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Objective: To present the cases of two patients with laser-induced iatrogenic subfoveal choroidal neovascular membranes (CNVMs) who underwent surgical removal of the membranes with favorable outcomes., Design: Interventional case reports., Participants: Two patients with iatrogenic subfoveal CNVM. One case developed after laser treatment for macular edema due to branch retinal vein occlusion, and the second case developed after focal laser photocoagulation for diabetic retinopathy., Intervention: Surgical removal by pars plana vitrectomy., Main Outcome Measures: Visual acuity, scotoma, retinal examination with fundus photography, and fluorescein angiography before surgery and during the postoperative period., Results: Both patients underwent surgical removal after progression of the membrane with severe visual loss of 20/200 was noted. At present follow-up, there is a significant improvement in visual acuity and a reduction in the size of the scotoma. No recurrence of CNVM is noted., Conclusion: Both patients with laser-induced iatrogenic subfoveal CNVM achieved a good visual outcome after surgical removal of the membrane. The reasons for a good surgical result are thought to be twofold. First, the origin of the CNVM is extrafoveal at the site of laser application. The chance for foveal cone cell damage during the surgery is reduced. Second, the degree of cellular destruction in iatrogenic CNVM is usually focal without extensive retinal photoreceptor cell and retinal pigment epithelial damage. Therefore, a better chance of postoperative visual recovery is anticipated.

Purpose: To report a surgical method for translocation of the foveal retina in eyes with subfoveal choroidal neovascularization., Methods: In three eyes of three patients, a crescent-shaped, partial-thickness scleral resection was performed near the equator at either the superotemporal or the inferotemporal quadrant. A near-total retinal detachment was created; then the edges of the resected sclera were sutured, causing shortening of the sclera with subsequent reattachment of the retina, resulting in translocation of the fovea to an area overlying nonfoveal retinal pigment epithelium and choroid., Results: In three eyes of three patients, the fovea was surgically translocated to overlie retinal pigment epithelium that preoperatively was not underlying the fovea. In two patients, laser photocoagulation was applied to the choroidal neovascularization that, after translocation of the fovea, was no longer subfoveal, so that the photocoagulation was not associated with immediate visual loss. After a follow-up of 4 to 6 months, the visual acuity had improved in all patients (from 20/126 preoperatively to 20/70 in one patient, from 20/200 preoperatively to 20/70 in the second, and from 20/160 to 20/30 in the third). The patients noted distortion or tilting of the images, which improved over time., Conclusions: Limited foveal translocation may offer a therapeutic modality to preserve or improve vision in cases of subfoveal choroidal neovascularization. Additional follow-up is needed to assess the impact of potential complications associated with the surgical procedure, such as retinal detachment, proliferative vitreoretinopathy, and cataract, as well as the possibility of recurrent choroidal neovascularization.

Purpose: To document the visual outcome after successful foveal translocation with intentional retinal detachment and scleral shortening for the treatment of myopic neovascular maculopathy., Methods: Two severely myopic patients with subfoveal neovascular membranes underwent surgical translocation of the fovea to an area of healthy retinal pigment epithelium by means of scleral shortening and intentional retinal detachment. In the postoperative period, monocular and binocular visual function were studied., Results: In one patient, best-corrected visual acuity improved from 20/150 to 20/20 postoperatively. In the second patient, acuity initially improved from 20/70 to 20/30. In both patients, the fixation point shifted from the site of the neovascular membrane. Oblique astigmatism developed and was managed with hard contact lenses. Diplopia and subjective torsion occurred transiently. Micropsia occurred in one patient. Peripheral fusion assessed by Worth four-dot testing after resolution of diplopia disclosed suppression in the nondominant eye in both cases., Conclusions: Foveal translocation with intentional retinal detachment and scleral shortening was useful in improving visual acuity in two patients with myopic neovascular maculopathy. Diplopia and aniseikonia occurred but resolved over time as suppression developed. This technique is promising for patients with myopic neovascular maculopathy.

Purpose: To report a surgical method for retinal translocation as a potential treatment for eyes with subfoveal choroidal neovascularization., Methods: Thirty right eyes of 30 pigmented rabbits were used for this study. The first 15 were used to develop the technique. The complete surgical technique for retinal translocation was performed in the last consecutive 15 rabbits. Intravitreal injection of sulfur hexafluoride was performed to compress and liquefy the vitreous. Two weeks later, we used transscleral subretinal hydrodissection to create a retinal detachment. A scleral resection was then performed near the equator in the superotemporal quadrant. Fundus photographs were taken to record the retinal status before, immediately after, and 1, 3, and 7 days after surgery. Electroretinography was performed in three rabbits 3, 7, and 14 days after retinal translocation. Histologic studies were performed in one rabbit 7 days after retinal translocation., Results: Our results are based on experiments performed in the last consecutive 15 rabbits. One day after surgery, retinal reattachment was observed in 14 of the 15 animals. The remaining animal developed endophthalmitis. A predictable retinal translocation of about 1,000 microm was achieved. Retinal tears were noted on the retinal folds in four cases after 1 week. Electroretinographic studies showed transient reduction in retinal function. Mild morphologic damage to the outer retinal layers was seen histologically. Retinal detachment or proliferative vitreoretinopathy did not develop in any rabbit in the 14 days of follow-up., Conclusions: Limited retinal translocation with repositioning of the central retina was accomplished in rabbits.

Purpose: This study aimed to assess the feasibility of laser photocoagulation of feeder vessels of subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration., Patients and Methods: Of 170 consecutive patients with subfoveal CNV secondary to age-related macular degeneration, feeder vessels were detected in 37 patients by means of indocyanine green videoangiography using a scanning laser ophthalmoscope. Dye laser photocoagulation was applied to extrafoveal feeder vessels, with the fovea spared., Results: Twenty-six (70%) of those 37 patients had complete resolution of exudative manifestations. Persistent or worsened manifestations were seen in 11 patients (30%) because of recurrent CNV or persistent CNV. The visual acuity improved or stabilized in 25 patients (68%). Ten patients (27%) had a final visual acuity of 20/40 or better and six patients (16%) had a final visual acuity of 20/50 to 20/100. Significant factors prognostic of the visual outcome of 20/100 or better were small CNV (2 disc areas or smaller, Fisher's exact probability test, P = 0.041), the absence of white, fibrous tissue in neovascular membranes (Fisher's exact probability test, P = 0.003), and the closest distance of laser burns to the center of the foveal avascular zone (Fisher's exact probability test, P = 0.049). Preoperative visual acuity had a significant positive correlation with final visual acuity (Spearman's rank correlation test, P = 0.0076)., Conclusion: Feeder vessel photocoagulation should be considered as a treatment option for subfoveal CNV secondary to age-related macular degeneration, because no other treatment method has a better visual outcome.

