Morphological changes in the diseased retina on a healthy choroid-retinal pigment epithelial complex after full macular translocation for exudative age-related macular degeneration.

PURPOSE: To describe the change in the retinal morphology after full macular translocation (FMT) for exudative age-related macular degeneration (AMD) and identify predictive factors for the visual outcome. METHODS: All patients who underwent FMT from December 2008 through July 2013 were selected. Exclusion criteria were FMT for other disease than AMD, age <60 years, <12 months of follow-up or no available images. Spectral domain optical coherence tomography, fundus autofluorescence, fluorangiography and indocyanine green angiography were evaluated. RESULTS: In total, 51 patients were included with a mean follow-up of 30 months. The presence of the external limiting membrane (ELM) was a significant predictor for a favourable visual outcome 1 year after FMT (OR = -0.30). Other significant predictive factors were the absence of intraretinal fluid (OR = 0.28) and the mixed choroidal neovascularization type (OR = -0.47), whereas nonresponders (OR = 0.41) and fibrotic lesions (OR = 0.35) were less likely to have a good visual function after surgery. CONCLUSION: Full macular translocation (FMT), that permits to relocate the diseased macula onto an area of unaffected retinal pigment epithelial and choroid, can restore the anatomy and visual function in some patients with AMD when the outer retina layers are not irreversibly damaged. The presence of the ELM seems to be the most reliable factor in predicting the functional outcome.

Retinal pigment epithelium transplantation: concepts, challenges, and future prospects.

The retinal pigment epithelium (RPE) is a single layer of cells that supports the light-sensitive photoreceptor cells that are essential for retinal function. Age-related macular degeneration (AMD) is a leading cause of visual impairment, and the primary pathogenic mechanism is thought to arise in the RPE layer. RPE cell structure and function are well understood, the cells are readily sustainable in laboratory culture and, unlike other cell types within the retina, RPE cells do not require synaptic connections to perform their role. These factors, together with the relative ease of outer retinal imaging, make RPE cells an attractive target for cell transplantation compared with other cell types in the retina or central nervous system. Seminal experiments in rats with an inherited RPE dystrophy have demonstrated that RPE transplantation can prevent photoreceptor loss and maintain visual function. This review provides an update on the progress made so far on RPE transplantation in human eyes, outlines potential sources of donor cells, and describes the technical and surgical challenges faced by the transplanting surgeon. Recent advances in the understanding of pluripotent stem cells, combined with novel surgical instrumentation, hold considerable promise, and support the concept of RPE transplantation as a regenerative strategy in AMD.

Long-Term Results of Full Macular Translocation for Choroidal Neovascularization in Age-Related Macular Degeneration.

PURPOSE: To investigate the long-term outcome of full macular translocation (FMT) for neovascular age-related macular degeneration (AMD) and to identify predictive factors. DESIGN: Retrospective, uncontrolled case series. PARTICIPANTS: Patients were considered for FMT if they had low vision in the fellow eye and choroidal neovascularization (CNV) along with (1) no response to vascular endothelial growth factor (VEGF) inhibitors, (2) retinal pigment epithelium (RPE) tear, (3) subretinal hemorrhage, (4) foveal scar tissue of recent onset, or (5) CNV before the availability of VEGF inhibitors. From 2004 through 2012, a total of 255 patients underwent FMT. Exclusion criteria were patients younger than 60 years, FMT for disease other than AMD, and a follow-up of less than 12 months. METHODS: Preoperative, annual, and last distance best-corrected visual acuity (BCVA) were obtained retrospectively from patient files. Complications were recorded using funduscopy, optical coherence tomography, autofluorescence, and angiography. MAIN OUTCOME MEASURES: Distance BCVA at 1 year and 5 years after surgery and at last visit compared with preoperative BCVA. RESULTS: One hundred fifty-eight patients (mean follow-up, 45 months) were included. Median BCVA improved from 0.90 logarithm of the minimum angle of resolution (logMAR) before surgery to 0.70 logMAR 1 year after FMT (2 lines gained; P = 0.000). In a subgroup of 56 patients followed up for 5 years or more, median BCVA improved from 0.95 logMAR before surgery to 0.70 logMAR 1 year after surgery, and remained improved 5 years after FMT with a median BCVA of 0.80 logMAR (1.5 lines gained compared with preoperative BCVA; P = 0.000). The main complications were foveal RPE atrophy (n = 73; 47%) and CNV recurrence (n = 47; 30%). Foveal RPE atrophy (odds ratio [OR], 7.0), CNV recurrence (OR, 2.6), and proliferative vitreoretinopathy (PVR; OR, 17.6) were statistically significant predictors (P < 0.05) for losing 1 line or more at last visit. CONCLUSIONS: In this study, BCVA was improved up to 5 years after FMT. Foveal RPE atrophy, CNV recurrence, and PVR carried a worse prognosis. In patients who are unlikely to benefit from VEGF inhibitors, FMT can be considered for second eyes with neovascular AMD.

