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Foveal translocation with secondary confluent laser for subfoveal CNV in AMD: 12 month follow up
  1. DAVID WONG,
  2. SIMON HARDING,
  3. IAN GRIERSON
  1. St Paul's Eye Unit, Royal Liverpool University Hospital, Prescot Street, Liverpool L7 8XP
  1. Mr Wong shdwong{at}mail.msn.com

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Editor,—Foveal relocation surgery for the treatment of subfoveal choroidal neovascularisation (CNV) secondary to age related macular degeneration (AMD) has received significant publicity in the lay press and has given rise to some controversy reported in theBJO.1 We describe the 12 month follow up of a case reported in the press in December 1998.

CASE REPORT

Mr JB, a 70 year old retired dentist was referred from another unit on 31 August 1998 with AMD and a history of poor vision for 5 years in the right eye and 5 months in the left. Refraction visual acuity was right eye 5/60 (+1.50/+1.50), left eye 6/60 (+2.25 sphere), Snellen equivalent. Figure 1A shows a subfoveal pure classic CNV of less than 1 disc area in extent in the left eye. The right eye was affected by end stage fibrotic scar. After full discussion of risk/benefit of confluent laser and the experimental nature of surgery he underwent surgery on 24 September 1998 (DW). Scleral plication was achieved by using 14 radially disposed sutures applied to the superotemporal quadrant of the globe. A three port pars plana vitrectomy was carried out and a subtotal retinal detachment was induced by subretinal infusions via three posterior retinotomies. The retina was reattached with a fluid/air exchange and the fovea was manipulated to its final position with a small bore flute needle. A radial fold formed in the upper nasal aspect of the fundus.

Figure 1

Fluorescein angiogram images before and after foveal relocation surgery (A) preoperatively, showing pure classic subfoveal CNV less than 1 disc area in extent; (B) 7 days postoperatively showing fovea located below CNV; (C) 5 months postoperatively showing recurrence; (D) 4 weeks after confluent laser to recurrence shown in (C) showing complete closure of CNV.

Figure 2A shows the retina on the 7th postoperative day with the superonasal fold and Figure 1B the midphase fluorescein angiogram (FA) showing the CNV now located superior to the fovea. On 8 October 1998 confluent laser was applied to the CNV (SPH) (Fig 2B). On 5 November 1998 refraction VA was 6/15; a small zone of persistent CNV was treated. On 8 January 1999 refraction VA was 6/12. Figure 2C shows a flattening retinal fold and Figure 1C a zone of recurrent CNV which received repeat confluent laser. On 12 February 1999 the post-laser follow up FA (Fig 1D) shows no persistent leakage; the VA had improved to 6/9. After 9 and 12 months VA was 6/18, N6 (−0.75/+0.50; +3.00 add) with no further evidence of CNV recurrence; the clinical appearance on 1 October 1999 is shown in Figure 2D.

Figure 2

Colour fundus photographs of follow up after foveal relocation surgery: (A) 7 days postoperatively showing fold extending from disc into superonasal retina; (B) 1 week after (A) showing confluent laser applied to CNV and fovea located inferiorly to laser; (C) 5 months postoperative CNV recurrence with blood (VA = 6/9); (D) 12 months postoperatively (VA = 6/18).

COMMENT

At present, foveal relocation surgery is the only therapeutic option which aims to improve the vision for patients with CNV caused by AMD. The case we report gained a substantial improvement of vision which was at its best 6 months postoperatively but still maintained at a good level after 12 months. The importance of close angiographic monitoring is illustrated by the development of recurrent CNV, which is not unexpected in laser treated CNV.2

Mr JB was one of the first patients to undergo foveal relocation as part of a pilot study performed with the approval of the Liverpool research ethics committee. The results and complications of a small consecutive series of patients treated without scleral plications or 360 retinotomies are reported in theBJO.3 The reports of our patients and those of other series in the literature clearly indicate that the vision can be made worse as well as better.3-6Whether the overall surgical results are better than natural history remains unknown. A prospective randomised controlled trial is needed and we are in the process of mounting such a trial. We are encouraged by the fact that improvements in surgical techniques are reducing the risks of retinal detachment and proliferative vitreoretinopathy,3 7 and also by the long term benefit of a surgical approach to AMD as illustrated by this patient.

References

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