Subfoveal choroidal neovascular membrane is a leading cause of legal blindness. Photocoagulation has been effective, but photocoagulation of the fovea causes a decrease in vision immediately after treatment. Surgical removal of the choroidal neovascular membrane is effective for choroidal neovascular membrane in some cases, but it restores useful vision for reading (20/40 or better) in a small number of cases of choroidal neovascular membrane not due to presumed ocular histoplasmosis syndrome. A new treatment for subfoveal choroidal neovascular membrane, foveal translocation, is an innovative procedure in which the fovea is translocated onto healthier retinal pigment epithelium. Three techniques have been developed to relocate the retina, 2 of which (retinotomy and scleral shortening) we performed in 5 cases each. Preliminary results in these 10 cases indicate that foveal translocation provides improvement of visual acuity in 40% of eyes and final visual acuities useful for reading (better than 20/40) in 20% of eyes undergoing translocation with either technique. Further study is essential to refine the amount of translocation needed and to decrease complications of the 2 techniques, including retinal detachment, proliferative vitreoretinopathy, macular pucker, corneal astigmatism, and constricted visual field., (Copyright 1998 W.B. Saunders Company.)

Objective: To determine whether lysing subretinal fibrin with tissue plasminogen activator (t-PA) before excising subfoveal choroidal neovascularization improves visual acuity in patients with age-related macular degeneration., Design: Randomized, double-masked trial., Participants: Eighty eyes of 80 patients with subfoveal choroidal neovascularization secondary to age-related macular degeneration were studied., Intervention: Each eye underwent pars plana vitrectomy and received a subretinal injection of t-PA or balanced salt solution (BSS) before the neovascular membrane was excised. Preoperative and postoperative protocol refraction, ophthalmic examination, color photography, and fluorescein angiography were performed in all 80 eyes., Main Outcome Measures: Visual acuity and fluorescein angiographic evidence of leakage after 1 year., Results: Visual acuity did not differ between the t-PA group (n = 40) and the BSS group (n = 40), and median best-corrected visual acuity was 20/320 for both groups (P = 0.38). Changes in visual acuity from baseline were also equal, with a median loss of 1 line in each group (P = 0.78). Patients whose initial visual acuity was 20/250 or less were more likely to improve by 2 or more lines (P = 0.01) and less likely to lose 2 or more lines (P < 0.001). Patients with choroidal neovascularization of at least 4 disc areas were more likely to improve by 2 or more lines (P = 0.02) and less likely to lose 2 or more lines (P < 0.001). After 1 year, choroidal neovascularization was present in seven of the t-PA eyes and in eight of the BSS eyes (P = 0.78)., Conclusions: With current surgical techniques, the use of t-PA before surgical excision of subfoveal choroidal neovascularization is of no visual or anatomic benefit to patients with age-related macular degeneration.

Objective: To determine the visual results, recurrence rates, and postoperative complications of surgical removal of subfoveal choroidal neovascularization (CNV) in patients with the presumed ocular histoplasmosis syndrome., Design: A consecutive surgical series of 63 eyes of 62 patients with subfoveal CNV and the presumed ocular histoplasmosis syndrome with longer than 6 months of follow-up., Setting: Tertiary care university medical center., Methods: Patients underwent surgical removal of subfoveal CNV using vitreoretinal surgical techniques. The anatomical and functional results of surgery were analyzed., Results: The median age of the patients was 42 years (range, 16-68 years), and the median follow-up time was 24 months (range, 6-48 months). Visual acuity improved by 2 or more Snellen lines in 22 (35%) of the 63 eyes, was unchanged in 28 (44%) of the eyes, and worsened in 13 (21%) of the eyes. Eleven (17%) of the 63 eyes improved to a visual acuity of 20/50 or better. Eyes with an initial visual acuity of 20/200 or worse had a better prognosis for improved vision (ie, 26 [41%] of the eyes) than those with an initial visual acuity of 20/100 or better (ie, 5 [8%] of the eyes). Recurrence of the subfoveal CNV occurred in 24 (38%) of the 63 eyes and was more common in those eyes that received preoperative laser photocoagulation (ie, 15 [47%] of the eyes). The median time to recurrence was 5 months after surgery. Post-operative complications included macular striae in 4 (6%) of the 63 eyes, rhegmatogenous retinal detachment in 2 (3%) of the eyes, retinal tear in 1 (1.6%) of the eyes, and progression of cataract in 19 (30%) of the eyes., Conclusions: Surgical excision of subfoveal CNV may be an effective therapeutic modality in patients with the presumed ocular histoplasmosis syndrome that offers the possibility of improving central vision in many patients. Factors possibly associated with a favorable visual prognosis include younger patient age and the absence of previous laser photocoagulation.

Objectives: To verify and quantify previously reported risk factors for development of choroidal neovascularization (CNV) in the fellow eye of patients with 1 eye affected with CNV secondary to age-related macular degeneration, to examine the value of characteristics of the pericentral macula in the quantification of risk for developing CNV, and to explore whether the presence of occult CNV in the first eye affects the development of CNV in the fellow eye., Design, Patients, and Setting: Follow-up study of fellow eyes of 670 patients enrolled in multicenter, randomized clinical trials of laser photocoagulation of juxtafoveal or subfoveal CNV., Main Outcome Measure: Development of CNV., Results: Three characteristics of the central macula of the fellow eye and 1 systemic factor were associated independently with an increased risk of developing CNV: the presence of 5 or more drusen (relative risk, 2.1; 95% confidence interval, 1.3-3.5), focal hyperpigmentation (relative risk, 2.0; 95% confidence interval, 1.4-2.9), 1 or more large drusen (relative risk, 1.5; 95% confidence interval 1.0-2.2), and definite systemic hypertension (relative risk, 1.7; 95% confidence interval, 1.2-2.4). Estimated 5-year incidence rates ranged from 7% for the subgroup with no risk factors to 87% for the subgroup with all 4 risk factors. Characteristics of the pericentral macula were not strongly associated with the development of CNV. The presence of occult CNV in the first eye affected had no influence on the development of CNV or on the type of CNV in the fellow eye., Conclusions: The prognosis of the fellow eye is affected strongly by characteristics of its central macula and by systemic hypertension. These factors should be considered when counseling patients with unilateral neovascular age-related macular degeneration and when targeting patients for preventive interventions.

Background: Occult choroidal neovascularization (CNV), poorly defined on fluorescein angiography, is present in the majority of patients with exudative complications of age-related macular degeneration. For patients who present with this type of subfoveal CNV but who have useful visual acuity, no form of treatment is of proven benefit. Accordingly, a pilot randomized trial of indirect laser treatment was performed. The rationale of this treatment was to inhibit the CNV through laser-induced effects on the retinal pigment epithelium., Methods: Patients with occult subfoveal CNV without retinal pigment epithelial detachment and with visual acuity of 20/200 or better were randomized to treatment or control groups. A grid of laser burns was applied to the macula beyond the area of serous retinal detachment and of angiographically defined occult CNV., Results: After an average follow-up of 38 months, there was no difference in mean final visual acuity (0.12 treated, 0.14 control) or clinical outcome between treated and untreated groups. Fluorescein angiography showed gradual enlargement in the occult CNV in 58% of eyes in both groups. A decrease in visual acuity to worse than 20/200 (54% of treated, 50% of control eyes) was associated with ingrowth of well-delineated CNV (6 treated, 7 control eyes) or progression to a fibroglial or atrophic scar (11 treated, 8 control eyes)., Conclusions: No benefit was demonstrated for scatter photocoagulation of the macula in patients with age-related macular degeneration and occult subfoveal CNV with initially good visual acuity. There were, however, no complications related to treatment.