Consecutive case series with long-term follow-up of full macular translocation for myopic choroidal neovascularisation.

AIM: To examine the long-term outcomes of full macular translocation (FMT) for myopic choroidal neovascularisation (mCNV). METHODS: We evaluated a consecutive case series of 60 eyes with mCNV that underwent FMT. We assessed the best-corrected visual acuity (BCVA), fundus photographs and fluorescein angiography images, and evaluated the anatomic and visual outcomes. RESULTS: The mean follow-up period was 76.3 months. The macula was relocated successfully in all eyes. The mean distance of macular translocation was 2842 µm. The baseline BCVA was 0.78 logarithm of the minimum angle of resolution (logMAR) unit; the logMAR BCVA values at 1, 3 and 5 years postoperatively significantly (p<0.001) improved to 0.54 at 1 year and then remained stable. The new fovea was associated with enlargement of the myopic chorioretinal atrophy in 19 (31.7%) eyes. Subfoveal or juxtafoveal CNV at the translocated new fovea developed in five (8.3%) eyes. CONCLUSIONS: FMT for mCNV maintained the improvement in VA for more than 5 years. However, postoperative complications and progression of chorioretinal atrophy due to myopia still seem to limit the visual improvement after FMT for mCNV.

Visual function 5 years or more after macular translocation surgery for myopic choroidal neovascularisation and age-related macular degeneration.

PURPOSE: To evaluate the changes in the best-corrected visual acuity (BCVA) after 1 year and after ≥ 5 years after macular translocation for age-related macular degeneration (AMD) or myopic choroidal neovascularisation (mCNV). METHODS: The medical records of 61 consecutive patients who underwent macular translocation with 360° retinotomy for AMD (35 eyes) or mCNV (26 eyes) were reviewed. Overall, 40 patients, 17 mCNV and 23 AMD, were followed for at least 5 years. BCVA and area of the Goldmann visual field (VF) measured before, 12 months after surgery, and at the final visit. RESULTS: In the 23 AMD eyes followed for ≥ 5 years, the mean preoperative BCVA was 1.149 ± 0.105 logMAR units, which significantly improved to 0.69 ± 0.06 logMAR units at 1 year (P<0.001). This BCVA was maintained at 0.633 ± 0.083 logMAR units on their final examination. In the 17 eyes with mCNV followed for ≥ 5 years, the mean preoperative BCVA was 1.083 ± 0.119 logMAR units, which was significantly improved to 0.689 ± 0.121 logMAR units at 1 year (P = 0.001). This BCVA was maintained at 0.678 ± 0.142 logMAR units on their final examination. The area of the VF was significantly decreased at 12 months and did not change significantly thereafter. CONCLUSIONS: Our results show that macular translocation surgery significantly improves the BCVA and significantly decreases the VF area of eyes with mCNV or AMD after first 1 year. The BCVA and VF area do not change significantly from the values at 1 year for at least 5 years.

Assessment of reading behavior with an infrared eye tracker after 360° macular translocation for age-related macular degeneration.

