shifting the center of the fovea to outside the area of the choroidal neovascular membrane in each case. Reading performance was evaluated in seven patients preoperatively and postoperatively (2 to 8 months after foveal translocation surgery) using a Japanese version of the MNREAD reading acuity chart. Critical print size improved more than 0.2 logMAR unit in five patients, and remained within 0.2 logMAR unit in two patients (Figure 6). Ten patients were examined preoperatively for stability
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FIGURE 5. Relationship between subjective and objective cyclotorsion. Objective cyclodeviation correlated well with subjective cyclodeviation (r ⴝ .85, P ⴝ .001).
FIGURE 4. Visual acuity before and after foveal translocation surgery. Visual acuity had improved in eight eyes (greater than 0.2 logMAR unit), was unchanged in two eyes, and had worsened in one eye (greater than 0.2 logMAR unit).
simultaneous muscle surgery in the right eye. The choroidal neovascular membrane was neither excised nor photocoagulated in this patient. Postoperative measurements revealed the retina to be rotated clockwise by 29 degrees and the globe counterclockwise by 27 degrees (Figure 8). The horizontal axis was preserved, and the patient had no complaints of tilting or double vision. The fovea was determined to have moved 1.5 disk diameters in relation to the choroid. Postoperative fluorescein angiography showed that the translocated fovea was now located over healthyappearing retinal pigment epithelium. The patient’s fixation was excellent both preoperatively and postoperatively (Figure 9). Visual acuity in the right eye improved to 20/25 by 1 month after surgery and 20/20 by 3 months. The critical print size for the right eye improved to 20/45, and the patient can read a newspaper without a magnifying lens.
of fixation using SLO microperimetry. Fixation was excellent in four patients, fair in four patients, and poor in two patients. All four patients with excellent preoperative fixation exhibited good postoperative visual acuity (equal or better than 20/50). The two patients with poor fixation had poor visual acuity results (20/200 or worse). Patients with fair fixation had varying visual results ranging from 20/250 to 20/25 (Figure 7). After initial foveal translocation surgery, silicone oil was observed adhering to the endothelial surface of the cornea in two eyes; the silicone oil was removed and C3F8 gas injected in one of these eyes. Partial peripheral retinal detachment developed in two eyes; retinal reattachment was successfully achieved by a second surgical procedure in both eyes. One eye developed proliferative vitreoretinopathy after removal of the silicone oil; membrane peeling and gas tamponade was performed in this eye with subsequent reattachment of the retina. Persistent vitreous hemorrhage occurred in one eye that eventually cleared without surgical intervention. Finally, one eye developed a macular hole after surgery; this was closed by a second surgical procedure.
DISCUSSION THE POPULATION OF PATIENTS WITH MYOPIA IS LARGER IN
Asian countries compared with North American and European countries. Accordingly, the number of patients with pathologic myopia is also high in Asia.12 The leading cause of deterioration of vision in high myopia is the development of choroidal neovascularization.13,14 However, the results of treatment using either laser photocoagulation15 or submacular surgery have been disappointing.16 –19 Because surgical translocation of the fovea has been shown to restore reading vision in some patients with age-related macular degeneration,6 we attempted to translocate the fovea with 360-degree retinotomy and simultaneous muscle surgery in patients with myopic choroidal neovascular membranes.
CASE REPORT A 69-YEAR-OLD WOMAN WITH BILATERAL MYOPIC NEOVAS-
cular maculopathy was referred to our hospital with the complaint of difficulty reading. The best-corrected visual acuity was RE, 20/50 and LE, 20/130. Reading ability for the right eye as assessed by critical print size was 20/150. After informed consent was obtained, the patient underwent foveal translocation with 360-degree retinotomy and 106
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FIGURE 6. Reading performance evaluated by critical print size before and after foveal translocation surgery. Critical print size improved more than 0.2 logMAR unit in five patients and remained within 0.2 logMAR unit in two patients.
Visual acuity improved more than 0.2 logMAR unit in eight of 11 eyes (73%) in the present study. This is better than the improvement of vision in 13 of 30 eyes (42%) reported by Eckardt and associates for age-related macular degeneration.6 Of the 11 patients in our study, four achieved driving visual acuity (20/25 or better). Importantly, nine of the patients did not complain of diplopia, as binocular fusion developed in five patients and suppression in four patients. The two patients who did complain of diplopia resulting from vertical deviation were successfully managed by the addition of Fresnel prisms to their spectacles. The angle of retinal rotation was comparable to the degree of globe rotation achieved, and subjective cyclodeviation was within the fusional limit20 (8 degrees) in 10 patients. One patient (patient 8) with 17-degree excyclotorsion was able to adapt to the cyclodeviation by suppression.21 Because the size of the choroidal neovascular membrane is small in myopic eyes, the required angle of retinal rotation is also small. Therefore, adequate globe rotation could be achieved with manipulation of only the two oblique muscles, leaving the rectus muscles untouched. Subjective cyclodeviation as assessed by slit-light projection correlated well with objective cyclodeviation. The assessment of subjective cyclodeviation (Figure 3) can be easily performed during fundus examination even on the first postoperative day in the eye filled with silicone oil. The foveal shift was 1.5 disk diameters on average, which is large compared with the average size of the choroidal neovascular membrane (0.8 disk diameter). By the scleral shortening procedure, the foveal shift was only 0.5 disk diameter, just to the border of the neovascular membrane.3,4 With scleral shortening, the effective visual field is still limited, because the new fovea is very close to VOL. 131, NO. 1
FIGURE 7. Relationship between stability of fixation and preoperative and postoperative visual acuity. Fixation was defined as being “excellent” when all fixation points were confined to a circle of radius 0.4 disk diameter, “fair” when points lay outside a radius of 0.4 disk diameter but still within a radius of 0.8 disk diameter, and “poor” when points lay outside a radius of 0.8 disk diameter. All four patients with excellent preoperative fixation exhibited good postoperative visual acuity (equal or better than 0.4 logMAR unit, which corresponds to equal or better than 20/50). The two patients with poor fixation had poor visual acuity results (0.1 or worse logMAR unit, corresponding to 20/200 or worse). Patients with fair fixation had varying visual results ranging from 0.1 to 1.1 logMAR unit, corresponding to visual acuities of 20/25 to 20/250.
