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Purpose: To report a case of pitchfork sign following pars plana vitrectomy for idiopathic epiretinal membrane., Study Design: Case report., Results: A 75-year-old man was referred to the surgical retina service due to a quantitative and qualitative decline in vision in the left eye (LE) for several months. Optical coherence tomography (OCT) examination revealed the presence of a stage III epiretinal membrane (ERM) according to the Govetto classification. Seven days after undergoing a 25-gauge pars plana vitrectomy (PPV) with ERM peeling and balanced salt solution (BSS) tamponade, OCT examination revealed the presence of the 'pitchfork sign' in the macular region, along with the detection of a choroidal neovascularization (CNV) through OCT-A examination. After receiving two monthly intravitreal anti-VEGF injections, a complete regression of the MNV was observed., Conclusions: We reported, for the first time, the iatrogenic onset of the pitchfork sign following vitreoretinal surgery. This discovery highlights the unique presentation of the pitchfork sign in the context of surgical procedures, expanding our comprehension of its range of causes., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: No large-mammal surgical models exist for geographic atrophy (GA), choroidal neovascularization (CNV), and pachychoroidal vascular remodeling. Our goal was to develop a porcine RPE debridement model of advanced macular degeneration to study photoreceptor cell loss and choroidal remodeling., Methods: Seven 2-month-old female domestic pigs were used for this study. After 25G vitrectomy, the area centralis was detached via subretinal bleb. A nitinol wire (Finesse Flex Loop) was used to debride RPE cells across a 3- to 5-mm diameter region. Fluid-air exchange was performed, and 20% SF6 gas injected. Animals underwent fundus photography, fluorescein angiography, optical coherence tomography (OCT), and OCT-angiography (OCTA) at 2 weeks, 1 month, 2 months, 3 months, and 6 months postoperatively. Retinal histology was obtained at euthanasia, 2 months (n = 3), 3 months (n = 2), or 6 months (n = 2) after surgery., Results: RPE debridement resulted in GA with rapid loss of choriocapillaris, progressive loss of photoreceptors, and pachychoroidal changes in Sattler's and Haller's layers in all seven eyes undergoing debridement within 2 months. OCT and histological findings included subretinal disciform scar with overlying outer retinal atrophy; outer retinal tubulations and subretinal hyper-reflective material. OCTA revealed type 2 CNV (n = 4) at the edges of the debridement zone by 2 months, but there was no significant exudation noted at any time point., Conclusions: Surgical debridement of the RPE results in GA, CNV, and pachychoroid and reproduced all forms of advanced macular degeneration. This surgical model may be useful in examining the role of RPE and other cell replacement in treating advanced macular disease.

Introduction: Alexandrite laser is generally used for hair removal and treatment of hyperpigmented skin lesions. It is important to use protective equipment during treatment. In previous cases, complications such as conjunctival hyperemia, anterior uveitis, and choroidal neovascularization were reported. We report a case who developed chorioretinal anastomosis secondary to inadvertent alexandrite laser exposure., Case Description: A 44 year-old woman presented with decrease of vision in the left eye. She had an history of alexandrite laser treatment for facial hair removal two weeks ago. Fundus examination of the left eye revealed an elevated yellowish lesion in the temporal macula and retina pigment epithelium (RPE) atrophy was observed in the inferotemporal perifoveal region. Optical coherence tomography (OCT) of the left eye revealed the disorganization of inner and outer retinal layers, a rupture in the Bruch membrane, and an absence of RPE. Fluorescein angiography images showed early hyperfluoresence inferior to the fovea. OCT angiography revealed an abnormal vascular network between deep retina layers and choroid. B-scan with flow overlay demonstrated the blood flow in the abnormal vascular network which is suggestive of chorioretinal anastomosis. The patient was followed monthly for choroidal neovascularization development. Six months after laser exposure the best corrected visual acuity was partially improved in the left eye and fundus examination showed pigmentary changes., Conclusion: Chorioretinal anastomosis may rarely develop secondary to inadvertent alexandrite laser treatment. It is important to use protective equipment during treatment to prevent ophthalmological complications.

Purpose: To report on the outcome of surgical submacular choroidal neovascular membrane (CNV) removal in children and to perform a comprehensive review of literature concerning this intervention in children., Methods: In this retrospective, noncomparative, interventional case series, we included 8 eyes of 7 consecutive children with subfoveal choroidal neovascularization treated by pars plana vitrectomy (PPV) and CNV removal. Main outcome measures were visual acuity and complications., Results: Mean age at surgery was 8.6 ± 5.2 years (range: 2-16). Two out of 8 eyes were idiopathic. Corrected-distance visual acuity (CDVA) improved from 1.01 ± 0.45logMAR (range:0.3-1.5) at presentation to 0.60 ± 0.37 (range:0-1) at last follow-up (p = 0.03). Mean follow-up was 3.9 ± 3.9 years. Six eyes received at least one intravitreal injection of bevacizumab prior to surgery. Recurrence occurred in one eye with Best's disease.Literature review revealed a total of 42 cases with the most frequent etiologies being Presumed ocular histoplasmosis syndrome (POHS) and idiopathic CNV. Considering all cases together, mean CDVA improved from 1.00 ± 0.37logMAR to 0.52 ± 0.42 (p < 0.01). CNV recurrence occurred in 11 eyes (22.0%), 7 of which had an inflammatory etiology. Other complications included pigment epithelium tear, atrophy and retinal tear., Conclusion: Surgical removal of CNV is a viable, effective and safe option in children with persistent submacular neovascular membranes.

Purpose: To compare the clinical effects of postoperative versus perioperative injection of anti-vascular endothelial growth factor (VEGF) drugs before and after pars plana vitrectomy (PPV) in patients with vitreous hemorrhage secondary to polypoidal choroidal vasculopathy (PCV). Methods: This was a retrospective study of patients who underwent PPV due to vitreous hemorrhage between October 2013 and June 2019 at Ningbo Eye Hospital. The patients who underwent PPV surgery due to PCV-secondary vitreous hemorrhage were included. The primary outcome was the changes in best-corrected visual acuity. The secondary outcome was the central macular thickness. Results: Compared with the postoperative group ( n  = 20), the perioperative group ( n  = 18) showed a smaller number of postoperative anti-VEGF injections (5.1 ± 0.8 vs. 8.0 ± 1.5, P  < 0.05) and lower frequencies of early hyphema (5.6% vs. 30.0%, P  < 0.05), and recurrent vitreous hemorrhage (11.1% vs. 30.0%, P  < 0.05). The logarithm of minimal angle resolution (LogMAR) was smaller in the perioperative group compared with the postoperative group at 1 week, 1 month, and 3 months after PPV ( P  < 0.05), but there were no differences thereafter. Compared with the postoperative group, the perioperative group had thinner fovea at 1 week, 1 month, and 3 months ( P  < 0.05), but the differences disappeared after 3 months. Conclusion: In patients with PCV and vitreous hemorrhage, compared with postoperative anti-VEGF, perioperative anti-VEGF could reduce the difficulty of surgery and reduce the occurrence of postoperative complications, but there were no differences in long-term vision and macular thickness after surgery.