PURPOSE. Macular translocation (MT360) is complex surgery used to restore reading in exudative age-related macular degeneration (AMD). MT360 involves retinal rotation and subsequent oculomotor globe counterrotation and is not without significant surgical risk. This study attempts to gauge the optimal potential of MT360 in restoring reading ability and describe the quality and extent of recovery. METHODS. The six best outcomes were examined from a consecutive series of 23 MT360 cases. Reading behavior and fixation characteristics were examined with an infrared eye tracker. Results were compared to age-matched normal subjects and patients with untreated exudative and nonexudative AMD. Retinal sensitivity was examined with microperimetry to establish threshold visual function. RESULTS. MT360 produced significant improvements in visual function over untreated disease and approximated normal function for reading speed and fixation quality. Relative to the comparative groups, eye tracking revealed the MT360 cohort generated a greater number of horizontal and vertical saccades, of longer latency and reduced velocity. In contrast, saccadic behavior when reading (forward and regressive saccades) closely matched normal function. Microperimetry revealed a reduction in the central scotoma with three patients recovering normal foveal sensitivity. CONCLUSIONS. Near normal reading function is recovered despite profound surgical disruption to the anatomy (retinal/oculomotor). MT360 restores foveal function sufficient to produce a single stable locus of fixation, with marked reduction of the central scotoma. Despite the limitations on saccadic function, the quality of reading saccadic behavior is maintained with good reading ability. Oculomotor surgery appears not to limit reading ability, and the results of retinal surgery approximate normal macular function.

Long-term outcomes following full macular translocation surgery in neovascular age-related macular degeneration.

BACKGROUND/AIMS: Long-term data of macular translocation for choroidal neovascularisation (CNV) secondary to age-related macular degeneration is lacking. Therefore, we describe the 3-year acuity outcomes. METHODS: This is a retrospective, interventional case series consisting of 40 consecutive patients who underwent translocation between 2003 and 2008. Best-corrected visual acuity (BCVA) at the most recent follow-up visit was compared to that of the 1 year and pre-operative visits. Delayed post-operative complications were recorded, as diagnosed by clinical examination, spectral-domain optical coherence tomography, fundus autofluorescence imaging and angiography. RESULTS: The mean (range) follow-up duration was 37.6 months (range 12.4-67.4 months). Median BCVA values were 0.80, 0.70 and 0.78 log(MAR) at the baseline, 1 year and most recent visits (p=0.13). A three-line gain in BCVA was seen in 12 (30%) patients at 1 year and 10 (25%) patients at the last observation. Twenty-seven (68%) patients achieved a BCVA of 6/60 or better and six (15%) patients, 6/12 or better at the final visit. In the subset of the cohort followed for two or more years, 24 of 32 patients (75%) achieved a BCVA of 6/60 at 1 year but six of these (25%) lost two lines of BCVA thereafter due to recurrent CNV, idiopathic macular oedema, macular hole or macular pucker. Recurrent CNV developed in nine patients (23%) within the first 2 years and their final mean VA was 6/30. CONCLUSIONS: With close post-operative monitoring and early treatment of delayed complications, 25% of this cohort maintained a three-line gain in acuity at 3 years after macular translocation.

Macular pigment and fixation after macular translocation surgery.

BACKGROUND: After full macular translocation (MT) surgery with 360 degrees retinotomy, the fovea is rarely identifiable. Our aim was to verify the position of the fovea, to determine how patients fixate after MT and to examine distribution and optical density of macular pigment (MP). METHODS: 9 patients after MT were investigated. The Utrecht Macular Pigment Reflectometer was used to quantify the MP optical density. A scanning laser ophthalmoscope (SLO) was used to identify the fovea as the centre of MP distribution and determine the retinal locus of fixation. RESULTS: In all patients, the fovea was identified as the centre of MP distribution. The retinal areas used for fixation were displayed by SLO fixation analysis. Comparing their spatial relationship with the fovea, five patients fixated centrally and four eccentrically up to 7.5 degrees . In those patients, microperimetry showed that the atrophy caused by choroidal neovascularisation (CNV) extraction prevented central fixation. CONCLUSION: The combination of MP distribution and fixation analysis allows fixation behaviour to be quantified, even if the fovea morphologically cannot be localised. Our results suggest that the scotoma caused by spreading chorioretinal atrophy is the main cause for reduced visual acuity after MT, and so the MT rotation angle is crucially important.

Long-term follow-up of full macular translocation for choroidal neovascularization.

