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Surgery in AMD
19
In recent years, new treatment modalities such as photo-
dynamic therapy and intravitreal anti-VEGF injections
have been added to the treatment armamentarium for
age-related macular degeneration (AMD). Prior to the
introduction of these therapies, only laser photocoagula-
tion had been shown in a large randomized controlled
trial to confer a statistically significant benefit in the treat-
ment of subfoveal choroidal neovascularization (CNV)
secondary to AMD regarding to long-term visual acuity
(VA) when compared to the natural history of the con-
dition
(1-3)
. Unfortunately, the Macular Photocoagulation
Study also showed that laser photocoagulation was asso-
ciated with immediate average reduction of VA, with
benefits over no treatment apparent only six months
after treatment
(1-3)
. In fact, recovery of good vision rarely
occurred in these patients.
As a result of the limited treatment options, alternative
therapies, such as submacular surgery for CNV removal,
were pursued with limited or no success. Meanwhile a
different management paradigm for AMD was estab-
lished with macular translocation. However, because of
its higher risk of complications, its popularity has waned
with the wider availability of photodynamic therapy
and the introduction of intravitreal anti-VEGF agents.
Nonetheless, they remain potentially useful treatment
options, even if their role in the management of AMD is
neither established nor consensual.
In the meantime, vitreoretinal surgery and vitrectomy
have had important developments, mostly due to
advances in sutureless transconjunctival vitrectomy, use
of dyes, tamponade agents and new equipments. Novel
surgical approaches for AMD are under scrutiny: the
association of submacular surgery with pigment cell
transplantation, the use of adjuncts, such as recombi-
nant tissue plasminogen activator (r-TPA) for subretinal
hemorrhages displacement combined with anti-VEGF
treatment.
Recently, a new insight involving the vitreoretinal sur-
face has been proposed for the pathophysiologic mecha-
nisms underlying the development of CNV in AMD.
Accordingly, posterior vitreomacular adhesion may be
another risk factor in a subpopulation of patients with
wet AMD, opening another path for a surgical approach
in the treatment algorithm for this condition
(4-7)
. Future
studies are needed to define the role of vitreoretinal sur-
gery in such cases.
2. Macular translocation
The first experiments on retinal relocation were con-
ducted and reported in the beginning of the 80’s. Their
aim was to study the anatomic dependency of the foveal
retina on foveal retinal pigment epithelium (RPE) and
choroid. The assumption that visual function could be
preserved with foveal displacement has originated from
cases of ectopic macula from retinal traction or after
surgery in patients with retinopathy of prematurity and
retinal detachments with giant tears
(8)
. They ended up
showing the feasibility of rotating the macula around
the optic disc with reattachment of the fovea in animal
eyes
(9)
. One might say that this was the starting point
for the idea of rotating the macula of eyes with sub-
foveal CNV to a new area of underlying RPE-Bruch’s
membrane-choriocapillaris complex –
macular transloca-
tion
(MT) - as a treatment for the condition.
Although the exact pathogenesis of CNV secondary to
AMD is not known, the natural history of this condition
is progressive loss of central vision over time. The initial
retinal dysfunction responsible for impaired vision in
eyes with subfoveal CNV may be attributable to factors
1. Introduction
Authors:
Angelina Meireles, MD
1
Rui Martinho, MD
2
1
Hospital Sto. António - Porto, Portugal
2
Hospital da Boavista (Hospitais Privados de Portugal) - Porto, Portugal