the choroidal neovascular membrane site. Furthermore, in cases of choroidal neovascular membrane recurrence or enlargement, the new fovea continues to be at risk of involvement. In contrast, the 360-degree retinotomy procedure has the advantage of being able to achieve a large foveal shift, producing a larger effective visual field and being associated with a smaller risk of involvement should the choroidal neovascular membrane recur. A reading chart was used to evaluate reading ability. A certain size of retinal area without a deep scotoma (sensitive retinal area) is necessary for reading. If the sensitive area is too small, reading speed is very slow and useful reading is not attained.5 To evaluate reading performance, critical print size10 (minimum letter size with normal reading speed) was measured. Five of seven patients showed improvement in the critical print size after surgery, showing the effectiveness of this surgery in improving reading vision. As suggested by Eckardt and associates,6 it is necessary to perform surgery early if the patient wants to recover reading acuity. Distance visual acuity does not always give an accurate assessment of the retinal status, because only a very small sensitive area is necessary to measure the minimum separable angle of a target. Disease processes occurring in the fovea, such as exudative retinal
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FIGURE 8. Preoperative and postoperative fundus photographs and fluorescein angiography of the right eye of patient 7. (Top) A subfoveal Fuchs spot (arrow) was present preoperatively (left). Midphase fluorescein angiography revealed hyperfluorescence indicative of the subfoveal neovascular membrane (right). (Bottom) Postoperatively, the subretinal neovascular membrane was located in an extrafoveal site (left). Fluorescein angiography revealed that the fovea has shifted on to healthy retinal pigment epithelium, 1.5 disk diameters superior to the neovascular membrane (right). Preoperative and postoperative foveal centers are marked by arrowheads (top left and bottom left).
detachment, often cause metamorphopsia. Because reading efficiency can be strongly affected by metamorphopsia, reading ability may be a good index to use in deciding the appropriateness of surgery. To evaluate the function of the fovea overlying the choroidal neovascular membrane, we examined stability of fixation using scanning laser ophthalmoscope (SLO) microperimetry. Although it is only a semiquantitative evaluation compared with the quantitative original method,22 we found that good visual results were obtained in patients with excellent fixation preoperatively. Two patients (patients 1 and 10) who had good postoperative vision but only fair fixation preoperatively had juxtafoveal hemorrhage observed before surgery. It is possible that this subretinal hemorrhage may have interfered in accurate 108
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preoperative assessment of foveal function. Therefore, except in cases of choroidal neovascular membranes associated with hemorrhage, we found stability of fixation to be a useful parameter in predicting existing foveal function as well as the chance for improvement in vision with surgery (Figure 7). Retinal detachment occurred postoperatively in three eyes, one of which was associated with proliferative vitreoretinopathy. The retina was reattached by a second surgical procedure in all cases. In addition, macular hole developed in one eye that was closed after repeat surgery. Eyes required frequent examination in the first several months of the postoperative period. Although the complications of foveal translocation surgery appear to be manageable, the potential gain in visual acuity with such OF
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FIGURE 9. Preoperative and postoperative fixation map of the right eye of patient 7. (Top) Preoperatively, fixation points (arrow) were confined to the area of the neovascular membrane. The extent of scattered dots was within a radius of 0.4 disk diameter, and therefore this eye was classified as having excellent fixation. The preoperative visual acuity was 20/50. (Bottom) Postoperatively, fixation points (arrow) were identified in the translocated fovea, and visual acuity improved to 20/20.
surgery clearly needs to be weighed against the high rate of complications, in particular, retinal detachment. Photodynamic therapy may be another option available for eyes with myopic choroidal neovascular membranes, although choroidal neovascular membrane recurrence appears to be almost inevitable by this therapy23 and visual recovery may not be satisfactory. In conclusion, foveal translocation with 360-degree VOL. 131, NO. 1
retinotomy achieved improvement in visual acuity in some patients with myopic choroidal neovascular membranes. However, this study was based on a small number of patients with relatively short follow-up. Furthermore, although the development of torsional diplopia can be avoided in most eyes with simultaneous muscle surgery, the surgical complication rate is high. A randomized study with longer follow-up is necessary to evaluate properly the
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efficacy of this procedure, including an assessment of the long-term risk of choroidal neovascular membrane recurrence or enlargement.
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