Purpose: To demonstrate whether pars plana vitrectomy (PPV) changes the progression of dry age-related macular degeneration (AMD) by assessing longitudinal changes in drusen volume over follow-up., Methods: Dry AMD patients who had undergone unilateral PPV for symptomatic vitreomacular disorders were evaluated for the progression of disease by spectral domain-optical coherence tomography (SD-OCT) features including drusen volume, development of geographic atrophy, or choroidal neovascularization during follow-up. Drusen volume was manually calculated using an image processing software (ImageJ, NIH) on raster SD-OCT scans. Mean change in drusen volume of surgery eyes was compared with values of the fellow eyes of the same subjects (control group)., Results: Among 183 eyes with both vitreoretinal disorder and dry AMD, 48 eyes of 24 patients met the inclusion criteria and were included. The mean drusen volume change during a mean of 25.49 ± 23.35 months of follow-up (range: 6.00-86.87 months) was 4.236.899 ± 20.488.913 μm 3 in the study eye and 7.796.357 ± 34.798.519 μm 3 in the fellow eye (p = 0.297). Best-corrected visual acuity (BCVA) significantly increased from 0.40 ± 0.18 logMAR (≈ 20/50 Snellen equivalent) to 0.32 ± 0.31 (≈ 20/41 Snellen equivalent) after surgery (p = 0.012) in the study group while BCVA remained stable in the control group (0.19 ± 0.34 logMAR [≈ 20/30 Snellen equivalent] at baseline and 0.20 ± 0.31 logMAR [≈ 20/31 Snellen equivalent], p = 0.432). Choroidal neovascularization developed in 1 vitrectomized eye (4.54%) and in 1 eye (4.54%) from the control group during follow-up., Conclusion: Vitrectomy did not seem to worsen dry AMD progression; even more visual acuity may improve despite a slight increase in drusen volume following surgery.

A 70-year-old woman presented with sudden decrease of vision 2 months following a successful vitrectomy with inverted internal limiting membrane flap for a full thickness macular hole. Serial review of fundus pictures and optical coherence tomography scans revealed a focal retinal pigment epithelial disruption at the site of the macular hole after surgery and a choroidal neovascular membrane arising from the same. This report describes the possible role of the surgical technique in causation of the membrane and discusses modifications to avoid the same., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: We reported a rare case of indirect choroidal neovascularization (CNV) secondary to a posterior-segment intraocular foreign body (IOFB) that was not located in the area of direct injury but in the fovea. After intravitreal injections (IVIs) of aflibercept, the choroidal neovascularization (CNV) lesion disappeared and vision improved., Case Presentation: A 26-year-old male patient suffered from a fast-shot metallic IOFB in his right eye. He underwent primary corneal repair, pars plana vitrectomy, IOFB removal and an IVI of antibiotics in the right eye. Two weeks later, cataract surgery was performed on the right eye for traumatic cataract after an episode of acute phacolytic glaucoma. The best-corrected visual acuity (BCVA) of the right eye improved to 20/20 5 months after the first surgery. However, the vision of the right eye worsened suddenly with metamorphopsia 1 year after the first surgery. Color fundus images showed a whitish lesion with faint retinal hemorrhage and surrounding sensory elevation. Fluorescein angiography (FA) revealed a lesion with early- and late-phase severe leakage. Optical coherence tomography (OCT) demonstrated a CNV lesion with surrounding subretinal fluid. The patient received an IVI of aflibercept every 8 weeks for 3 times. Finally, the BCVA of the right eye improved to 20/25., Conclusions: For rare cases of fovea-spared injury by a metallic IOFB, it is still necessary to pay close attention to the foveal microstructure to avoid possible CNV formation. Treatment with IVIs of anti-VEGF, aflibercept, as early as possible could provide good visual outcomes.

Purpose: There is an urgent need for a more effective intervention to slow or prevent progression of age-related macular degeneration (AMD) from its early stages to vision-threatening late complications. Subthreshold nanosecond laser (SNL) treatment has shown promise in preclinical studies and a pilot study in intermediate AMD (iAMD) as a potential treatment. We aimed to evaluate the safety of SNL treatment in iAMD and its efficacy for slowing progression to late AMD., Design: The Laser Intervention in Early Stages of Age-Related Macular Degeneration (LEAD) study is a 36-month, multicenter, randomized, sham-controlled trial., Participants: Two hundred ninety-two participants with bilateral large drusen and without OCT signs of atrophy., Methods: Participants were assigned randomly to receive Retinal Rejuvenation Therapy (2RT ® ; Ellex Pty Ltd, Adelaide, Australia) SNL or sham treatment to the study eye at 6-monthly intervals., Main Outcome Measures: The primary efficacy outcome was the time to development of late AMD defined by multimodal imaging (MMI). Safety was assessed by adverse events., Results: Overall, progression to late AMD was not slowed significantly with SNL treatment compared with sham treatment (adjusted hazard ratio [HR], 0.61; 95% confidence interval [CI], 0.33-1.14; P = 0.122). However, a post hoc analysis showed evidence of effect modification based on the coexistence of reticular pseudodrusen (RPD; adjusted interaction P = 0.002), where progression was slowed for the 222 participants (76.0%) without coexistent RPD at baseline (adjusted HR, 0.23; 95% CI, 0.09-0.59; P = 0.002), whereas an increased progression rate (adjusted HR, 2.56; 95% CI, 0.80-8.18; P = 0.112) was observed for the 70 participants (24.0%) with RPD with SNL treatment. Differences between the groups in serious adverse events were not significant., Conclusions: In participants with iAMD without MMI-detected signs of late AMD, no significant difference in the overall progression rate to late AMD between those receiving SNL and sham treatment were observed. However, SNL treatment may have a role in slowing progression for those without coexistent RPD and may be inappropriate in those with RPD, warranting caution when considering treatment in clinical phenotypes with RPD. Our findings provide compelling evidence for further trials of the 2RT ® laser, but they should not be extrapolated to other short-pulse lasers., (Copyright © 2018 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Polypoidal choroidal vasculopathy (PCV) is seen with polypoidal lesions and branching vascular networks (BVNs) (Spaide et al. in Retina 15(2):100-110, 1995; Yannuzzi et al. in Retina 10(1):1-8, 1990). There are reports about laser photocoagulation for PCV (Yuzawa et al. in Japan J Ophthalmol 47(4):379-384, 2003; Lee et al. in Eye 23(1):145-148, 2009); however, all these reports are about final vision and frequent relapses. Therefore, this treatment merits rigorous scrutiny using optical coherence tomography angiography (OCTA).

Purpose: To report an association between a Stage 4 full-thickness macular hole and focal choroidal excavation., Methods: Case report., Results: A 46-year-old male patient with high myopia was referred for macular hole surgery and found to have an associated focal choroidal excavation. The patient underwent uneventful combined procedure with closure of macular hole., Conclusion: Successful macular hole surgery can be achieved even in the presence of focal choroidal excavation.

