Elsevier

Ophthalmology

Volume 109, Issue 8, August 2002, Pages 1492-1498
Ophthalmology

Retinal pigment epithelium translocation after choroidal neovascular membrane removal in age-related macular degeneration3,

Presented in part at the Association for Research in Vision and Ophthalmology annual meeting, Fort Lauderdale, Florida, May 1999.
https://doi.org/10.1016/S0161-6420(02)01099-0Get rights and content

Abstract

Purpose

To test the feasibility of a new surgical technique and to assess visual function over the translocated retinal pigment epithelium (RPE) cells in patients operated on for subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration (ARMD).

Design

Retrospective, noncomparative, interventional case series.

Participants

Nine patients with previously untreated exudative ARMD underwent surgical excision of the subfoveal CNV with RPE translocation and were observed for 12 to 32 months.

Methods

The surgery consisted of a standard three-port pars plana vitrectomy, excision of the CNV, and RPE translocation. Pre- and postoperative ocular examination included best-corrected visual acuity measurement, fundus color stereo photography, and fundus fluorescein angiography. Optical coherence tomography and confocal laser scanning ophthalmoscopy (cLSO) were performed after surgery. A crossfixation target and a single-point flashing light were projected on different areas of the posterior pole using a cLSO. Photopic 10 to 2 perimetry, photopic fine matrix mapping, and cLSO microperimetry were also performed after surgery in six patients.

Main outcome measures

Optical coherence tomography cross-sectional scans and cLSO RPE autofluorescence were recorded to detect the presence of viable translocated RPE. Visual acuity, fixation, photopic 10 to 2 perimetry, photopic fine matrix mapping, and cLSO microperimetry were used to test central visual function.

Results

Retinal pigment epithelium was translocated successfully at the time of CNV removal from the edge of the RPE defect to a subfoveal location in seven of nine patients. One patient experienced proliferative vitreoretinopathy, but significant hemorrhage was not a feature. Optical coherence tomography showed the translocated RPE as an area of increased optical reflectivity with optical shadowing external to it. Confocal laser scanning ophthalmoscopy showed autofluorescence of the translocated RPE. The crossfixation target was seen when projected on the translocated RPE. During eccentric fixation, the patients could see a flashing point-target projected on the translocated RPE. Photopic 10 to 2 perimetry, photopic fine-matrix mapping, and cLSO microperimetry showed the presence of central visual function.

Conclusions

The authors propose that translocation of RPE at the time of CNV removal, from the edge of the RPE defect to a subfoveal location, may have a role in the surgical management of ARMD.

Section snippets

Patients and methods

Nine previously untreated patients diagnosed with subfoveal CNV secondary to ARMD participated in the study. All but two patients had visual loss of 20/200 or worse for at least 3 to 9 months duration in their study eye (Table 1). The remaining two patients had a preoperative vision of 20/100 with a 2-month history of visual loss. Choroidal neovascularization was confirmed by fluorescein angiography, and in each case the complex was larger that one disc area. All patients previously had lost

Results

In all but two of the nine patients, it proved possible to translocate a full-thickness graft of RPE and choroid to a subfoveal location, where it remained. In patient 1, we attempted to maintain a pedicle, but it was not possible to achieve sufficient translocation to position it under the fovea. In patient 4, review of the surgical video suggested that the graft had become inverted during translocation. Subretinal hemorrhage was not a significant problem. Intraoperative bleeding was

Discussion

In 1991, Thomas and Kaplan6 published the first report on the surgical excision of subfoveal neovascular membranes. It became evident that in ARMD, this was associated with loss of the central RPE and choriocapillaris with a poor visual outcome.9, 29 The observations of Gass,30 in which he defined type 1 and type 2 lesions, showed that this is inevitable. He addressed the need to find the means for resurfacing the bed of the surgically excised CNV with RPE. Animal studies show that transplanted

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    Supported by the Lady Anne Allerton Fund, London, England.

    3

    The authors have no proprietary or financial interest related to this manuscript.

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