PURPOSE: To report the long-term (>5 years) results of full macular translocation in patients with choroidal neovascularization (CNV). DESIGN: Retrospective, interventional case series. METHODS: This study involved 32 eyes of 32 patients who had undergone full macular translocation for CNV. The median follow-up was 6.5 years (range, 5.2 to 7.7 years). We evaluated the best-corrected visual acuity, fundus examination results obtained before and 1 and 5 years after operation, and postoperative complications. RESULTS: At the 1-year follow-up, foveal retinal pigment epithelium atrophy was observed in only 3 eyes (12%), and the mean logarithm of the minimal angle of resolution (logMAR) visual acuity (VA) at that time (1.39 +/- 0.67) was not significantly changed from that before surgery (logMAR, 1.31 +/- 0.66) in 25 eyes with age-related macular degeneration (AMD). However, at 5-year follow-up, foveal retinal pigment epithelium atrophy increased (18 eyes; 72%), and final mean logMAR VA (1.88 +/- 0.76) was significantly lower (P < .01). Five eyes with myopic CNV maintained their VA from before operation (mean logMAR, 0.88 +/- 0.35) until final follow-up (mean logMAR, 0.73 +/- 0.31). The final VA was significantly better in myopic CNV than in exudative age-related macular degeneration on multiple regression analysis (P = .019). CONCLUSIONS: Long-term follow-up of full macular translocation showed that the final VA was poor in age-related macular degeneration, but relatively better in myopic CNV.

Magnetic resonance imaging of the extraocular muscle path before and after strabismus surgery for a large degree of cyclotorsion induced by macular translocation surgery.

PURPOSE: To evaluate the changes in the location of the extraocular muscles (EOMs) following strabismus surgery to treat a large degree of torsional diplopia induced by macular translocation surgery. METHODS: Six consecutive patients who underwent macular translocation surgery with 360 degrees of retinotomy and subsequent strabismus surgery were studied. Magnetic resonance imaging (MRI) was performed before and after the surgery. The angle made by the line connecting the center of the orbit and the center of each rectus muscle and the horizontal was measured. The changes in these angles before and after strabismus surgery were studied. RESULTS: The average rotation of the globe after strabismus surgery was 28 degrees (SD = 7.21; range, 17 degrees -39 degrees ). The average measured EOM shift was -0.3 degrees (SD = 8.04; range, -20.4 degrees to 20.2 degrees ). CONCLUSIONS: Despite large torsional rotation of the globe, there was no corresponding torsional repositioning of the deep paths of the rectus muscles. The paths of the operated muscles were essentially unchanged.

Macular translocation for neovascular age-related macular degeneration.

BACKGROUND: Macular translocation has been proposed by vitreoretinal surgeons to displace the neuroretinal tissue onto healthy retinal pigment epithelium and choroid when the macula has been invaded by subretinal neovascularisation. OBJECTIVES: This review aims at assessing the effectiveness of macular translocation for preserving or improving vision in patients with neovascular age-related macular degeneration (AMD). SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE and Caribbean Literature on Health Sciences (LILACS). There were no language or date restrictions in the search for trials.The electronic databases were last searched on 21 July 2008. SELECTION CRITERIA: We included randomised or quasi randomised controlled trials comparing macular translocation with any other treatment or observation. DATA COLLECTION AND ANALYSIS: Two authors independently extracted the data. The risk ratio (RR) of visual loss and visual gain was estimated at one year after treatment. MAIN RESULTS: Only one small unblinded study on 50 people compared full macular translocation with photodynamic therapy (PDT) in AMD patients with predominantly classic subfoveal choroidal neovascularisation (CNV). At the last examination, performed in most of the cases after one year, there was no difference in the rate of visual loss of 3 or more lines (translocation versus PDT: RR 0.56, 95% confidence interval (CI) 0.22 to 1.43), as well as in the mean change of contrast sensitivity (1 letter favouring translocation; 95% CI -3.51 to 5.51) and the rate of recurrence of CNV (translocation versus PDT: RR 1.56, 95% CI 0.83 to 2.91). Other outcomes significantly favoured translocation, such as the gain of 3 or more ETDRS lines (RR 21, 95% CI 1.30 to 340.02), the mean change of visual acuity (mean difference (MD) 14.60, 95% CI 5.39 to 23.81) and the mean change of near visual acuity score (MD 17.80, 95% CI 3.98 to 31.62) which is obtained with an algorithm. Serious complications reported after macular translocation were retinal detachment in 6/25 patients and diplopia requiring prismatic correction in 5/25 patients. AUTHORS' CONCLUSIONS: There is insufficient evidence from randomised controlled trials on the effectiveness of macular translocation, which is also not free of important risks. Furthermore, this technique is difficult to perform and a long surgical training is required. Future studies might include patients with small neovascular lesions that failed to respond to current pharmacological therapies and are willing to accept the risks associated with surgery to try to improve visual acuity.