Purpose: To investigate the efficacy of the surgical removal of subfoveal choroidal neovascularization in patients with type 2A idiopathic juxtafoveolar retinal telangiectasis., Methods: Two patients with bilateral acquired idiopathic juxtafoveolar retinal telangiectasis and a subfoveal choroidal neovascular membrane underwent surgical excision of the membrane using standard subretinal surgical techniques., Results: In both cases, surgical removal of the neovascular membrane was complicated by an intimate adherence of the membrane with the overlying neurosensory retina in an area of retinochoroidal anastomosis. A retinal dehiscence occurred in both instances at the time of surgery. Postoperative visual outcome was poor., Conclusion: The retinochoroidal anastomoses often visualized in cases of subretinal neovascularization complicating bilateral acquired IJFRT could indicate that there is a fairly marked adherence of the neovascular membrane to the neurosensory retina. Attempts at surgical removal of subretinal membranes in this disease entity with current techniques may be contraindicated.

Purpose: The authors assess the stability of visual acuity outcomes after the surgical removal of subfoveal choroidal neovascularization in a large series of patients with presumed ocular histoplasmosis syndrome (POHS)., Methods: A retrospective study of 117 consecutive patients undergoing vitrectomy between February 1990 and December 1994 was performed. All patients underwent the surgical removal of subfoveal choroidal neovascularization due to POHS and had at least 3 months of follow-up. Postoperative Snellen visual acuity was the primary study endpoint., Results: With a median follow-up of 13 months (range, 3-46 months), 35% of patients had postoperative visual acuity of 20/40 or better, and 40% had improvement of three or more Snellen lines after surgery. In a subset of 54 eyes followed for at least 1 year, 91% showed stable or improved vision between the 3- and 12-month time points, and 85% showed stable or improved vision between 3 months and final visit., Conclusion: Follow-up of a large number of patients appears to confirm initially encouraging results and to suggest stability of beneficial effect after the surgical removal of subfoveal choroidal neovascularization in POHS.

Purpose: To evaluate factors influencing visual acuity after laser photocoagulation for subfoveal choroidal neovascularization of exudative age-related macular degeneration., Methods: Subfoveal choroidal neovascular membranes were photocoagulated. Factors favoring a visual acuity of 20/200 or better were analyzed using Fisher's exact probability test or chi-square test on 28 eyes in which visual acuity was 20/200 or better, and 23 eyes with a visual acuity below 20/200 at the most recent follow-up examination., Results: Factors predicting a postoperative visual acuity of 20/200 or better were (1) distance between one lateral margin of the neovascular membrane and the center of the foveal avascular zone was one-third disc diameter or less, and (2) pretreatment retinal sensitivity at the fixation point was 10 dB or more., Conclusion: Good indications for photocoagulation treatment of subfoveal choroidal neovascular membrane were a neovascular membrane margin near the center of the foveal avascular zone and relatively good retinal sensitivity at the fixation point adjacent to the scotoma. These factors predict a visual acuity of 20/200 or better after treatment.

Objectives: To determine the effects of macular scatter ("grid") laser photocoagulation compared with observation on the visual function of eyes with subfoveal choroidal neovascularization (CNV) that has poorly demarcated boundaries and to provide preliminary data for the evaluation of the feasibility and design of a larger, definitive trial., Design: Randomized pilot clinical trial., Setting: Two tertiary care retinal referral practices., Patients: Symptomatic individuals with subfoveal CNV secondary to age-related macular degeneration in whom fluorescein angiography showed occult CNV with poorly demarcated boundaries; classic CNV was allowed but did not need to be present for entry into the study., Main Outcome Measure: Change in visual acuity from baseline to specified time periods., Results: Fifty-two eyes were assigned to observation. Fifty-one eyes were assigned randomly to treatment consisting of macular scatter ("grid") laser photocoagulation to the area of CNV. The treatment protocol for 8 of these eyes also included confluent laser photocoagulation to areas of classic CNV. The average visual acuity decrease from baseline was greater in the treated than in the observed group. The difference between these groups was greatest within the first year after study enrollment. At 24 months, slightly more than 40% of the eyes in each group had lost 6 or more lines of visual acuity. Similar results were noted for the subgroup of eyes initially with angiographic features of occult CNV but no classic CNV., Conclusions: These short-term study results suggest that macular scatter ("grid") laser treatment is not beneficial and is possibly harmful compared with observation for symptomatic subfoveal CNV with poorly demarcated boundaries in age-related macular degeneration. With or without treatment, a significant proportion of these patients are at risk of severe visual loss within 2 years of seeking treatment, even when the eye initially has occult CNV and no classic CNV.

Purposes: To evaluate submacular surgery for the management of subfoveal choroidal neovascularization in punctate inner choroidopathy, to describe the histopathology and ultrastructure of the excised subretinal tissue, and to propose a staging system that characterizes the development of choroidal neovascularization with associated subretinal fibrosis., Methods: The authors reviewed the records of five patients (6 eyes) with punctate inner choroidopathy who underwent submacular surgery for subfoveal choroidal neovascularization. Surgical specimens were examined using light and transmission electron microscopy., Results: Visual improvement was noted postoperatively in all six eyes, with follow-up ranging from 8 to 36 months (median, 14 months). Recurrences (6 in 4 eyes) were common. Five of the six recurrences required additional procedures: three were managed surgically, two with laser photocoagulation, and one with observation. "Bridging" of separate foci of choroidal neovascularization resulted in stellate or "dumbbell-shaped" areas of subretinal fibrosis in four of six eyes. Histopathologic evaluation of the excised tissue showed endothelial-lined vascular channels, retinal pigment epithelium, lymphocytes, plasma cells, fibrocytes, collagen fragments, and rarely, outer retinal elements., Conclusions: Subfoveal choroidal neovascularization in punctate inner choroidopathy may be managed with submacular surgery. Recurrences are common and may result in substantial loss of vision. Choroidal neovascular membranes with an accompanying fibrotic reaction are responsible for the stellate or dumbbell-shaped areas of subretinal fibrosis. No beneficial effect was demonstrated using corticosteroid treatment of the choroidal neovascularization.

