Macular Translocation

Surgically Moving the Macula

By Igal Leibovitch MD, Anat Loewenstein MD
Department of Ophthalmology,
Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine,
Tel-Aviv University, Tel-Aviv, Israel.

Introduction: Macular translocation is a new surgical technique designed to move the area of the retina responsible for fine vision (macula) away from the diseased underlying layers (the retinal pigment epithelium and choroid). The macula is moved to an area where these underlying tissues are healthier. Consequently, safe treatment of the sick blood vessels [choroidal neovascularization (CNV)] with, for example, laser treatment can be performed without harming central vision.

Two Surgical techniques are Used:

In the first technique, the entire retina is cut 360 degrees around the periphery. It remains attached to the optic nerve at the back of the eye. Then, like an umbrella, the whole retina is rotated around the optic nerve and the macula becomes repositioned. The abnormal blood vessels once under the fovea are now outside of the center of vision and can be treated.

In the second technique, no large retinal cuts or rotations are needed. Instead, the outer part of the eye-wall (the sclera) is shortened with sutures (stitches). This results in there being more retina than its underlying eye-wall. That is, when you look into the eye, the retina is wrinkled and folded. Then the surgeon flattens the retina over the shortened eye-wall, causing the macular retina to move away from the optic nerve toward the periphery. As with the first technique, the central macula has been moved. The abnormal blood vessels once under the fovea are now outside of the center of vision and can be treated.

Complications: Possible complications of these techniques are retinal tears, retinal detachment, intraocular bleeding, infection and cataract formation. After surgery the abnormal vessels can regrow and new subretinal neovascularization can develop. Most patients do not develop these complications.

Results: Macular translocation has been shown beneficial in a few series of patients (phase-I studies), showing improvement of visual acuity in 30-40%, and stabilization of visual acuity in 15-30%. Controlled studies comparing this surgery to the natural course of the disease or to laser and photodynamic treatments are needed.

Conclusion: Macular translocation is a new and possibly helpful method in treating patients with subfoveal CNV with a unique potential to improve visual acuity. Randomized controlled (statistically significant) clinical studies are needed to evaluate the effectiveness and safety of macular translocation for treating visual loss from AMD and to compare it to other techniques.

References:

1. de Juan E Jr, 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.

2. Eckardt C, Eckardt U, Conrad H. Macular rotation with and without counter rotation of the globe in patients with age-related macular degeneration. Graefes Arch Clin Exp Ophthalmol 1999;237:313-325.

3. Lewis H, Kaiser PK, Lewis S, Estafanous M. Macular translocation for subfoveal choroidal neovascularization in age-related macular degeneration: a prospective study. Am J Ophthalmol 1999;128:135-148.

4. American Academy of Ophthalmology. Macular translocation. Ophthalmology 2000;107:1015-1018.

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