Recurrent choroidal neovascularization after macular translocation surgery with 360-degree peripheral retinectomy.

PURPOSE: To evaluate the pattern of age-related macular degeneration in the new foveal location after macular translocation surgery with 360 degree peripheral retinectomy for neovascular age-related macular degeneration. METHODS: Clinical data, fundus photos, and fluorescein angiograms of patients in the Duke Macular Translocation Study were reviewed with 2-year follow-up data. RESULTS: With 56 patients completing follow-up, no patient developed de novo choroidal neovascularization (CNV), geographic atrophy, or drusen in the new subfoveal retinal pigment epithelium bed. By 2 years, 14 patients (25%) developed recurrent CNV and 13 of these 14 recurrences clearly arose from the old CNV bed. Of the 13 recurrences clearly arising from the old bed, 12 of them had recurrent CNV that involved the margin of the bed closest to the repositioned fovea. Smokers were 5.3 times (95% confidence interval: 1.2-24) more likely to develop recurrent CNV over 2 years. Despite treatment, median visual acuity for the 14 eyes with recurrent CNV was 20/200 compared with 20/80 in eyes without recurrence. CONCLUSIONS: Findings in this study support the hypotheses that the development of CNV occurs via a signaling mechanism from the fovea.

Fundus autofluorescence after full macular translocation surgery for myopic choroidal neovascularization.

BACKGROUND: To investigate fundus autofluorescence (FAF) findings in patients who underwent full macular translocation surgery with 360-degree retinotomy (MT360) for myopic choroidal neovascularization (CNV). METHODS: Observational case series. Thirty-one eyes of 31 patients who underwent MT360 for myopic CNV from February 1999 through September 2005 were included. We measured the best-corrected visual acuity and obtained color fundus photographs, optical coherence tomography (OCT) images, and fluorescein angiography images. FAF imaging by confocal scanning laser ophthalmoscope was obtained postoperatively in all study eyes and preoperatively in two study participants. FAF features at the new macula were qualitatively evaluated and compared with preoperative lesions associated with CNV. The FAF features at the retinal pigment epithelial (RPE) area with preoperative CNV also were evaluated. RESULTS: The mean interval between MT360 and the final FAF examination was 58 months (range, 8-94 months). FAF imaging was almost normal in five eyes (16%), the increased FAF was well defined at the new macula area in 23 eyes (74%), and the FAF was decreased in three eyes (10%). Neither newly developed CNV nor subretinal fluid was seen at the new macular region in any eyes on fluorescein angiography or OCT imaging. The configurations of well-defined increased FAF in 23 eyes corresponded with the preoperative CNV in two eyes (9%) and subretinal hemorrhages in five eyes (22%). Well-defined increased FAF larger than the CNV or subretinal hemorrhage was seen in 16 eyes (69%). The RPE area located at the area of the preoperative CNV had a FAF defect or decreased FAF in 30 eyes (97%) on postoperative FAF imaging; there were no increased FAF changes. CONCLUSIONS: Well-defined increased FAF at the new macula after MT360 suggests that FAF reflects not only fluorophores in the RPE but also in the neurosensory retina. These fluorophores may result from interactions between the retina and CNV/pathologic RPE.

Avoiding retinal slippage during macular translocation surgery with 360 retinotomy.

PURPOSE: To describe a surgical technique to avoid retinal slippage. METHOD: An audit was carried out on a consecutive series of 75 consecutive cases of macular translocation for age-related macular degeneration (MT360). We encountered two cases of slippage, which led to a change in technique. RESULT: No further cases of slippage were encountered. We were able to perform an exchange of perfluorocarbon liquid with air or directly with silicone oil. DISCUSSION: Retinal slippage is caused by the presence of aqueous in the infusion tubing. Meticulous removal of all aqueous from the infusion system and vitreous cavity can eliminate this complication.

Full macular translocation following photodynamic therapy in neovascular age-related macular degeneration.