Purpose: To report a surgical procedure for excising subfoveal neovascular membranes and translocating the fovea in an attempt to maintain the function of the sensory retina to preserve central vision, based on the technique of macular relocation., Methods: Three patients with subfoveal neovascular membranes underwent surgery for the creation of a nearly 180-degree retinal flap, removal of neovascular tissue, and reattachment and rotation the retina with translocation of the fovea over functional pigment epithelium., Results: In one patient with age-related macular degeneration, best-corrected visual acuity improved from 20/200 preoperatively to 20/20 postoperatively. A second patient, also with age-related macular degeneration, experienced a worsening of best-corrected visual acuity from 20/700 to 20/ 2,000. In the third patient, with myopic degeneration, best-corrected visual acuity improved from 20/700 to 20/70. Complications included the development of epimacular proliferation in two eyes and retinal detachment and neovascular glaucoma in one eye., Conclusion: The technique of foveal translocation has the potential for restoring central visual function in certain patients with subfoveal neovascular membranes.

Background: We investigated the functional outcomes of macular surgery for idiopathic, myopic and age-related subfoveal neovascular membranes and looked for preoperative features associated with better final visual acuity (VA)., Methods: We retrospectively studied 61 patients who had undergone macular surgery in our department between October 1992 and September 1994. Follow-up ranged from 5 to 27 months. Of 61 eyes with subfoveal neovascularizations, 6 were idiopathic, 21 had high myopia (-13 D median) and 34 displayed age-related macular degeneration (AMD). Median preoperative VA was 5/200 in AMD, 20/300 in myopia and 20/200 in idiopathic cases., Results: Four of the six eyes with idiopathic subfoveal neovascularization had VA 20/60 or better after a median follow-up of 18 months. Of the 21 eyes with high myopia, 10 (48%) improved and 13 (62%) were 20/200 or greater after a median follow-up of 12 months. Among the 34 eyes with AMD, VA improved in 7 (21%), but only 6 (18%) were 20/200 or better after a median follow-up of 7 months. Overall, complications included five retinal detachments, ten cataracts and an increase in size of the retinal pigment epithelium defect over the neovascular membrane of 2.3 +/- 0.8 times (mean +/- SD) in idiopathic eyes. 5.9 +/- 3.6 times in myopia and 19.5 +/- 12.2 times in AMD. Recurrence rates for idiopathic, myopic and age-related neovascular membranes were 33%, 19% and 18% respectively. Etiology (P = 0.035), initial VA in myopic eyes (P = 0.026) and initial size of the neovascular membranes in AMD (P = 0.025) were preoperative factors with a significant effect on final visual outcome., Conclusions: Surgical excision of subfoveal neovascular membranes yields different functional results depending on the underlying disease. Severe alteration of the retinal pigment epithelium-Bruch's membrane complex may be responsible for the poor visual outcomes in AMD.

Purpose: To report the authors' experience with recurrent neovascularization after subfoveal surgery in the presumed ocular histoplasmosis syndrome (POHS)., Methods: One-hundred seventeen patients with POHS and subfoveal choroidal neovascularization were followed a median of 13 months after submacular surgery., Results: Recurrent neovascularization developed in 51 eyes (44%). The median time to recurrence was 3 months (range, 0.5-28 months). Recurrence location was extrafoveal in 16%, juxtafoveal in 18%, and subfoveal in 66%. Sixteen eyes were treated with laser photocoagulation, 17 eyes underwent repeat submacular surgery, and 18 eyes were observed. The visual outcome for patients with recurrences amenable to laser was better than that for patients who were observed or who underwent surgery., Conclusion: Recurrent neovascularization after surgery is common; prompt recognition may allow laser photocoagulation.

Objectives: To document the incidence of choroidal neovascularization (CNV) in unaffected fellow eyes among individuals with ocular histoplasmosis and extrafoveal or juxtafoveal CNV in 1 eye; to determine whether the location and type of "histo spots" in the macula predict the site of future CNV development in second eyes; to describe changes over time in neovascular lesions present in fellow eyes at baseline; and to describe changes in visual acuity of fellow eyes with and without CNV at baseline., Design, Patients, and Setting: Five-year prospective follow-up study of fellow eyes of 516 patients enrolled in 2 randomized clinical trials of laser photocoagulation of extrafoveal and juxtafoveal CNV. Best-corrected visual acuity and reading vision were measured, and both maculas were photographed at baseline and at 6-month intervals., Main Outcome Measures: Cumulative incidence of CNV in fellow eyes free of neovascular maculopathy at the time of study enrollment, 5-year change in visual acuity of fellow eyes from baseline, and incidence of legal blindness (visual acuity < or = 20/200 in the better eye)., Results: Photographically documented CNV developed in 35 (9%) of 394 eyes initially free of neovascular maculopathy; nevertheless, good visual acuity was maintained in most newly affected eyes until the end of the 5-year follow-up period. Histo spots of any type in the macula at baseline tripled the risk for later development of CNV in comparison to eyes without histo spots in the macula. Although the type of histo spots present in the central macula at baseline did not predict future CNV development, in 32 of 35 second eyes in which CNV developed and in 7 of 9 fellow eyes in which a second area of CNV developed during follow-up, CNV was preceded by an "atypical" histo spot in the same location. Among 122 patients who had bilateral neovascular maculopathy initially, 100 were examined 5 years later; 8 (8%) were legally blind, compared with 3 (1%) of 339 patients examined who had unilateral CNV initially. At the 5-year examination, 355 (81%) of 439 patients examined had a visual acuity of 20/20 or better in at least 1 eye, including 74 (55%) of 134 patients who had bilateral neovascular maculopathy., Conclusions: Although the incidence of CNV in fellow eyes that initially were unaffected remained low throughout 5 years of follow-up, it persisted at a nearly constant rate. The risk of legal blindness was low, even for patients who had bilateral involvement. Perhaps most important, 81% of all patients followed up for 5 years retained a visual acuity of 20/20 in at least 1 eye, and 20% retained this visual acuity in both eyes. Retrospective review of photographs suggests that the ophthalmologist should pay special attention to areas of the central macula in which new "atypical" histo spots are observed, with the goal of treating CNV that may develop in the same area at a time when the benefits of laser treatment may be greatest.

Purpose: To describe the clinical outcomes of patients undergoing pars plana vitrectomy to remove subretinal neovascular membranes caused by traumatic choroidal ruptures., Methods: Three patients with traumatic choroidal rupture in whom subfoveal choroidal neovascularization developed underwent pars plana vitrectomy with surgical excision of the neovascular membrane. Surgical specimens were examined histopathologically in two patients., Results: The choroidal neovascularization was removed completely in each patient. Visual results were excellent with visual acuities improving to 20/30 or better in each patient. Recurrence of choroidal neovascularization has not been observed. Fibrovascular membranes with reactive retinal pigment epithelium were observed in two specimens examined histopathologically., Conclusion: Surgical removal of subretinal neovascular membranes emanating from traumatic choroidal ruptures produced an excellent visual outcome in three patients studied. The neovascular membranes, which were removed with minor disturbance to the underlying pigment epithelium, have similar characteristics to those obtained from patients with ocular histoplasmosis syndrome.

