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Research - Age-related macular degeneration (AMD)

Macular translocation surgery

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For the vast majority of AMD patents there is no effective treatment. However, macular translocation is an exciting development in surgery. The part of the retina, which has been most used or worn, is shifted from the centre, so that a fresher healthier part of the retina is brought into the centre to take over the job of providing reading and fine vision. This procedure is difficult to perform but the signs are promising and more research is needed, particularly in identifying those patients who will do well with the procedure and those who do not do so well.

Macular translocation surgery: How is it doing?

Macular Translocation with 360^o retinotomy was started in Liverpool in December 2000. To date 100 cases have been operated upon. Virtually all patients who had undergone surgery suffered from age-related macular degeneration (AMD) in both eyes. In other words, it is only when the second eye becomes affected that surgery is offered. Most patients selected for surgery had no other treatment options, either because their visions were too poor to benefit from photodynamic therapy (PDT) or because of ineligibility (e.g. their lesion is occult or associated with large haemorrhages).

Developing an integrated service

Liverpool was the first centre to develop photodynamic therapy as a service to the NHS. Over the last few years, St Paul’s Eye Unit has built up a wealth of expertise in the treatment of AMD. We were uniquely placed in being the first to offer a range of treatments including laser and photodynamic therapy with surgery as an option. To give an idea of our activity, we have treated over 1000 patients with PDT and around 100 with surgery. There may well be many more patients that would benefit from surgery. Although the treatment is available, we do not always get patients in a timely fashion to benefit from the various treatments we have to offer.

Long term results

The long term results of the first 61 of our 100 patients were presented at the 2005 conference of The Association for Research in Vision and Ophthalmology (ARVO). This is the main international meeting of scientists researching vision and eye disease and takes place in Fort Lauderdale in the USA.

These 61 patients had an average follow-up of 3 years (ranging from 1 to 4+ years). The visual outcome of the treated eye was compared to the un-operated fellow eye. The operated eye had a variety of subtypes of AMD but they were all wet cases. Compared to its fellow, the operated eye had significantly greater chance of any visual improvement by 1 line; 2 lines and 3 lines; had no greater chance of any visual deterioration by 1 line; 2 lines or 3 lines; had less chance of seeing 20/500 or worse and better chance seeing of 20/200 or better. The incidence of vision being 20/800 or worse is the same in both eyes (Reference 1).

How does it fit in with other treatments?

If the results are so good, why it is not used as first line treatment? The reason is two fold.

1. Surgery unlike PDT has its complications. The surgery is complex and up to 20% need further surgery for one form of complication or another. Even when surgery goes perfectly well, most patients do have some form of ‘confusion’ as their two eyes do not work together. After surgery many patients tend to use the operated eye for reading and the fellow eye for navigation.
   
   
2. The results of randomised trials are still not available. Such trials are regarded essential to guide us on treatment options for the future. A pilot trial from Tubingen, Germany showed that compared to PDT, macular translocation had a significantly better chance of visual improvement and no greater chance of losing 3 or more lines of vision (Reference 2).

Who would benefit from macular translocation?

Patients with sudden (within a few weeks) and profound loss of vision (6/36 or worse) are most likely to benefit. They must have fluorescein angiography to confirm that there are new subretinal blood vessels. Most patients need to be screened by their local consultant to make sure they are not eligible for PDT.

Where is it available?

St Pauls' Eye Unit at the Royal Liverpool University Hospital and Moorfields Eye Hospital, London are the two centres with the most experience at present, but many other hospitals are developing the service. Your local ophthalmologist will have more information.

What of the future?

Some surgeons have modified the surgery to simply replace the diseased underlying retinal pigment epithelium without rotating the neuro-sensory retina. This operation is exciting because it makes the procedure easier and therefore potentially will have fewer complications (Reference 3). Most excitingly, it has been applied to patients with dry AMD who just lost the ability to read. Early results are encouraging but there is no long-term information yet. It may be that the benefit is only temporary, and studies are being undertaken to determine the long-term results in dry AMD (Reference 4).

References

1. Stappler T, Wong D. Does it work? A longitudinal and comparative study of eyes with exudative AMD treated with 360^o macular translocation using the fellow eye as control. Invest. Ophthalmol. Vis. Sci., 2005; 46: Abstract
   
   
2. Bartz-Schmidt KU, Aisenbrey S, Gelisken F. Full macular translocation versus PDT: 1 year results of a prospective, controlled, randomized pilot trial (Tübingen, Germany). Presented at the 3rd International Conference of Innovations in Vitreous and Retinal Diseases, Vienna, Austria, 2005. http://www.vienna-retina.at/abstracts.pdf
   
   
3. van Meurs JC, Van Den Biesen PR. Autologous retinal pigment epithelium and choroid translocation in patients with exudative age-related macular degeneration: short-term follow-up. Am. J. Ophthalmol. 2003;136:688-95
   
   
4. Kirchhof B, Joeres S, Prinz B, Heussen FMA, Joussen AM. Autologous translocation of choroid and RPE in neovascular age-related macular degeneration (Koln, Germany). Presented at the 3rd International Conference of Innovations in Vitreous and Retinal Diseases, Vienna, Austria, 2005. http://www.vienna-retina.at/abstracts.pdf
   

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