PURPOSE: To report the long-term functional and anatomical outcome of full macular translocation (FMT) in eyes with neovascular age-related macular degeneration (AMD) following photodynamic therapy (PDT). METHODS: Twelve eyes of 12 consecutive patients with neovascular AMD who were PDT-nonresponders and underwent FMT were analysed. Best-corrected visual acuity (BCVA) measurement, fundus photography, and fluorescein angiography at baseline and at follow-up examinations in 3 months intervals were performed. Primary end point was change of BCVA from baseline to last visit. RESULTS: Totally 12 eyes of 12 patients were analysed. Mean time interval between the last PDT and FMT was 3.7 months (range 1-10 months). Mean follow-up after FMT was 25.6 months. BCVA ranged at baseline from 20/1000 to 20/80 (mean 20/230). At the last visit, mean BCVA was by 20/185. BCVA improved in 50% (6/12) of eyes by more than 1 line. Twenty five per cent (3/12) of eyes had final BCVA within +/-1 line from baseline. In 25% (3/12) of eyes the BCVA decreased by more than 1 line. One eye had recurrent CNV. In four eyes a cystoid macular oedema developed. No retinal detachment or disturbing diplopia was noted. CONCLUSIONS: In the present study, FMT in PDT-nonresponders stabilised or improved visual acuity in the majority of the eyes in a mean follow-up period of nearly 2 years. FMT can be considered as a therapeutical option in eyes who are nonresponders to the PDT in neovascular AMD.

[Strabismus surgery after macular translocation]. / Problemy strabologiczne zwiazane z operacja przesuniecia plamki.

PURPOSE: To present the application of various extraocular muscle surgery techniques to eliminate incyclotorsion induced by macular translocation. MATERIAL AND METHODS: Authors present surgical options and present the case of the patient in whom macular translocation was performed in Tübingen (Germany). Afterwards five strabismological surgeries were done: 2 in Tübingen and 3 in Department of Strabismology, Cracow District Eye Hospital. RESULTS: At the end of strabismological treatment the patient was free of disabling image tilt and diplopia. CONCLUSIONS: We present this case as an announcement of future challenge for strabologists if macular translocation surgeries will be performed in Poland.

New algorithm for assessing patient suitability for macular translocation surgery.

PURPOSE: We propose a case selection algorithm to assess suitability for macular translocation for subfoveal neovascular membrane (CNV) secondary to age-related macular degeneration. The algorithm is based on preoperative assessment of residual foveal function, as assessed by a slit-lamp fixation task and duration of visual loss, in patients with poor acuity. We validate our slit-lamp fixation task against an objective analysis (Nidek MP-1 Microperimetry) and proceed to examine surgical outcomes as selected by the algorithm. METHODS: A prospective series of 27 consecutive patients with CNV underwent translocation at Moorfields Eye Hospital, London between May 2003 and May 2006. RESULTS: Validation of the slit-lamp fixation task revealed 100% concordance in classification of fixation between the slit-lamp task and the microperimeter. At an average follow up of 12.2 months, the mean Early Treatment of Diabetic Retinopathy Study distance acuity improved from logMAR 0.88 to 0.68 (P < 0.03). Sixty-six per cent of patients achieved an acuity of < or =logMAR 0.8 (6/30), 22% an acuity of < or =logMAR 0.3 (6/12) and 33% gained three lines of acuity. The mean MN Read reading acuity improved from logMAR 1.23 to 0.91 (P < 0.01). Forty-four per cent of patients achieved an acuity of > or =logMAR 0.7 (N10), 15% an acuity of > or =logMAR 0.4 (N5) and 44% gained three lines of acuity. DISCUSSION: We have demonstrated a simple case selection algorithm that is based on residual foveal function and suggests good outcomes. The strongest indicators of foveal function are fixation characteristics and duration of visual loss. In contrast to previous studies, our algorithm suggests good outcomes independently of preoperative visual acuity and CNV characteristics.

Reading performance with low-vision aids and vision-related quality of life after macular translocation surgery in patients with age-related macular degeneration.