The macula is the area of retina responsible for central, detailed vision, its importance for visual function being out of proportion to its small size. It is the site of several diseases, including age-related macular degeneration, the most common cause of blindness in the UK. Recent advances in microsurgical techniques have introduced the possibility of treatment for many previously untreatable macular diseases.

Background: The clinical management of subfoveal neovascularization in age-related macular degeneration remains controversial. Large multicenter clinical trials recommend laser photocoagulation for certain subfoveal membranes, but many ophthalmologists are reluctant to treat patients with such lesions because a substantial initial visual loss may be induced by the treatment itself. Despite these controversies in management, the attitude of patients toward treatment of these lesions has not been assessed systematically., Methods: In this article, a newly designed survey containing five hypothetical clinical scenarios was given to 68 patients with age-related macular degeneration to measure their relative preferences for the potential long-term benefits of laser photocoagulation compared with the immediate visual loss induced by laser therapy., Results: This pilot study reveals a strong preference by these patients for laser intervention, despite the risk of immediate visual loss. On all five questions, the laser treatment outcome was preferred over the natural course of the disease., Conclusion: Ophthalmologists, when making clinical recommendations to patients with subfoveal exudative macular degeneration, may wish to consider the results of this survey, which suggest a substantial patient preference for laser treatment versus no intervention.

The natural prognosis of subfoveal neovascularization is severe visual acuity loss. Perifoveal laser photocoagulation is meant to spare a small portion of the central retina so as to possibly preserve foveal fixation. The aim of this retrospective study was to detect the persistence of central fixation and to evaluate the visual function of patients who had undergone perifoveal laser photocoagulation one year before, due to the presence of age-related macular degeneration with subfoveal neovascularization. The visual function was assessed by means of visual acuity (VA) measurement, central perimetry, scanning laser ophthalmoscope (SLO) scotometry and capability of using low-vision aids with success. Twelve eyes of 12 patients, 5 males and 7 females, with mean age 72.6 +/- 9.62 years, were included in the Study Group. Mean VA was 0.22 +/- 0.089 before laser treatment, 0.17 +/- 0.054 one week after laser treatment (p = 0.0152) and 0.13 +/- 0.063 one year after laser treatment (p = 0.045), with a statistically significant reduction of VA overtime (initial-final p = 0.0015). Mean lesion size was 2.12 +/- 0.528 disc diameters on the last follow-up fluorescein angiogram. One year after laser treatment, perimetry showed the persistence of central fixation in 2 eyes, while 10 eyes seemed to have lost it. SLO scotometry revealed central dot stimulus perception in 6 eyes and no central residual in 6 eyes. The SLO fixation plot showed persistence of central fixation also in 1 eye in which static perimetry had not detected it. The preferential retinal locus was located on the upper or upper-right margin of the lesion in 8 of the 9 eyes with paracentral fixation. All patients achieved a useful reading VA using low-vision aids, with 7.16 +/- 6.1 mean magnification power. The eyes with central visual residual on SLO scotometry had a final VA slightly higher than those without central residuals (VA 0.158 +/- 0.03 and 0.098 +/- 0.07, respectively), though the difference was not statistically significant (p = 0.0977).

Purpose: To study the choroidal circulation after surgical excision of subfoveal choroidal neovascular membranes (SFCNVM) in age-related macular degeneration (ARMD)., Methods: Twelve eyes of eleven patients with ARMD that underwent surgical excision of SFCNVMs were evaluated with stereoscopic color fundus photography, stereoscopic fluorescein angiography (FA) and scanning laser ophthalmoscope-indocyanine green videoangiography (SLO-ICGv). The patients were followed for a mean of 7.9 months (range 2 to 14 months)., Results: Preoperatively, all eyes had angiographic evidence of a SFCNVM, with SLO-ICGv showing the presence of a choriocapillary blush. Postoperatively, stereoscopic color fundus photographs documented that the bed of the surgical excision was characterized by an absence of visible retinal pigment epithelial (RPE) pigmentation in all eyes. Stereoscopic FA of the excision bed revealed choriocapillary hypofluorescence with visible dye perfusion in the underlying medium and large choroidal vessels in all eyes. SLO-ICGv of the excision bed disclosed the presence of perfused medium and large choroidal vessels, but a marked choroidal hypofluorescence with loss of the choriocapillary and small choroidal vascular filling within the excision bed in eleven of the twelve eyes., Conclusion: Our results indicate that both choriocapillary and small choroidal vascular filling is frequently abnormal or absent in the bed of surgically excised subfoveal neovascular membranes in ARMD. This finding, which may represent either pathologic or iatrogenic choriocapillary and small choroidal vascular atrophy or occlusion with preservation of perfusion in the underlying medium and large choroidal vessels, may influence structural and visual recovery after submacular surgery for ARMD, despite RPE transplantation or regeneration.

Purpose: To evaluate the occurrence of cataract formation after pars plana vitrectomy and gas-fluid exchange in patients younger than 50 years of age., Methods: Twenty-eight patients younger than 50 years of age with bilaterally symmetric crystalline lenses underwent pars plana vitrectomy and gas-fluid exchange in one eye. Postoperatively, lens photographs were used to assess any asymmetry between the surgical and nonsurgical eye. Lens photographs were graded by three independent masked observers using the Lens Opacities Classification System III (LOCS III). Significant cataract progression was defined as either cataract extraction in the surgical eye or a greater than a 0.9 LOCS III unit difference in lens opacity between the surgical and nonsurgical eye. Results were compared with 28 patients older than 50 years of age who had undergone identical surgery., Results: In only 7% of patients younger than 50 years of age (mean age, 36.5 years; range, 16-47 years) did significant lens opacity develop in the surgical eye compared with the nonsurgical eye during the follow-up period (mean follow-up, 25.4 months; range, 12-43 months). Of patients older than 50 years of age (mean age, 68.2 years; range, 51-85 years), 79% developed significant lens opacity in the surgical eye compared with the nonsurgical eye during the follow-up period (mean follow-up 27.3 months; range, 12-49 months). The difference in cataract progression between patients younger than 50 years of age and patients older than 50 years of age was statistically significant (P < 0.0000001)., Conclusion: Pars plana vitrectomy with gas-fluid exchange is minimally cataractogenic within the first few years in patients younger than 50 years of age.

We investigated the use of tissue plasminogen activator (t-PA) as an adjunct to the surgical removal of subfoveal choroidal neovascular membranes. t-PA in a concentration of 6 micrograms/0.1 cc dissolved the fibrin rim surrounding recent subfoveal membranes but was less effective on more mature lesions. t-PA may be a useful intraoperative tool to limit the damage to surrounding structures during the surgical excision of recent subfoveal choroidal neovascular membranes with surrounding fibrin rims.

