Elsevier

Ophthalmology

Volume 114, Issue 3, March 2007, Pages 551-560
Ophthalmology

Original Article
Autologous Translocation of the Choroid and Retinal Pigment Epithelium in Patients with Geographic Atrophy

https://doi.org/10.1016/j.ophtha.2006.08.016Get rights and content

Purpose

To evaluate the functional and anatomical outcomes of autologous translocation of peripheral choroid and retinal pigment epithelium (RPE) in patients with geographic atrophy.

Design

Prospective nonrandomized study.

Participants

Twelve consecutive patients with geographic atrophy secondary to age-related macular degeneration presenting with recent loss of reading vision.

Methods

An autologous peripheral full-thickness graft of RPE, Bruch’s membrane, and choroid was positioned under the macula in patients with geographic atrophy.

Main Outcome Measures

Functional tests included Early Treatment Diabetic Retinopathy Study distant vision, reading (Radner Test, measured as logarithm of the reading acuity determination [logRAD]), threshold static perimetry, and determination of the point of fixation. Fluorescein and indocyanine green angiography, autofluorescence, and optical coherence tomography served to evaluate the anatomical outcome in a 6-month follow-up (12 months in 7 patients).

Results

Preoperative visual acuity (VA) ranged from 20/800 to 20/40 (mean, 0.6±0.4 logarithm of the minimum angle of resolution), and reading vision from 1.1 to 0.5 logRAD (mean, 0.8±0.2). Three patients were unable to read. Six months after surgery, VA ranged from hand movements to 20/32, with an increase of ≥5 letters in 2 eyes. Two patients without reading ability preoperatively were able to read after surgery. Reading was possible in a total of 8 patients after 6 months (1.3–0.4 logRAD). In 7 patients who were observed for 1 year, VA remained stable (±1 line) in 5 eyes and decreased in 2 eyes between 6 months’ and 1 year’s follow-up. In all eyes but 2, revascularization was visible on indocyanine green angiography as early as 3 weeks after surgery. Autofluorescence of the RPE was independent of revascularization of the graft and persisted throughout follow-up. Four eyes had unstable fixation and/or extrafoveal fixation before surgery. Two of these eyes stabilized during follow-up. Areas overlying atrophic areas demonstrated low threshold sensitivities that persisted after translocation of a free graft with only limited recovery. Revisional surgery due to proliferative vitreoretinopathy was required in 5 eyes.

Conclusions

The translocation of a full-thickness graft usually results in a vascularized and functioning graft in patients with geographic atrophy, although is associated with a high risk of complications and visual loss. Longer follow-up is necessary to learn about the long-term survival and functionality of the graft.

Section snippets

Patients

Twelve patients with geographic atrophy secondary to AMD presenting with recent loss of reading vision (loss of ability to read newspaper print within the past 3 months) were included in the study. Inclusion for all patients was independent of the number of eyes affected in a single patient. Patients participating in other clinical trials were excluded from the study, as well as patients with severe systemic disease or progressive ocular disease in either eye that could likely contribute to

Free Retinal Pigment Epithelium and Choroid Translocation Surgery

Free RPE and choroid translocation was performed successfully in all patients. Few intraoperative complications, such as macular hole formation and problems in inserting and positioning of the free graft, occurred. Four patients presented with tight retina–RPE adhesion resulting in macular hole formation during hydrodissection in 1 patient. In one eye, a dialysis occurred intraoperatively and was treated by cryotherapy.

Angiographic Appearance and Vascularization of the Graft

Choroidal channels from the recipient side and those of the graft were

Discussion

Atrophic macular disease generally is characterized by a gradual loss of vision. Geographic atrophy progresses with time, often sparing the fovea until late in the course of the disease.1 According to a current hypothesis, RPE cell atrophy leads to secondary changes in the choriocapillaris. Nevertheless, RPE damage is tightly related to dysfunction of the outer retinal layers. Rod dysfunction and loss with aging and AMD may be due to retinoid deficiency at the level of the photoreceptors,

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      Inducing retinal separation in the macula has a number of indications, such as displacement of submacular hemorrhage,32 limited macular translocation,33 translocation of the entire retina,34 implantation of autologous RPE,35 and removal of subretinal folds, among others. However, detachment of GA has been historically limited to few cases with limited description of the challenges and methods used.35 In these cases, the complications associated with the whole translocation procedure or autologous RPE harvesting (e.g., proliferative vitreoretinopathy) prevented widespread adoption, although there were some signs of transient visual improvement.

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      The device uses the argon blue laser with a wavelength of 488 nm as the excitation light, and the barrier filter allows the passage of wavelengths of 500 nm and above. The task of FAF is to give information about RPE and photoreceptor viability by demonstrating lipofuscin activity in retinal pigment epitelial tissue. [17–30] This study supports that only a healthy RPE, bruch's membrane, and choriocapillaris can recover macular photoreceptors and central visual function.

    • Looking into the future: Using induced pluripotent stem cells to build two and three dimensional ocular tissue for cell therapy and disease modeling

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      Current efforts to develop a cell replacement therapy for AMD using pluripotent stem cell-derived RPE are supported by a long history of autologous RPE transplants in AMD patients. Successful transplants have been done using autologous RPE/choroid grafts cut out from the peripheral portion of same patient׳s eye (Joussen et al., 2007; Maaijwee et al., 2007; van Zeeburg et al., 2011). This concept has provided hope that autologous RPE patch derived from patient-specific iPS cells can provide visual benefits for the patients.

    • Stem cell based therapies for age-related macular degeneration: The promises and the challenges

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      Transplantation of autologous extramacular RPE sheets underneath the fovea was associated with visual improvement, providing proof-of-principle that RPE replacement therapy is a potential treatment for dry AMD (Majji and de Juan, 2000; Joussen et al., 2006; Binder et al., 2007). However, the cell sources for autologous transplants are limited and harvesting them is a challenging operation associated with multiple complications (Joussen et al., 2007; Caramoy et al., 2010). In addition, autologous peripheral RPE shares the same genetic defects as the diseased RPE in the macula.

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    Manuscript no. 2006-264.

    Supported in part by the Deutsche Forschungsgemeinschaft, Bonn, Germany (grant nos.: Jo 324/6-1, Jo 324/6-2 [Emmy Noether]; Jo 324/4-1; Ki 743/5-1; Ki 743/2-1); Brunnenbusch Stein Stiftung, Essen, Germany; Glaser Stiftung, Essen, Germany; and RetinoVit Stiftung, Cologne, Germany.

    The authors have no proprietary interest in any of the materials used in the study.

    1

    Drs Joussen and Joeres contributed equally to the study.

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