Purpose: To investigate if the contiguity between native and transplanted retinal pigment epithelium (RPE) represents a protective factor against the progression of atrophy after autologous choroidal graft. In addition, the changes in fundus autofluorescence (FAF) in the contiguous and noncontiguous RPE areas were explored., Methods: The first postoperative reliable FAF image was selected and divided into sectors based on the characteristics of the RPE at the edge of the graft. The sectors were categorized into three groups: contiguous RPE, noncontiguous RPE, and not classifiable. The area of RPE atrophy, inside and outside the graft, was measured for each sector at baseline, one, three, and five years of follow-up. The FAF pattern outside the graft was evaluated for every sector at baseline and during the follow-up., Results: Nineteen patients met the inclusion criteria and were included in this study. Trend analysis showed that the atrophy progression outside the graft was statistically significant in areas where native and transplanted RPE were noncontiguous (P < 0.0001) yet not so in contiguous areas (P < 0.058). Inside the graft, both groups showed an increase in atrophy over time. In addition, the noncontiguous group developed more severe increased FAF patterns compared with the contiguous group., Conclusions: RPE contiguity after autologous choroidal graft seems to be a protective factor against atrophy progression, whereas any area of damaged or absent RPE tends to enlarge over time. This may suggest that the transplantation of an RPE sheet is more likely to be effective than an RPE cell suspension.

Objective: To assess how polypoidal choroidal vasculopathy (PCV) is recognized and treated, and to assess whether treatment outcomes are different between Chinese and Caucasian Canadian patients with age-related macular degeneration (AMD)., Design: Retrospective chart review., Participants: 154 eyes from 135 Chinese patients and 2291 eyes from 1792 Caucasian patients who were newly diagnosed with either AMD or PCV and had more than 1 year of follow-up were included., Methods: All newly diagnosed AMD patients presenting to the Retina Service of 3 Toronto University Hospitals, between March 25, 2008, to September 30, 2014, were reviewed., Results: 10/154 eyes (6.5%) in Chinese Canadians and 16/2291 eyes (0.7%) in Caucasian Canadians were diagnosed as having PCV. Indocyanine green angiography (ICGA) was used to diagnose PCV in 20% of Chinese Canadians and 8.8% of Caucasian Canadians. Clinical practices with a larger percentage of Chinese patients were more likely to diagnose PCV in both Chinese (p = 0.004) and Caucasian patients (p = 0.03), were more likely to use photodynamic therapy (PDT) (p < 0.01), and had significantly greater central retinal thickness decrease (p < 0.001)., Conclusion: Our study has shown that PCV is under-recognized in a Canadian population, and ICGA is underutilized. In clinical practices with a greater portion of Chinese patients, PCV is more often recognized and PDT is used more liberally., (Copyright © 2017. Published by Elsevier Inc.)

Purpose: To compare the outcome after choroidal neovascular (CNV) membrane excision and retinal pigment epithelium (RPE) transplantation and make further evaluation of two types of RPE grafts on the visual function in patients with neovascular age-related macular degeneration (AMD), complicated by massive subretinal haemorrhage., Methods: We retrospectively reviewed 80 patients who underwent CNV membrane excision with or without RPE transplantation. Two types of RPE grafts were adopted, RPE-Bruch's membrane complex graft (subgroup 1) and RPE monolayer sheet graft (subgroup 2). Outcome measures included pre- and postoperative visual acuity score (VAS), clinical findings, complications and recurrence rates., Results: The mean VAS [Early Treatment of Diabetic Retinopathy Study (ETDRS)] in the CNV membrane excision group was 11.06 ± 18.28 at baseline and 14.41 ± 16.86 at follow-up (p = 0.12) in a mean follow-up period of 24.35 ± 9.31 months. While in subgroup 1, VAS increased from 22.62 ± 23.72 to 35.50 ± 24.46 (p = 0.02) in a mean period of 20.63 ± 6.25 months. The percentage of visual acuity (VA) improvement (at least two or more lines changed) in subgroup 1 is 62.5%, which is significantly higher than that in CNV excision group (23.5%), p = 0.02. In subgroup 2, VAS increased from 16.61 ± 27.98 to 29.16 ± 23.80 (p = 0.02) in a mean period of 21.72 ± 11.09 months. The percentage of VA improvement in subgroup 2 is 58.0%, which is also significantly higher than that in CNV excision group (23.5%), p = 0.02. Postoperative VA elevation was comparable between the two subgroups (p = 0.05). Complications including retinal detachment, proliferative vitreal retinopathy and CNV recurrence occurred in both techniques. Central fixation stability was observed in eight eyes in subgroup 1 and five eyes in subgroup 2., Conclusions: The autologous RPE transplantation can increase the vision of patients with haemorrhagic AMD. Two types of autologous RPE grafts were both effective and comparable in restoring visual function and central fixation stability., (© 2016 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

We report a case of polypoidal choroidal vasculopathy (PCV) presented with massive submacular hemorrhage (SMH) and macular hole (MH). Spectral domain optical coherence tomography confirmed the presence of MH along with SMH and also revealed an extrafoveal-notched pigment epithelium detachment (PED) suggestive of PCV. Urgent pneumatic displacement with perfluoropropane (C3F8) was done. Indocyanine green angiography done 3 weeks later showed polyps in the superonasal macula corresponding to PED. Extrafoveal polyps were treated with laser photocoagulation. Inverted flap MH surgery was planned but the patient was lost to follow-up., Competing Interests: There are no conflicts of interest.

Purpose: To evaluate the long-term results of limited macular translocation (LMT) surgery with radial chorioscleral outfolding in patients with wet age-related macular degeneration (AMD) and subfoveal choroidal neovascularization (CNV). In addition, to identify the factors associated with the final best-corrected visual acuity (BCVA)., Methods: The medical records of 20 eyes of 20 consecutive patients (65.2±9.8 years) who had undergone LMT for the treatment of wet AMD and were followed for at least 5 years, were reviewed. The surgical outcomes including the BCVA, degree of foveal displacement, and complications were recorded., Results: The mean foveal displacement was 1332 ± 393 μm after the LMT. The CNV was removed in 16 eyes and photocoagulated in 4 eyes. The mean preoperative VA was 0.83 ± 0.33 logMAR units which significantly improved to 0.59 ± 0.37 logMAR units at 1 year after the surgery (P = 0.015). This BCVA was maintained at 0.59 ± 0.41 logMAR units on the final examination. The final BCVA was significantly correlated with that at 1 year after the surgery (r = 0.83, P<0.001). Multiple linear regression analysis showed that the final BCVA was significantly correlated with the BCVA at 1 year after the surgery (P<0.001), a recurrence of a CNV (P = 0.001), and the age (P = 0.022)., Conclusions: LMT improves the BCVA significantly at 1 year, and the improved BCVA lasted for at least 5 years. These results indicate that the impaired function of the sensory retina at the fovea can recover on the new RPE after the displacement for at least 5 years. The ability to maintain good retinal function on the new RPE for a long period is important for future treatments of CNVs such as the transplantation of RPE cells and stem cells.