Purpose: To examine the direct relationship between the extent of treatment with krypton red laser photocoagulation and visual acuity loss in eyes with choroidal neovascularization secondary to ocular histoplasmosis or age-related macular degeneration., Patients and Methods: Photographic and visual acuity records from 129 eyes treated in the Ocular Histoplasmosis Study--Krypton Laser and 224 eyes treated in the Age-Related Macular Degeneration Study--Krypton Laser were reviewed. The proportion of eyes with severe visual acuity loss (6 or more lines of loss) was examined for subgroups of eyes based on the distance of the neovascular lesion from the center of the foveal avascular zone and on the extent of laser treatment to the lesion. Differences in the proportions with severe visual acuity loss were evaluated by longitudinal data analysis methods., Results: Among eyes in the Ocular Histoplasmosis Study--Krypton Laser with lesions less than 200 microns from the center of the foveal avascular zone, only 5% of eyes with laser treatment that covered the foveal side and had a narrow (< or = 100 microns) border of treatment to adjacent uninvolved retina experienced severe visual acuity loss compared with approximately 25% of eyes with either some of the foveal side of the lesion left untreated or a wide border of treatment on the foveal side. Treatment extent had little influence on severe visual acuity loss in eyes in the Ocular Histoplasmosis Study--Krypton Laser with neovascular lesions 200 to 500 microns from the center of the foveal avascular zone or in eyes in the Age-Related Macular Degeneration Study--Krypton Laser with lesions in either distance category., Conclusions: Accurate, complete treatment of choroidal neovascularization close to the foveal center is required to provide the patient with the best chance of avoiding further severe visual acuity loss, especially in patients with ocular histoplasmosis. Even among experienced retinal specialists, the required accuracy of treatment is difficult to achieve.

Objective: A retrospective analysis of patients who underwent surgical removal of subfoveal neovascular membranes caused by factors other than age-related macular degeneration (AMD) and presumed ocular histoplasmosis syndrome (POHS) was performed., Methods: 17 eyes (16 patients) were identified in which subfoveal neovascularization was caused by myopic degeneration (5 eyes), angioid streaks (5 eyes of 4 patients), idiopathic neovascularization (4 eyes), punctate inner choroidopathy (1 eye), multifocal choroiditis (1 eye), or candida chorioretinitis (1 eye)., Results: Visual acuity remained stable after surgery in 10 of 17 eyes (59%), improved by 2 or more Snellen lines in 6 eyes (35%) and decreased in 1 eye (6%). Preoperative visual acuity was 20/80 or better in only 1 of 17 eyes (6%), but 5 of 17 eyes (29%) achieved postoperative visual acuity of 20/80 or better. Intraoperative and postoperative complications included peripheral retinal tears (1 eye), peripheral rhegmatogenous retinal detachment (1 eye), and mild cataract formation (1 eye). Subretinal neovascularization recurred after surgical removal in 4 eyes, 2 of which underwent repeat surgery., Conclusion: Visual acuity remained stable or improved in 94% of eyes after surgical removal of subfoveal neovascularization, but postoperative visual acuity better than 20/80 was achieved in a minority of eyes.

Surgical excision of subfoveal neovascular membranes may result in recovery of excellent visual acuity in patients with presumed ocular histoplasmosis but not in patients with age-related macular degeneration. To provide an explanation for this discrepancy, I analyzed the clinical and histopathologic findings in five patients with presumed ocular histoplasmosis. These findings provide evidence that the new vessels arising in the choroid in these patients usually grow within the subsensory retinal space and not in the subpigment epithelial space, as occurs in patients with age-related macular degeneration. In presumed ocular histoplasmosis, the new vessels are partly engulfed by a monolayer of proliferating retinal pigment epithelium. Surgical excision of this membrane permits reapproximation of the retinal receptors and native pigment epithelium and may be associated with remarkable return of visual acuity.

Objective: To evaluate the risks and benefits of argon-green compared with krypton red laser photocoagulation in the treatment of subfoveal choroidal neovascularization (CNV)., Design: Prospective randomized clinical trial assessing efficacy of laser treatment vs no treatment in the course of subfoveal CNV. Patients randomly assigned to laser treatment were randomly allocated to either argon green or krypton red laser photocoagulation. Scheduled follow-up for periods up to 5 years was performed., Setting: Tertiary retinal referral centers., Patients: Individuals with age-related macular degeneration and new subfoveal CNV or recurrent subfoveal CNV enrolled in the Foveal Photocoagulation Studies of the Macular Photocoagulation Study., Main Outcome Measures: Visual acuity, contrast sensitivity, reading spread, persistent and/or recurrent CNV, and treatment complications., Results: There was no significant difference in average loss of visual acuity or contrast sensitivity from baseline levels in eyes treated with either wavelength. From baseline, eyes treated with argon green laser in the Subfoveal Recurrent CNV Study lost an average of 12 words per minute less than eyes treated with krypton red laser. Comparable rates of persistent and recurrent CNV were observed in the two laser treatment groups. Focal retinal vascular narrowing was more common in eyes treated with argon green laser., Conclusions: Small differences in outcomes favored argon-green treatment of subfoveal CNV, but the only statistically significant difference observed between green- and red-laser treatments was a smaller loss of reading speed among argon green-treated eyes in the Recurrent CNV Study. The multiple analyses performed in these two Macular Photocoagulation Study trials failed to identify any consistent clinically and statistically significant differences between green- or red-laser treatment in the management of eyes with subfoveal CNV.

Purpose: The authors report their experience with the surgical removal of subfoveal choroidal neovascularization. Correlations between preoperative characteristics and final postoperative visual acuity are explored., Methods: A retrospective study of 159 consecutive patients was performed between February 1990 and August 1993. Follow-up of 2 or more months was available for 147 eyes: presumed ocular histoplasmosis syndrome, 67 eyes; age-related macular degeneration, 41 eyes; myopia, 10 eyes; multifocal choroiditis, 9 eyes; idiopathic, 8 eyes; angioid streaks, 4 eyes; and miscellaneous, 8 eyes., Results: Sixty-seven eyes had presumed ocular histoplasmosis syndrome: mean follow-up was 10.5 months. Visual acuity was stable or improved in 56 (83%) eyes and 20/40 or greater in 21 (31%) eyes. Mean interval to best visual acuity was 3 months. A recurrence rate of 37% had no significant effect on final visual outcome (P = 0.952). Forty-one eyes had age-related macular degeneration: mean follow-up was 15 months. Visual acuity was improved in only five (12%) eyes and was 20/40 or greater in only two (5%) eyes. The interval to best visual acuity was 5 months. A recurrence rate of 27% had not significant effect on final visual outcome (P = 0.31). The visual results and recurrence rates for eyes with less common disorders are presented., Conclusion: The surgical excision of subfoveal choroidal neovascularization may stabilize or improve visual acuity in selected cases. Patients with focal disorders of the retinal pigment epithelium-Bruch's membrane complex appear to have a better surgical outcome than those with diffuse disease.