PURPOSE: The aim of the present study was to evaluate the power of magnification required, reading performance with low-vision aids and vision-related quality of life with reference to reading ability and ability to carry out day-to-day activities in patients after macular translocation. METHODS: This study included 15 patients who had undergone macular translocation with 360-degree peripheral retinectomy. The mean length of follow-up was 19.2 +/- 10.8 months (median 11 months). At the final examination, the impact of visual impairment on reading ability and quality of life was assessed according to a modified 9-item questionnaire in conjunction with a comprehensive clinical examination, which included assessment of best corrected visual acuity (BCVA), the magnification power required for reading, use of low-vision aids and reading speed. Patients rated the extent to which low vision restricted their ability to read and participate in other activities that affect quality of life. Responses were scored on a scale of 1.0 (optimum self-evaluation) to 5.0 (very poor). RESULTS: In the operated eye, overall mean postoperative BCVA (distance) was not significantly better than mean preoperative BCVA (0.11 +/- 0.06 and 0.15 +/- 0.08, respectively; p = 0.53). However, 53% of patients reported a subjective increase in visual function after treatment. At the final visit, the mean magnification required was x 7.7 +/- 6.7. A total of 60% of patients needed optical magnifiers for reading and in 40% of patients closed-circuit TV systems were necessary. All patients were able to read newspaper print using adapted low-vision aids at a mean reading speed of 71 +/- 40 words per minute. Mean self-reported scores were 3.2 +/- 1.1 for reading, 2.5 +/- 0.7 for day-to-day activities and 2.7 +/- 3.0 for outdoor walking and using steps or stairs. Patients' levels of dependency were significantly correlated with scores for reading (p = 0.01), day-to-day activities (p < 0.001) and outdoor walking and using steps (p = 0.001). CONCLUSIONS: The evaluation of self-reported visual function and vision-related quality of life in patients after macular translocation is necessary to obtain detailed information on treatment effects. Our results indicated improvement in patients' subjective evaluations of visual function, without significant improvement in visual acuity. The postoperative clinical benefits of treatment coincide with subjective benefits in terms of reading ability, quality of life and patient satisfaction. Our study confirms the importance and efficiency of visual rehabilitation with aids for low vision after surgery.

Fixation switch and diplopia after full macular translocation surgery.

PURPOSE: We sought to identify and evaluate treatment of patients who switched fixation to the poorer-seeing eye and complained of persistent diplopia 6 to 12 months after full macular translocation surgery (MT360) and extraocular muscle surgery. METHODS: All patients enrolled in a prospective study undergoing MT360 and extraocular muscle surgery were included. All patients had sensorimotor examinations. Visual acuity and fixation preference between 6 and 12 months after MT360 and extraocular muscle surgery were analyzed. RESULTS: Preoperative median visual acuity was 20/100 in operated vs 20/640 in fellow eyes; after MT360, the values were similar to the preoperative values (n = 67). After MT360 but before extraocular muscle surgery, all patients preferred the fellow eye for ambulation. Six to 12 months after MT360, 58 of 67 (86%) patients fixated with the better-seeing eye (52 operated vs 6 fellow eyes); 4/67 (6%) fixated with the operated eye despite its poorer or equal visual acuity; 5 of 67 (8%) fixated with the poorer-seeing fellow eye, all 5 of whom experienced diplopia (ie, fixation switch and diplopia). Treatment of diplopia included Fresnel prism, additional extraocular muscle surgery, and occlusion. CONCLUSIONS: Fixation switch to the poorer-seeing eye can occur after MT360, despite a successful visual outcome in the operated eye and the diplopia is difficult to treat.

Progressive visual loss in subfoveal exudation in age-related macular degeneration: a meta-analysis using Lineweaver-Burke plots.

PURPOSE: To analyze the randomized clinical trials in exudative age-related macular degeneration (AMD) to reveal apparent differences in the behavior of untreated control eyes among these trials. Herein we test the hypothesis that the behavior of untreated control eyes is actually the same in all studies, with apparent differences arising from differences in the time of entry of eyes into clinical trials. DESIGN: Retrospective meta-analysis of prior clinical trials. METHODS: Control eye data from six AMD studies (Macular Photocoagulation Study, Subfoveal Surgery Trial, Photodynamic Therapy [TAP] With Visudyne, pegaptanib trial for neovascular AMD, anecortave acetate trial, and 360 degree Macular Translocation Study) were plotted on a double reciprocal plot of 1/(Letters Lost) vs 1/(Months After Enrollment). To account for differences in time of entry into clinical trials, we introduced a horizontal translation factor to shift each data subset horizontally to maximize r(2) for the cumulative trend line. RESULTS: Cumulative data for untreated control eyes fits a straight line on a double reciprocal plot (r(2) = .9521); an untreated eye would eventually deteriorate to a final vision of 20/640. The slope of the line predicts that patients would experience half of the maximum final vision within 10.88 months after exudation onset. CONCLUSIONS: The pattern of vision loss experienced in AMD eyes with subfoveal neovascularization is uniform across a wide range of clinical trials, with apparent differences arising from differences in the time of entry of patients into clinical trials.