Background: Polypoidal choroidal vasculopathy (PCV) is characterized by the presence of polyps with or without a branching vascular network and more prevalent among Asians. The aim of this study was to compare the outcomes of conbercept therapy between two different angiographic subtypes of PCV., Methods: Fifty-eight patients of PCV were classified into two phenotypes according to indocyanine green angiography (ICGA). In Type 1, both feeder and draining vessels are visible on ICGA and network vessels are numerous. In Type 2, neither feeder nor draining vessels are detectable, and the number of network vessels is small. The patients were treated with intravitreal conbercept (IVC) for 3 months. Additional IVC was given at subsequent monthly visits, if needed. The patients were followed up for 12 months, and changes in mean best-corrected visual acuity (BCVA), central retinal thickness (CRT), subretinal fluid (SRF) thickness, pigmented epithelial detachment (PED), hemorrhage, and number of polypoidal lesions were evaluated., Results: The mean BCVA in Type 2 PCV (15.92 ± 9.76 letters) achieved a significantly greater improvement than that in the Type 1 (14.10 ± 9.07 letters) at month 12 (t = 2.37, P< 0.01). Moreover, the mean CRT decrease was numerically greater in Type 2 (120.44 ± 73.81 μm) compared with Type 1 (106.48 ± 72.33 μm) at month 6 (t = 4.31, P< 0.01), and greater in Type 2 (130.21 ± 76.28 μm) compared with Type 1 (111.67 ± 79.57 μm) at month 9 (t = 1.87, P< 0.01). There was no significant difference between the two types for the decrease in SRF thickness, PED height, and regression of polyps from month 3 to 12 (t = 2.97, P > 0.05)., Conclusion: Classification systems for PCV will show differences in presentation, natural history, or response to anti-vascular endothelial growth factor treatment and might, therefore, provide a new key to the choice of treatment for the disease.

Purpose: To describe a successfully treated case of autologous retinal pigment epithelium and choroidal patch in a patient with choroidal neovascularization secondary to angioid streaks., Methods: A 53-year-old man with angioid streaks and a subfoveal choroidal neovascularization underwent autologous retinal pigment epithelium and choroid transplantation. Lensectomy, pars plana vitrectomy, 200° peripheral temporal retinotomy, isolation of the patch, endolaser, and silicone oil tamponade 1,000 cts were performed. Preoperative and postoperative ophthalmic examinations included best-corrected visual acuity, fluorescein angiography, indocyanine green angiography, autofluorescence, and optical coherence tomography., Results: Two months after surgery, best-corrected visual acuity (Snellen equivalent) improved from 20/200 to 20/100. At 6 months, best-corrected visual acuity further increased to 20/40 and the reading ability, which was absent preoperatively, improved to J2. Visual results were maintained after 2.5 years and no recurrence of choroidal neovascularization was observed., Conclusion: Transplantation of a full-thickness patch of retinal pigment epithelium and choroid under the fovea may be considered to prevent retinal atrophy with significant visual improvement in the case of a low active choroidal neovascularization secondary to angioid streaks. Moreover, preoperative optical coherence tomography might guide in highlighting those patients in whom the outer retinal layers are still visible as the best candidate for surgery.

The purpose of this study was to report the surgical outcomes after creating a 120° intentional giant retinal tear for use in removing hemorrhage and subretinal proliferative tissue in patients with polypoidal choroidal vasculopathy (PCV) or age-related macular degeneration (ARMD). This study involved 12 eyes of 12 patients (10 eyes: PCV, 2 eyes: ARMD). After removal of the lens in phakic eyes, we performed a vitrectomy with artificial posterior vitreous detachment. Subsequently, a 120° intentional giant retinal tear was created in the temporal periphery, the retina was then turned, and the subretinal hemorrhage and proliferative tissue were removed. In order to preserve as much of the retinal pigment epithelium (RPE) as possible, we used a bimanual technique under direct visualization. After stretching the retina by use of perfluorocarbon liquid (PFCL), we performed endophotocoagulation around the tear followed by PFCL/silicone oil exchange. Except for 1 eye in which extensive loss of the RPE occurred, the fundus findings and the visual acuity (VA) improved in all patients. In addition, postoperative VA improved to ≥20/50 in 3 eyes in which the macular RPE was preserved. This surgical procedure is an effective treatment for PCV or ARMD patients with extensive subretinal hemorrhage and proliferative tissue.

Purpose: To investigate the long-term outcome of full macular translocation (FMT) for neovascular age-related macular degeneration (AMD) and to identify predictive factors., Design: Retrospective, uncontrolled case series., Participants: Patients were considered for FMT if they had low vision in the fellow eye and choroidal neovascularization (CNV) along with (1) no response to vascular endothelial growth factor (VEGF) inhibitors, (2) retinal pigment epithelium (RPE) tear, (3) subretinal hemorrhage, (4) foveal scar tissue of recent onset, or (5) CNV before the availability of VEGF inhibitors. From 2004 through 2012, a total of 255 patients underwent FMT. Exclusion criteria were patients younger than 60 years, FMT for disease other than AMD, and a follow-up of less than 12 months., Methods: Preoperative, annual, and last distance best-corrected visual acuity (BCVA) were obtained retrospectively from patient files. Complications were recorded using funduscopy, optical coherence tomography, autofluorescence, and angiography., Main Outcome Measures: Distance BCVA at 1 year and 5 years after surgery and at last visit compared with preoperative BCVA., Results: One hundred fifty-eight patients (mean follow-up, 45 months) were included. Median BCVA improved from 0.90 logarithm of the minimum angle of resolution (logMAR) before surgery to 0.70 logMAR 1 year after FMT (2 lines gained; P = 0.000). In a subgroup of 56 patients followed up for 5 years or more, median BCVA improved from 0.95 logMAR before surgery to 0.70 logMAR 1 year after surgery, and remained improved 5 years after FMT with a median BCVA of 0.80 logMAR (1.5 lines gained compared with preoperative BCVA; P = 0.000). The main complications were foveal RPE atrophy (n = 73; 47%) and CNV recurrence (n = 47; 30%). Foveal RPE atrophy (odds ratio [OR], 7.0), CNV recurrence (OR, 2.6), and proliferative vitreoretinopathy (PVR; OR, 17.6) were statistically significant predictors (P < 0.05) for losing 1 line or more at last visit., Conclusions: In this study, BCVA was improved up to 5 years after FMT. Foveal RPE atrophy, CNV recurrence, and PVR carried a worse prognosis. In patients who are unlikely to benefit from VEGF inhibitors, FMT can be considered for second eyes with neovascular AMD., (Copyright © 2015 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

A 33-year-old man presented with vision loss in his right eye due to rhegmatogenous retinal detachment, for which he underwent pars plana vitrectomy with silicone oil injection. Three months later, the patient presented with sudden vision loss. On examination, his visual acuity was 20/200 with presence of subretinal haemorrhage with attached retina and silicone oil in situ. Fluorescein angiography confirmed the diagnosis of choroidal neovascularisation (CNV). The patient underwent intravitreal ranibizumab injection (0.5 mg per 0.05 mL). He subsequently underwent oil removal along with intravitreal bevacizumab injection (1.25 mg per 0.05 mL). The CNV completely regressed. At 7 years follow-up, the patient's best corrected visual acuity was 20/50 with attached retina and macular scar due to regressed CNV. His other eye was within normal limits throughout the follow-up period. This unique case demonstrates the successful outcome of intravitreal ranibizumab injection in a silicone oil-filled eye with myopic CNV., (2015 BMJ Publishing Group Ltd.)