Background: The poor results of laser photocoagulation in patients with age-related macular degeneration who have subfoveal neovascular membranes, as reported by the Macular Photocoagulation Study Group, have posed the question as to whether the surgical removal of the neovascular membranes by subfoveal surgery might provide superior functional results, possibly in subgroups of patients., Methods: The authors' first ten patients treated by subfoveal surgery were followed prospectively. Follow-up of a mean duration of 2 years is presented, with particular emphasis on visual and anatomic outcomes. Preoperative subfoveal choroidal neovascular membranes and postoperative retinal pigment epithelial defects were measured using digitized planimetry., Results: Initial visual acuities were equal to or less than 20/400, with a mean duration of visual loss of 8 months. The mean choroidal neovascular membrane size was 7 disc areas. Eight of ten patients improved one to two lines of Snellen visual acuity postoperatively. One patient achieved visual acuity of 20/60 at 15 months before declining because of recurrent neovascularization. Surgically induced retinal pigment epithelial defects were invariable; the mean defect was 14 standard disc areas in size. Choriocapillaris atrophy and focal losses of deeper choroidal tissue also occurred. Surgical complications were frequent but responded to routine management. The authors observe a 2-year recurrence rate of 40%. Recurrences often are atypical, fibrous, and poorly vascularized., Conclusions: Although substantial visual improvements are common, long-term reading vision has not been achieved. Retinal pigment epithelial incorporation into late subfoveal membranes remains a major limiting factor. The role of early surgery and the role of surgery for patient subgroups need to be compared directly with the results of foveal laser treatment, using several visual outcomes.

Background: Subfoveal neovascular membranes cause significant visual loss in age-related macular degeneration (AMD) and the ocular histoplasmosis syndrome. The frequency of post-laser treatment persistence or recurrence of subfoveal membranes in AMD is as high as 51%. The reason for the high incidence of failure after laser treatment is unknown. The authors performed a histopathologic study of subfoveal membranes to determine the distribution of blood vessels within the neovascular complex, and to see if the blood vessel pattern would provide insight into the reason for laser treatment failure., Methods: The authors used light microscopy to examine serial sections of subfoveal membranes from six patients (4 with AMD, 2 with the ocular histoplasmosis syndrome). The data from this examination were used to create detailed two-dimensional vascular maps of each membrane., Results: The authors found that subfoveal membranes from patients with AMD and the ocular histoplasmosis syndrome, whether occurring de novo or after laser treatment, have a nonuniform distribution of blood vessels, and that large areas which include the membrane margin may be avascular., Conclusions: Using current laser treatment protocols, it is likely that avascular or poorly perfused peripheral areas of the neovascular complex would be left untreated after laser photocoagulation. Partial treatment of the neovascular complex may contribute to the high rate of post-laser treatment persistence or recurrence of subfoveal membranes.

Objective: To determine the incidence and visual impact of and risk factors for persistent and recurrent neovascularization after laser photocoagulation of subfoveal choroidal neovascularization (CNV) in patients with age-related macular degeneration., Design, Patients, and Methods: The records of 189 eyes in the Subfoveal New CNV Study and 100 eyes in the Subfoveal Recurrent CNV Study assigned to laser photocoagulation were examined. Persistent CNV (detected within 6 weeks of treatment) and recurrent CNV (detected after 6 weeks) were defined angiographically by fluorescein leakage from the periphery of the treatment scar. Incidence was estimated using survival analysis methods., Results: In both studies, persistent CNV was observed in approximately 13% of the eyes, and recurrent CNV was estimated to have developed by 3 years in an additional 35% of the eyes. In the New CNV Study, by 3 years, 36% of the eyes with persistent CNV had lost 6 or more lines of visual acuity as had 19% of the eyes with recurrent CNV and 27% of the eyes without persistence or recurrence. The presence of neovascular maculopathy in the fellow eye was associated with an increased risk for persistence or recurrence in the study eye. In the New CNV Study, partial coverage of the lesion with heavy laser treatment and/or runoff was associated with increased risk for persistence; less extensive natural scarring of the lesion at study entry was associated with increased risk for recurrence., Conclusions: Close to half of the eyes treated for subfoveal CNV have persistent or recurrent CNV within 3 years. There is a strong association between neovascular maculopathy in the fellow eye and the inability of laser photocoagulation to permanently obliterate signs of CNV from the study eye. Within these two studies, there was little additional damage to visual function resulting from persistent or recurrent neovascularization. There appears to be no reason to deviate from the protocol goal of covering the entire neovascular complex when treating eyes with subfoveal CNV.

Objective: To provide detailed information specific to the initial visual acuity and initial lesion size on the outcome of patients with subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration., Design and Patients: The 189 eyes assigned to laser photocoagulation and the 184 eyes assigned to observation in the Subfoveal New CNV Study were divided into nine subgroups based on initial visual acuity and initial lesion size., Main Outcome Measures: The pattern of visual acuity loss for both treated and untreated eyes through 4 years of follow-up was compared among the subgroups. Reading speed and contrast thresholds also were examined., Results: Four patterns (A, B, C, D) of visual acuity loss in treated eyes relative to untreated eyes were identified. Eyes in group A (small lesion and moderate or poor initial visual acuity or medium lesion and poor visual acuity) had the best visual outcome with treatment; treated eyes were better throughout follow-up. Eyes in group B (small lesion and good initial visual acuity or medium lesion and moderate or good visual acuity) had substantial treatment benefit by 12 months, but were worse immediately after treatment. Eyes in group C (large lesion and poor initial visual acuity) had a small treatment benefit throughout follow-up. Eyes in group D (large lesion and moderate or good visual acuity) had the worst visual outcome with treatment; treated eyes were substantially worse for the first 18 months and were not appreciably better through 4 years of follow-up., Conclusions: Recommendations for treatment of subfoveal CNV should take account of the initial visual acuity and lesion size. Eyes in group D are poor candidates for laser treatment.

Objective: To summarize findings from three randomized clinical trials of krypton laser treatment of juxtafoveal neovascular lesions regarding changes in visual acuity during 5 years of follow-up, rates of persistent and recurrent choroidal neovascularization, and status of macular lesions 5 years after enrollment. DESIGN, PATIENTS, AND PRIMARY OUTCOME MEASURES: Follow-up of patients enrolled in three randomized trials of choroidal neovascularization secondary to age-related macular degeneration (AMD), ocular histoplasmosis, or idiopathic causes ended in March 1991. All patients were eligible to complete at least 3 years of follow-up examinations. Data on visual acuity, reading vision, and anatomic outcomes during 5 years of follow-up were available for 276 (92%) of 300 patients with AMD, 236 (92%) of 256 patients with ocular histoplasmosis, and 38 (97%) of 39 patients with idiopathic choroidal neovascularization enrolled 5 or more years earlier who were still living., Results: Among eyes with AMD, the estimated relative risk (RR) of a loss of 6 or more lines of visual acuity from baseline to any examination from 6 months through 5 years after enrollment for untreated eyes in comparison with treated eyes was 1.20 (P = .04). Normotensive patients with AMD realized the greatest benefit from laser treatment (RR, 1.82) and hypertensive patients experienced little or no benefit (RR, 0.93). Untreated eyes with ocular histoplasmosis were at much greater risk of a 6-line decrease in visual acuity from the 1-year through the 5-year examination than were treated eyes (unadjusted RR, 2.60; RR, 4.26 after adjustment for visual acuity and hypertension at baseline; P < .001 for both). The treatment effect for eyes with idiopathic choroidal neovascularization was between the effects for eyes with AMD and eyes with ocular histoplasmosis., Conclusions: The early beneficial effects of laser treatment on visual acuity persisted for at least 5 years in eyes with all three underlying conditions. Laser treatment of similar eyes with choroidal neovascularization in a juxtafoveal location is recommended for patients with these conditions, with the caveat that hypertensive patients with AMD may fare no better with laser treatment than without treatment.

