202
improvement of ≥ 2 Snellen lines in 66%, while 28%
remained stable (±1 line) and 6% decreased by ≥ 2
lines
(17)
. In another prospective, interventional, consecu-
tive non-comparative case series of 61 AMD patients
who underwent the same procedure and followed-up for
12 months, the visual acuity improved by ≥ 1 Snellen
lines in 52%
(21)
. Toth et al. also showed improvements
in distance and near visual acuity, contrast sensitivity
and reading speed in a series of 25 consecutive AMD
patients
(22)
.
In addition to exceptional surgical technique, avoid-
ing intra and postoperative complications, the key for
success after macular translocation seems to be patient
selection
(23,24)
. If this procedure is performed on a patient
without viable foveal photoreceptors, there is no chance
for visual improvement.
Still, the main drawback of macular translocation lies on
its high rate of complications. Rhegmatogenous retinal
detachment, with or without proliferative vitreoretinop-
athy development, is the most common serious compli-
cation of macular translocation. Rates up to 19% have
been reported
(25)
. Persistent or recurrent subfoveal CNV
has been described in up to 30% of patients undergo-
ing this procedure
(25)
. With a longer follow-up, cystoid
macular edema and subfoveal RPE atrophy may be lim-
iting factors for improved postoperative visual acuity. In
a long-term follow-up of full macular translocation (14
to 79 months – mean 38,2 months), 28% of patients
developed subfoveal RPE atrophy associated with loss of
visual function by the third year postoperatively
(18)
.
In figures 1 to 4, we present two anecdotal cases in which
full macular translocation was performed. They pre-
sented with extensive submacular hemorrhages that were
considered inadequate for anti-VEGF therapy. Visual
rehabilitation was achieved, enabling the patient’s inde-
pendence for daily activities.
2.2 Limited macular translocation
In an effort to overcome the major complication following
macular translocation with large retinotomy: proliferative
vitreoretinopathy (PVR), de Juan developed a new tech-
nique in 1998
(26)
. His technique involved transretinal
hydrodissection using small posterior retinotomies to
induce a subtotal retinal detachment, a complete vitrec-
tomy, anterior-posterior shortening near the equator and
retinal reattachment. As no large retinal break was created,
the likelihood of developing PVR was thought to be lower.
As more experience was gained with this surgery, addi-
tional modifications were made to the original technique.
such as subretinal fluid, subretinal hemorrhage, and reti-
nal edema. When fibrous proliferation and degeneration
of the overlying photoreceptors occur during the later
stages of the disease, the visual loss becomes irreversible.
The rationale of macular translocation is that moving
the neurosensory retina of the fovea in one eye with
recent-onset subfoveal CNV to a new location before the
occurrence of permanent retinal damage, may allow it to
recover or to maintain its visual function over a healthier
bed of RPE-Bruch’s membrane-choriocapillaris complex.
In addition, relocating the fovea to an area outside the
CNV allows the ablation of the later, by laser photoco-
agulation without destroying the fovea, in an attempt to
preserve central vision. On the other hand, some sur-
geons have combined macular translocation with CNV
removal, allowing the fovea to be relocated to an area out-
side the RPE defect created during submacular surgery.
Several different surgical techniques for macular trans-
location have been described and are currently in use.
These techniques produce different degrees of postop-
erative foveal displacement, and can broadly be classified
into two categories: (2.1)
full
macular translocation, and
(2.2)
limited
macular translocation.
2.1 Full macular translocation
After developing their surgical techniques in rabbit
eyes
(9)
, Machemer and Steinhorst became, in 1993, the
first surgeons to demonstrate the feasibility of macular
translocation in humans
(10,11)
. Their technique involved
lensectomy, complete vitrectomy, planned total retinal
detachment by transretinal infusion of fluid under the
retina, 360º peripheral circumferential retinotomy, rota-
tion of the retina around the optic disc, and reattach-
ment of the retina with silicone oil tamponade. Besides
allowing retinal rotation to occur, the retinotomy also
made way to the subretinal space for syncronous blood
and CNV removal. Since then, a number of investiga-
tors have subsequently modified this technique
(12-15)
.
Corrective extraocular muscle surgery for globe counter-
rotation, due to frequent postoperative cyclovertical dip-
lopia or awareness of a tilted image, may be done during
the primary surgery or at a later stage
(13,16)
.
While some surgeons have found the results of macular
translocation encouraging
(13,17,18)
, others found the sur-
gery unpredictable
(19,20)
.
In a series of 50 consecutive eyes with subfoveal CNV
from AMD that underwent full macular transloca-
tion followed-up for a median period of 21 months
(12-36 months), Pertile and Claes reported an