Purpose: To investigate the role of vascular endothelial growth factor-A (VEGF-A) isoforms in neovascular age-related macular degeneration., Methods: Choroidal neovascular membranes (CNV) were excised in 24 patients, 8 of them underwent previous photodynamic therapy. All procedures were performed before anti-VEGF therapies were implemented in Germany. Normal human donor eyes served as controls. Messenger RNA expression of total VEGF-A and VEGF-A isoforms was measured., Results: Vascular endothelial growth factor-A121 is the most abundant isoform in CNV and control tissues. In controls, VEGF-A121 is lowest in neural retina and highest in choroids. For total VEGF-A and VEGF-A165, this is vice versa. VEGF-A165 and VEGF-A189 are significantly higher in CNV than in control choroids, the opposite is found for VEGF-A121. After photodynamic therapy, total VEGF-A and VEGF-A121 are increased, VEGF-A165 and VEGF-A189 are decreased. Age-dependently, there is an increase in VEGF-A165 and a decrease in VEGF-A121., Conclusion: Vascular endothelial growth factor-A isoforms are differentially distributed, suggesting that tissue-specific regulation of various isoforms is physiologically important. The disruption of this homeostasis in CNV membranes may be significant in the onset and progression of neovascular age-related macular degeneration. Our findings support the dominant role of VEGF-A121 in neovascular age-related macular degeneration but hint that VEGF-A165 may have an equivalent role in other neovascular retinal pathology.

Purpose: To report the utility of navigated laser (NAVILAS) in the treatment of leaking areas in central serous chorioretinopathy and a feeder vessel in choroidal neovascular membrane., Methods: Two patients with choroidal lesions were treated with NAVILAS. The first patient had central serous chorioretinopathy with visible leaking angiographic spots, and the second had choroidal neovascular membrane with a well-defined feeder vessel on angiography. Both patients underwent NAVILAS treatment., Results: Both patients were successfully treated with resolution of clinical symptoms after a single session of NAVILAS. In addition, complete resolution of the subretinal fluid and leakage, and the subretinal blood and feeder vessel, were noted in the central serous chorioretinopathy and feeder vessel cases, respectively., Conclusion: NAVILAS may be of utility in targeting choroidal vascular pathologies with laser.

Purpose: To evaluate low-voltage X-ray stereotactic radiotherapy (SRT) delivered in conjunction with intravitreal ranibizumab for the treatment of active macular polypoidal choroidal vasculopathy (PCV)., Methods: At baseline, all eyes received an intravitreal injection of ranibizumab, followed by 16-Gy X-ray SRT to the macula. Further ranibizumab injections were given pro re nata. The primary outcome measure was regression of the polyps assessed by indocyanine green angiography. Secondary outcome measures were best-corrected visual acuity (BCVA) and central foveal thickness (CFT) changes on optical coherence tomography. Local or systemic adverse events were evaluated as well., Results: We examined 12 eyes of 12 patients with PCV. At month 12, an angiographic regression of the polyps was observed in 10 of the 12 eyes. The mean BCVA improved by 7.6 letters: from 65.08 ± 11.4 to 72.7 ± 14.75 letters on the Early Treatment Diabetic Retinopathy Study (ETDRS) chart. The mean CFT decreased from 372.3 ± 79.6 to 215.9 ± 57.9 µm (p < 0.01). No local or systemic adverse events were reported., Conclusions: The preliminary data support the safety of low-voltage X-ray SRT for the treatment of macular PCV and show polyp closure, reduction in CFT and improvement in the mean BCVA. Additional research is warranted to confirm the efficacy and longer-term safety of this therapy in this population., (© 2014 S. Karger AG, Basel.)

Aim: To examine the long-term outcomes of full macular translocation (FMT) for myopic choroidal neovascularisation (mCNV)., Methods: We evaluated a consecutive case series of 60 eyes with mCNV that underwent FMT. We assessed the best-corrected visual acuity (BCVA), fundus photographs and fluorescein angiography images, and evaluated the anatomic and visual outcomes., Results: The mean follow-up period was 76.3 months. The macula was relocated successfully in all eyes. The mean distance of macular translocation was 2842 μm. The baseline BCVA was 0.78 logarithm of the minimum angle of resolution (logMAR) unit; the logMAR BCVA values at 1, 3 and 5 years postoperatively significantly (p<0.001) improved to 0.54 at 1 year and then remained stable. The new fovea was associated with enlargement of the myopic chorioretinal atrophy in 19 (31.7%) eyes. Subfoveal or juxtafoveal CNV at the translocated new fovea developed in five (8.3%) eyes., Conclusions: FMT for mCNV maintained the improvement in VA for more than 5 years. However, postoperative complications and progression of chorioretinal atrophy due to myopia still seem to limit the visual improvement after FMT for mCNV., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Purpose: To evaluate the long-term visual outcomes of pars plana vitrectomy (PPV) for polypoidal choroidal vasculopathy (PCV)-associated vitreous haemorrhage (VH)., Method: We retrospectively reviewed the records of patients with PCV-related VH who underwent PPV. The main outcome measures were best-corrected visual acuity (BCVA) and fundus findings at 3 months postoperatively and final visit., Results: Seventeen eyes of 17 patients with massive subretinal haemorrhage (16.7±7.1 disc size of mean subretinal haemorrhage area) were enrolled. The mean postoperative follow-up period was 25.2 months. Four eyes received intravitreal bevacizumab injections, and three eyes underwent photodynamic therapy before the onset of VH. The mean BCVA improved from logarithm of the minimum angle of resolution (LogMAR) of 2.63±0.57 preoperatively to 1.43±0.82 at final visit (P<0.001). Among the eyes with initial polyps at subfoveal or juxtafoveal area, 16.70% achieved final BCVA ≥20/400 (LogMAR 1.3), whereas 87.50% of eyes with initial polyps at extrafoveal area had final BCVA ≥20/400 (Fisher's exact test, P=0.026)., Conclusions: PCV with massive subretinal haemorrhage is at risk for breakthrough VH. The visual prognosis in eyes with PCV-related breakthrough VH is variable after vitrectomy. Initial polyps at the extrafoveal area led to better functional outcomes. Early vitrectomy may be beneficial for visual recovery after PCV-related VH.

The purpose of this study was to review the 12-year visual outcomes of patients who underwent surgical removal for subfoveal choroidal neovascularization (CNV) attributable to pathologic myopia. This retrospective study included 14 patients, with a mean age of 45.8 years, high myopia (>6 D) and classic subfoveal CNV. They were treated with pars plana vitrectomy and surgical removal of CNV. All patients were followed up every 3 months for 2 years, with visual acuity (VA), fundus examination, and fluorescein angiography and then every year for 5 years. Ten patients underwent a final visit with VA and fundus examination after a minimum 12-year follow-up. The main outcome measurement was VA and the secondary outcome measurement was the lesion size. After 12 years of follow-up, the mean VA did not significantly change over time, with a mean gain of 0.22 logMAR at 1 year, and 0.18, 0.12 and 0.05 at 2, 5 and 12 years, respectively. The anatomical evolution was characterized by a significant enlargement of the lesion size at 5 years. This study showed that final VA after surgical treatment with 12 years of follow-up was poor, due to the significant CNV scar enlargement over time. These results should prompt a prospective randomized study of other medical treatments, particularly anti-vascular endothelial growth factor therapy.

