Klaus Lucke, Bianca Kemper, Katrin Böhm – Augenklinik Universitätsallee, Bremen, Germany

Purpose:

Macular rotation surgery for age related macular degeneration has now been performed for more than 6 years as a regular and routine intervention in a few centers particularly in Europe. In our institution more than 350 such operations have been performed by now. Due to considerable advances in the surgical technique used the time for each procedure is now consistently below 2 hours and frequently even less than 90 minutes. Elsewhere this operation is still viewed with trepidation and skepticism. Published statistics are frequently discounted for lack of better and more convincing information. The purpose of this paper is to present data on a large series of cases for the vast majority of which there was no other “therapeutic modality” available as the observation of the natural course.

Materials and Methods:

Between September 1998 and February 2005 a total of 350 eyes underwent vitrectomy with concurrent phakoemulsification and IOL implantation if phakic, 360° retinotomy, removal of the subretinal neovascular membrane, 35-60° rotation of the retina (mostly upwards) and silicone oil filling. In most cases counter-rotation of the globe was performed 6-12 weeks later combined with silicone oil removal. Most eyes had large occult subretinal neovascular membranes (average size: 5mps disk areas), 21% had a subretinal hemorrhage of varying extent. In 88% of cases the felloweye had a VA of 20/200 or less, the operated on eye being functionally superior. Data were collected prospectively. Follow-up at the time of abstract ranged from 2 months to 5 years with an average of 1.5 years. There was minimal loss to follow-up.

Results:

Average VA changed from 0.25 preoperatively to 0.16 at the last follow-up visit. 81% of eyes had a VA of 0.1 or better and 37% of 0.3 or better. 51% of eyes had stabilized or improved VA whereas 49% lost 3 lines or more and 23% lost 6 lines or more. 47% of patients could read newsmagazine print. Whereas about 16% of eyes developed some degree of PVR, only 4 eyes were lost anatomically and functionally to this complication. In a recent subseries the rate of PVR was reduced to 6%. Other severe losses of vision could be attributed to recurrent neovascular membranes and keratopathy. Near vision tended to be better than far vision. Multivariate analysis showed that better outcomes were associated with relatively young patient age, no or only recent loss of reading vision and the absence of complications such as PVR or keratopathy.

Conclusion:

At present macular rotation with 360° retinotomy remains the only treatment modality offering any chance of preservation of reading ability in eyes with large occult subfoveal neovascular membranes or submacular hemorrhages. It is a new type of surgery, extensive, difficult and therefore potentially risky. However, anatomic and functional results after macular rotation surgery are highly satisfactory even in the long-term considering the expected natural course. In experienced hands this procedure offers selected patients the prospect of preserving vision which otherwise would be irrevocably lost.