Indocyanine green (ICG) is a dye with an absorption peak (795 to 810 nm) similar to the emission peak of the diode laser (805 nm). Therefore, ICG dye-enhanced diode laser photocoagulation may permit the selective ablation of ICG-retaining choroidal neovascular membranes (CNVM) with relative sparing of the neighboring neurosensory retina. Ten patients with poorly defined subfoveal CNVM were treated with ICG dye-enhanced diode laser photocoagulation and followed for an average of 15 months. One of the 10 patients experienced an immediate significant drop in visual acuity after photocoagulation. Obliteration of the CNVM at the site of laser photocoagulation was confirmed by fluorescein angiography and ICG angiography. Subfoveal chorioretinal scar formation was noted postoperatively in all 10 patients. At last follow up, 9 of these 10 patients had no more than a two-line increase or decrease in visual acuity. These preliminary results suggest that poorly defined subfoveal CNVM can be successfully treated by ICG dye-enhanced diode laser photocoagulation with minimal adverse affect on visual acuity in most cases.

Background: Visual recovery after submacular surgery for age-related macular degeneration (AMD) has been very limited., Methods: A patient with an extrafoveal fibrotic choroidal neovascular membrane from AMD had an overlying serous foveal detachment with the fibrotic tissue elevating the foveal retina. Photocoagulation of the neovascular membrane was not recommended because of its nonpigmented, fibrotic nature. The membrane was surgically excised., Results: Preoperative and postoperative visual acuity and central 30 degrees visual fields were followed. Visual acuity improved from 20/200 to 20/25, and a preoperative central scotoma resolved completely 18 months after surgical excision of the extrafoveal fibrotic neovascular membrane. There were no intraoperative or postoperative complications., Conclusion: This type of patient may represent a distinct subset of patients with AMD amenable to subretinal surgery who could potentially have good recovery of vision.

An understanding of the difference between the growth pattern of choroidal neovascularization within the subsensory retinal space, usually encountered in children and young adults, and that within the subpigment epithelial space, typically in older patients with age-related macular degeneration, is of fundamental importance in considering whether to surgically remove these subfoveal neovascular membranes. Their removal in young patients has some chance of restoring useful central visual function. Their removal in older patients will be associated with removal of the native pigment epithelium and little likelihood of restoration of function in the area of the membrane, unless some means are found to resurface the area with pigment epithelium.

Background: The use of laser photocoagulation with sparing of foveal photoreceptors to control exudative age-related macular degeneration (AMD) with subfoveal involvement was investigated., Methods: Patients with exudative AMD and visual acuity of 20/100 or worse were treated with foveal-sparing laser photocoagulation. The full extent of the choroidal neovascular membrane was treated with laser photocoagulation in addition to any associated retinal pigment epithelial detachment, with sparing of the foveal avascular zone. Three cases in which visual acuity improved dramatically are presented., Results: Laser photocoagulation resulted in control of the exudative process in all patients. The three patients whose cases are presented had dramatic visual improvement., Conclusion: Foveal-sparing laser photocoagulation is an alternative treatment modality in patients with exudative AMD involving the fovea. The definitive value of this treatment modality can only be determined by a prospective, randomized, clinical trial.

In contrast to focal laser treatment of large subfoveal neovascular membranes, perifoveal laser treatment sparing the central avascular zone can partially retain central macular function in some cases. The anatomical and functional outcome of this technique was analysed in 26 patients with large subfoveal neovascular membranes (0.6 to 3.0 disc diameter) secondary to age-related macular degeneration (24 cases) or presumed ocular histoplasmosis syndrome (two cases). Patients were followed for six to 39 months. Out of 26 patients 21 had a stable dry scar at the last follow-up examination. Central fixation was retained postoperatively in nine out of 13 patients with central fixation prior to laser treatment. Visual acuity was maintained or improved in 19 out of 26 treated eyes. Statpack analysis (Humphrey Field Analyser) of the long-term results of patients with central fixation indicated an increase in the depth of their relative central scotoma not only immediately after laser treatment but also in the first and second postoperative years. This increasing depth of central scotoma subsequently led to a shift of central fixation to a paracentral area in four out of nine patients six to nine months after treatment. Indocyanine-green angiography showed remaining subfoveal choroidal vasculature corresponding to the area of central fixation, as found in fundus microperimetry by scanning laser ophthalmoscope. Perifoveal laser treatment seems to be effective in maintaining some initial macular function for a limited time in selected patients suffering from subfoveal neovascular membranes.

Objective: To report 3- and 4-year visual outcomes in eyes followed up in two randomized clinical trials of laser photocoagulation for subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration., Design and Main Outcome Measures: Eyes of consenting patients were assigned randomly to laser treatment or no treatment. Visual acuity, reading speed, and contrast threshold were measured before random assignment, 3 and 6 months later, and at 6-month intervals thereafter. Visual acuities of treated and untreated eyes were compared 4 years after enrollment, in the Subfoveal New CNV Study (eyes without prior laser treatment), and 3 years after enrollment, in the Subfoveal Recurrent CNV Study (eyes with subfoveal recurrent CNV at the periphery of an earlier laser treatment scar)., Results: Four years after enrollment in the Subfoveal New CNV Study, 39 (47%) of 83 untreated eyes and 17 (22%) of 77 laser-treated eyes had lost 6 or more lines of visual acuity from baseline levels (P = .002). At the 3-year examination in the Subfoveal Recurrent CNV Study, 21 (36%) of 58 untreated eyes and six (12%) of 49 treated eyes had lost 6 or more lines of visual acuity from baseline levels (P = .009). Comparisons based on contrast threshold and reading speed for enlarged text also favored laser treatment in both trials., Conclusions: Stronger evidence favoring laser photocoagulation of subfoveal CNV has been provided by continued follow-up of patients enrolled in these two clinical trials. The benefits of laser treatment have persisted through at least 4 years of follow-up in the Subfoveal New CNV Study and 3 years of follow-up in the Subfoveal Recurrent CNV Study.