Purpose: To evaluate the long-term outcome of autologous simple RPE sheet transplantation in patients with simultaneous massive submacular hemorrhage and pigment epithelium detachment (PED)., Methods: Fourteen patients with 10 occult AMD eyes and 4 PCV eyes underwent a surgical procedure including a 180° peripheral temporal retinotomy, choroidal neovascular membrane (CNVM) excision, and transplantation of an autologous simple RPE sheet developed from the PED region outside the CNVM lesion. Best-corrected visual acuity, multifocal ERG, and microperimetry were recorded to evaluate macular function. Optical coherence tomography, fundus fluorescein angiography, and an RPE autofluorescence test were performed to observe the status of the transplanted simple RPE sheet., Results: Mean follow-up duration was 24 ± 6 months. Mean ETDRS score increased from 14.0 ± 23.4 preoperatively to 31.9 ± 23.8 at 18 months postoperatively (P < 0.05). Of 14 eyes, 5 (36%) presented with central fixation postoperatively, whereas only 3 (21%) eyes presented with central fixation preoperatively. Ten grafts (71%) showed normal RPE color. Postoperative complications included one (7%) retinal detachment due to proliferative vitreoretinopathy and one (7%) delayed recurrent submacular hemorrhage., Conclusions: Transplantation of an autologous simple RPE sheet for eyes with massive submacular hemorrhage associated with PED was achieved with a simplified surgical procedure, resulting in increased postoperative visual acuity.

We performed a study of the two clinical entities with a differential diagnosis with wet age-related macular degeneration, namely, idiopathic polypoidal choroidal vasculopathy (IPCV) and retinal angiomatous proliferation. We analyze the clinical and funduscopic characteristics of these entities as well as their differences with wet age-related macular degeneration. We present two cases that are representative of these two entities. The therapeutic possibilities, results and the latest publications are analyzed and compared. A statistical analysis of the latest publications is also presented., (Copyright © 2012 Sociedad Española de Oftalmología. Published by Elsevier Espana. All rights reserved.)

Purpose: The study aim is to describe the clinical outcomes of patients with polypoidal choroidal vasculopathy (PCV) treated with focal argon laser photocoagulation and ranibizumab combination therapy., Methods: This study is a retrospective case series of 6 patients (6 eyes) diagnosed with PCV who received combination therapy with argon laser photocoagulation and ranibizumab and have at least 12 months follow-up. Argon laser photocoagulation was applied directly to the polypoidal lesions as identified on indocyanine green angiography and followed by a course of intravitreal ranibizumab injections. The primary outcome measures were the mean change in logMAR visual acuity and the mean change in central macular thickness (CMT) at final follow-up., Results: The mean (SD) duration of follow-up was 1.09 (0.22) years. At the final follow-up the difference (95% confidence interval [CI]) in logMAR acuity was 0.48 (0.10-0.74) (p=0.01) and the difference (95% CI) in CMT was 207 µm (35-490) (p=0.02) on optical coherence tomography. The mean (SD) number of ranibizumab injections per eye was 4.83 (3.6). The mean (SD) number of laser treatments per eye was 1.16 (0.4)., Conclusions: In this study, combination therapy with focal argon laser photocoagulation and intravitreal ranibizumab resulted in improved visual acuity and clinical outcomes for patients with PCV for up to 1 year.

Neovascularization is a common pathological process in various retinal vascular disorders including diabetic retinopathy (DR), age-related macular degeneration (AMD) and retinal vein occlusion (RVO). The development of neovascular vessels may lead to complications such as vitreous hemorrhage, fibrovascular tissue formation, and traction retinal detachments. Ultimately, irreversible vision loss may result. Various proangiogenic factors are involved in these complex processes. Different antiangiogenic drugs have been formulated in an attempt treat these vascular disorders. One factor that plays a major role in the development of retinal neovascularization is vascular endothelial growth factor (VEGF). Anti-VEGF agents are currently FDA approved for the treatment of AMD and RVO. They are also extensively used as an off-label treatment for diabetic macular edema (DME), proliferative DR, and neovascular glaucoma. However, at this time, the long-term safety of chronic VEGF inhibition has not been extensively evaluated. A large and rapidly expanding body of research on angiogenesis is being conducted at multiple centers across the globe to determine the exact contributions and interactions among a variety of angiogenic factors in an effort to determine the therapeutic potential of antiangiogenic agent in the treatment of a variety of retinal diseases.

Purpose: To evaluate the changes in the best-corrected visual acuity (BCVA) after 1 year and after ≥ 5 years after macular translocation for age-related macular degeneration (AMD) or myopic choroidal neovascularisation (mCNV)., Methods: The medical records of 61 consecutive patients who underwent macular translocation with 360° retinotomy for AMD (35 eyes) or mCNV (26 eyes) were reviewed. Overall, 40 patients, 17 mCNV and 23 AMD, were followed for at least 5 years. BCVA and area of the Goldmann visual field (VF) measured before, 12 months after surgery, and at the final visit., Results: In the 23 AMD eyes followed for ≥ 5 years, the mean preoperative BCVA was 1.149 ± 0.105 logMAR units, which significantly improved to 0.69 ± 0.06 logMAR units at 1 year (P<0.001). This BCVA was maintained at 0.633 ± 0.083 logMAR units on their final examination. In the 17 eyes with mCNV followed for ≥ 5 years, the mean preoperative BCVA was 1.083 ± 0.119 logMAR units, which was significantly improved to 0.689 ± 0.121 logMAR units at 1 year (P = 0.001). This BCVA was maintained at 0.678 ± 0.142 logMAR units on their final examination. The area of the VF was significantly decreased at 12 months and did not change significantly thereafter., Conclusions: Our results show that macular translocation surgery significantly improves the BCVA and significantly decreases the VF area of eyes with mCNV or AMD after first 1 year. The BCVA and VF area do not change significantly from the values at 1 year for at least 5 years.

Background: To compare the efficacy of thermal laser photocoagulation versus intravitreal ranibizumab for the treatment of extrafoveal classic choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD)., Methods: We conducted a retrospective study on 24 eyes with extrafoveal classic CNV secondary to AMD, treated either with thermal laser photocoagulation (group 1) or with intravitreal ranibizumab (group 2). Visual acuity, number of injections/sessions and recurrence rate were assessed., Results: The mean follow-up time was 23.6 ± 2.26 and 19.1 ± 9.74 months for group 1 and 2, respectively. Mean best corrected visual acuity (BCVA) of groups 1 and 2 was 0.59 ± 0.32 and 0.46 ± 0.30 logMAR, respectively (p = 0.343). At the end of the follow-up, mean BCVA of group 1 was 0.92 ± 0.35 and of group 2 0.16 ± 0.12 logMAR and differed statistically compared to baseline (p = 0.02 and p = 0.006, respectively). There was a statistically significant difference between the two groups as far as BCVA at the end of the follow-up was concerned (p < 0.0001). The patients in group 1 received on average 1.38 sessions of thermal laser photocoagulation, while patients in group 2 received on average 4 injections of ranibizumab. The recurrence rate in the laser group was 84.6%, while in the ranibizumab group it was 18.2% (p < 0.001). Specifically, the mean time of recurrence in the laser group was 11.5 months, whereas in the ranibizumab group it was 18 months (p = 0.048)., Conclusion: Intravitreal ranibizumab showed promising results in BCVA improvement and decrease in macular thickness in patients with extrafoveal classic CNV due to AMD, with a small number of injections. Laser photocoagulation treatment presented worsening in BCVA and high recurrence rate in our study with long-term follow-up., (Copyright © 2012 S. Karger AG, Basel.)

Purpose: Precise monitoring of active angiogenesis in neovascular eye diseases such as age-related macular degeneration (AMD) enables sensitive use of antiangiogenic drugs and reduces adverse side effects. So far, no in vivo imaging methods are available to specifically label active angiogenesis. Here, we report such a technique using fluorophore-labeled cationic liposomes (CL) detected with a standard clinical in vivo scanning laser ophthalmoscope (SLO)., Methods: C57Bl/6 mice underwent laser coagulations at day 0 (d0) to induce choroidal neovascularization (CNV). Liposomes labeled with Oregon green, rhodamine (Rh), or indocyanine green (ICG) were injected into the tail vein at various time points after laser coagulation, and their fluorescence was observed in vivo 60 min later using an SLO, or afterwards in choroidal flatmounts or cryosections., Results: SLO detected accumulated fluorescence only in active CNV lesions with insignificant background noise. The best signal was obtained with CL-ICG. Choroidal flatmounts and cryosections of the eye confirmed the location of retained CL in CNV lesions. Neutral liposomes, in contrast, showed no accumulation., Conclusions: These results establish fluorophore-labeled CL as high affinity markers to selectively stain active CNV. This novel, non-invasive SLO imaging technique could improve risk assessment and indication for current intraocular antiangiogenic drugs in neovascular eye diseases, as well as monitor therapeutic outcomes. Labeling of angiogenic vessels using CL can be of interest not only for functional imaging in ophthalmology but also for other conditions where localization of active angiogenesis is desirable.

Background: The aim of this study was to evaluate retrospectively the clinical outcome of retinal photocoagulation of age-related juxtapapillary choroidal neovascularisation (CNV) with macular oedema. Juxtapapillary CNV represents a rare form of extrafoveal CNV in age-related macular degeneration (AMD)., Patients and Methods: In 15 eyes of 14 patients with age-related juxtapapillary choroidal neovascularisation, CNV was treated with several rows of frequency doubled Nd:YAG laser (532 nm) irradiation to protect the fovea. Classification of the CNV was performed with fluorescein angiography. Best corrected visual acuity was determined before and after photocoagulation. Follow-up time was 1 - 32 months., Results: In 13 eyes the juxtapapillary CNV was occult (87 %), one eye had a classic, one eye a minimally classic form. In 13 eyes (87 %) the centre of the fovea showed macular oedema in spite of the extrafoveal location of the CNV. Of these 13 eyes, in 10 eyes (77 %) visual acuity increased after photocoagulation. 7 eyes (53 %) had an increase in visual acuity of 1 or 2 lines, 3 eyes of ≥ 4 lines. 2 eyes showed a stable visual acuity, in 1 eye visual acuity deteriorated after photocoagulation. In 2 eyes without foveal involvement of macular oedema, CNV was located in the papillo-macular bundle and threatened the centre of the fovea. Postoperative visual acuity in theses eyes was stable after 1 and 5 months., Conclusion: The therapeutic benefit of photocoagulation of juxta- and extrafoveal classic CNV has already been proven. According to our results, photocoagulation is an effective therapeutic approach in the treatment of age-related juxtapapillary CNV especially, in the occult form, when the fovea is threatened by or involved in the macular oedema., (© Georg Thieme Verlag KG Stuttgart · New York.)

Macrophages can be polarized to exhibit either pro-inflammatory M1 or pro-angiogenic M2 phenotypes, but have high phenotypic plasticity. This pilot study investigated macrophage polarization in the macular retina and choroid of age-related macular degeneration (AMD) and non-AMD subjects, as well as in AMD choroidal neovascular membranes (CNVM). All specimens were evaluated for routine histopathology. Quantitative real-time polymerase chain reaction for representative M1 (CXCL11) and M2 (CCL22) transcripts were performed on macular choroidal trephines (MCT) of 19 AMD and nine non-AMD eye bank eyes, on the microdissected macular retinal cells from the archived slides of five geographic atrophic AMD, five exudative/neovascular AMD, and eight normal autopsied eyes, and on microdissected inflammatory cells from two surgically removed CNVM that did not respond to anti-vascular endothelial growth factor (VEGF) therapy. High M2-chemokine transcript and a low ratio of M1 to M2 chemokine transcript were found in aging non-AMD MCT. Advanced AMD maculae had a higher M1 to M2 chemokine transcript ratio compared to normal autopsied eyes. Macrophages in the two CNVM of patients unresponsive to anti-VEGF therapy were polarized toward either M1 or M2 phenotypes. The number of M2 macrophages was increased compared to M1 macrophages in normal aging eyes. A pathological shift of macrophage polarization may play a potential role in AMD pathogenesis., (© 2011 US Government. Pathology International © 2011 Japanese Society of Pathology and Blackwell Publishing Asia Pty Ltd.)

Purpose: To directly assess the recovery of the retina overlying choroidal neovascularization in neovascular age-related macular degeneration and to understand the relationship between macular sensitivity and visual functional measures and retinal structural alterations as predictive factors for outcome among eyes undergoing macular translocation surgery (MT360)., Methods: In a prospective, consecutive case series of 55 patients with subfoveal choroidal neovascularization undergoing MT360, we explored the relationship between macular sensitivity on the Nidek microperimeter-1 with pathologic features on optical coherence tomography and with distance and near visual acuity, reading speed, contrast sensitivity, color vision, and National Eye Institute Visual Function Questionnaire-25 composite quality-of-life (QOL) score, both before and at 1 year after MT360., Results: On average, there was improvement in all measures of visual function, macular sensitivity, and QOL after MT360. Preoperative median retinal sensitivity score did not predict postoperative measures of visual function, macular sensitivity, and vision-related QOL. Correlation between preoperative median retinal sensitivity score and preoperative measures of visual function and vision-related QOL was generally poor, excepting modest correlation for contrast sensitivity and color vision. However, correlation between postoperative median retinal sensitivity score and postoperative measures of visual function and vision-related QOL was uniformly modest, and change in median retinal sensitivity score correlated modestly with change in most measures of visual function and QOL. Among optical coherence tomography morphologic features, preoperative retinal pigment epithelium elevation predicted reduced postoperative contrast sensitivity (P = 0.04), while preoperative epiretinal membrane or vitreomacular traction predicted increased postoperative contrast sensitivity (P = 0.05). Preoperative cystoid macular edema, subretinal fluid, and subretinal lesion were associated with decreased median retinal sensitivity score (P values ≤0.03)., Conclusion: The authors' findings demonstrate the resilience and recovery of poorly functioning retina in neovascular age-related macular degeneration but fail to demonstrate a role for macular sensitivity as measured by Nidek microperimeter-1 in identifying irreversibly damaged retina that would not benefit from MT360.

Choroidal neovascularization (CNV) and geographic atrophy (GA) are serious and potentially devastating complications of age-related macular degeneration (AMD), a leading cause of blindness in the developed world. While anti-vascular endothelial growth factor (VEGF) therapies have emerged as the current standard treatment of choice for choroidal neovascularization, the requirement for indefinite injections places a tremendous burden on physicians and patients, and may have disappointing outcomes in hemorrhagic neovascular AMD. No superior agents exist to treat large subretinal hemorrhage and geographic atrophy. Over the years, several vitreoretinal surgical approaches have been developed to treat macular degeneration, and these surgical options may still play a role in the management of specific complications of AMD. This review summarizes the principles, techniques, and results of surgical treatments for neovascular and non-neovascular age-related macular degeneration, with emphasis on submacular surgery for removal of CNV, full and limited macular translocation, retinal pigment epithelium, and choroid transplants as well as treatment of thick subretinal hemorrhage.

Aims: To evaluate the outcome after two types of retinal pigment epithelium (RPE) transplantation techniques., Methods: Fourteen consecutive patients with advanced exudative age-related macular degeneration (AMD) were randomly assigned to RPE-choroid sheet transplantation (group 1) or RPE cell-suspension transplantation (group 2). Outcome measures included best corrected distance and near visual acuity (BCVA), complication and recurrence rates, autofluorescence (AF), angiography, and time-domain and spectral-domain optical coherence tomography (TD- and SD-OCT)., Results: A gain of three or more lines in BCVA at 24&emsp14;months was found in two patients in group 1 and in one patient in group 2, whereas a loss of vision of three or more lines occurred in one patient in each group. Revision surgery for proliferative vitreoretinopathy was required in one patient in group 1. Epiretinal membranes developed in two patients in group 1 and in one patient in group 2. No recurrence occurred in this series. AF showed hyperfluorescence coincident with the graft in group 1, and hyper- and hypofluorescence in irregular patterns in group 2. Revascularisation of the graft was present in all patients in group 1, and a normal choroidal vasculature in the area of RPE atrophy in all patients in group 2. OCT showed a decrease in retinal thickness in all patients, with an improved visualisation of inter- and intralaminar structures with SD-OCT., Conclusion: The anatomical and functional outcome after both RPE transplantation techniques was comparable. Intrastructural irregularities of the sheet assessed using SD-OCT might explain the rather limited visual gain in otherwise successful sheet transplants. Clinical Trial Registration NCT00401713.

Purpose: This review summarizes the data reported in peer-reviewed literature on the effects of submacular surgery for age-related macular degeneration (AMD) associated with choriodal neovascularization (CNV)., Methods: A review of the MEDLINE database has been performed in order to examine the therapeutic effects of submacular surgical treatments in patients affected by AMD., Results: The multicenter studies conducted by the Submacular Surgery Trials Research Group compare the removal of the CNV complex, both with (336) and without blood (454), with observation in patients affected by AMD. At a 1-year follow-up, no benefit in preventing visual loss had been shown. Furthermore, complications occurred in the surgery arm such as retinal detachment and lens opacification. No differences have been found between submacular surgery and laser photocoagulation in terms of visual acuity and quality of life. As yet, there are no randomized controlled trials concerning retinal pigment epithelium and choroid translocation or macular translocation, but only prospective, non-controlled case series with low quality of evidence., Conclusions: No evidence of potential benefit from submacular removal of the CNV complex due to AMD has been shown. Randomized clinical trails (RCT) concerning other submacular surgical approaches are not available. There are sufficient non-comparative data on retinal pigment epithelium (RPE) graft to warrant an RCT especially in patients with large subretinal haemorrhages, RPE rip or in Anti-VEGF non-responders.

Background/aims: Long-term data of macular translocation for choroidal neovascularisation (CNV) secondary to age-related macular degeneration is lacking. Therefore, we describe the 3-year acuity outcomes., Methods: This is a retrospective, interventional case series consisting of 40 consecutive patients who underwent translocation between 2003 and 2008. Best-corrected visual acuity (BCVA) at the most recent follow-up visit was compared to that of the 1 year and pre-operative visits. Delayed post-operative complications were recorded, as diagnosed by clinical examination, spectral-domain optical coherence tomography, fundus autofluorescence imaging and angiography., Results: The mean (range) follow-up duration was 37.6 months (range 12.4-67.4 months). Median BCVA values were 0.80, 0.70 and 0.78 log(MAR) at the baseline, 1 year and most recent visits (p=0.13). A three-line gain in BCVA was seen in 12 (30%) patients at 1 year and 10 (25%) patients at the last observation. Twenty-seven (68%) patients achieved a BCVA of 6/60 or better and six (15%) patients, 6/12 or better at the final visit. In the subset of the cohort followed for two or more years, 24 of 32 patients (75%) achieved a BCVA of 6/60 at 1 year but six of these (25%) lost two lines of BCVA thereafter due to recurrent CNV, idiopathic macular oedema, macular hole or macular pucker. Recurrent CNV developed in nine patients (23%) within the first 2 years and their final mean VA was 6/30., Conclusions: With close post-operative monitoring and early treatment of delayed complications, 25% of this cohort maintained a three-line gain in acuity at 3 years after macular translocation.

Purpose: To report the frequency and origins of increased fundus autofluorescence (AF) in age-related macular degeneration using the model of macular translocation., Methods: In this retrospective observational case series, postoperative serial fundus AF images from 40 consecutive patients were examined. The origin of well-delineated increased AF changes was explored by examining simultaneous spectral-domain optical coherence tomography (SD-OCT) scans and coregistered microperimetry., Results: AF images were taken between a mean of 13 and 36 months. Seven patients were excluded from analysis because of lack of postoperative AF imaging or extensive macular RPE atrophy. Of the remaining patients, 9 had masking pattern of foveal AF, 21 had small, round increased AF lesions in the fovea, and 3 had a near normal pattern of foveal hypo-AF. Parafoveal increased AF was seen in all 33 patients in 1 of 3 patterns: well-delineated homogenous increased AF patches (17), curvilinear increased AF bands (4), and speckled increased AF (12). Simultaneous SD-OCT showed loss of signal from the interface of the inner and outer segments of the photoreceptor cell layer with variable loss of outer nuclear layer thickness. Microperimetry showed subnormal retinal sensitivity in regions with increased AF. Parafoveal increased AF size remained stable for 2 to 5 years of follow-up., Conclusions: SD-OCT and microperimetry changes observed after translocation may be attributed to shortening of the outer segments. A corresponding reduction of visual pigment in the shortened outer segments may lead to an unmasking effect. Increased AF in some macular diseases may be attributed to unmasking of AF rather than to increased fluorophores within abnormal retina.

Purpose: To report the clinical and pathologic features of an idiopathic choroidal neovascular membrane (CNVM) in a 21-month-old child and to discuss the unique findings of infantile CNVM in the context of understanding the mechanism of membrane formation., Methods: The CNVM was removed by submacular surgery. Light and electron microscopic tissue analyses were used to elucidate the structure and constituents of the CNVM., Results: Postoperative vision was 20/60 at 10 months without evidence of recurrence. Endothelium-lined vascular channels were observed within a membrane composed entirely of retinal pigment epithelial (RPE) cells with an associated fibrocollagenous and amorphous matrix. No inflammatory cells were identified. The RPE cells toward the inner (photoreceptor) side of the membrane exhibited a less-differentiated appearance, having lost their polarity and most of their cytoplasmic melanin granules. They secreted more prominent fibrils and mucopolysaccharides. Fenestrated endothelial cells surrounded by pericytes were present between the proliferating RPE cells., Conclusions: Submacular surgery can be beneficial for idiopathic CNVM in pediatric patients, even at this early age. Proliferating RPE cells in the current membrane appear to be capable of performing all of the necessary functions associated with membranogenesis, even in the absence of inflammatory cells.