Kristel Johanna Maria Maaijwee

A Free Retinal Pigment Epithelium–Choroid Graft in Patients With Exudative Age-Related Macular Degeneration: Results up to 7 Years

PURPOSE To report and analyze long-term best-corrected visual acuity (BCVA) outcomes following a free autologous retinal pigment epithelium (RPE)-choroid graft translocation in patients with exudative age-related macular degeneration (AMD). DESIGN Prospective cohort study. METHODS SETTING Institutional. STUDY POPULATION One hundred and thirty consecutive patients (133 eyes) with AMD underwent RPE-choroid graft translocation between October 2001 and February 2006. All patients had a subfoveal choroidal neovascular membrane with or without hemorrhage and/or an RPE tear. All were either ineligible for or nonresponsive to photodynamic therapy, the standard treatment at the time of surgery. OBSERVATION PROCEDURES Data collection included preoperative and postoperative visual acuity measurements, fundus photography, fluorescein and indocyanine green angiography, and microperimetry. MAIN OUTCOME MEASURES Postoperative BCVA. RESULTS The mean preoperative BCVA was 20/250. Four years after surgery, 15% of the eyes had a BCVA of >20/200, and 5% had a BCVA of ≥20/40. One patient achieved a BCVA of 20/32, which was maintained at 7 years after surgery. Complications consisted of proliferative vitreoretinopathy (n = 13), recurrent neovascularization (n = 13), and hypotony (n = 2). CONCLUSIONS RPE-choroid graft transplantation may maintain macular function for up to 7 years after surgery, with relatively low complication and recurrence rates. Retinal sensitivity, BCVA data, and fixation on the graft suggest that the graft, rather than simply the removal of submacular hemorrhage and/or choroidal neovascular membrane, was responsible for the preservation of macular function. This surgery may be an alternative for patients with AMD who cannot undergo other standard treatment.

Autologous translocation of the choroid and RPE in age-related macular degeneration: 1-year follow-up in 30 patients and recommendations for patient selection

AimTo evaluate the long-term (1 year) functional and anatomical outcome of autologous translocation of peripheral choroid and retinal pigment epithelium (RPE) in 30 patients with age-related macular degeneration (AMD).MethodsAfter the extraction of the neovascular complex, an autologous peripheral full-thickness graft of RPE and choroid was positioned under the macula. Functional tests included ETDRS vision, reading (Radner test), and microperimetry (scanning laser ophthalmoscope). Fluorescein, indocyanine green angiography, and autofluorescence were monitored.ResultsPreoperative visual acuity ranged from 20/40 to 20/800 (0.3–1.6 log MAR). Vision ranged from 20/25 to LP (0.1–2.1 log MAR) 1 year after surgery, with stabilization in six eyes, an increase in five eyes, and a decrease in 19 eyes. Deterioration mostly occurred within the first 3 months after surgery. In patients who demonstrated vascularization of the graft after 3 months, this persisted up to 12 months as did fixation when initially stable. Autofluorescence decreased significantly from 6 to 12 months postoperatively. Eleven cases showed a recurrence of choroidal neovascularization (CNV) within this period.ConclusionPatch translocation results in a viable graft. There is no evidence of graft failure within a 1-year follow-up. Nevertheless, there is risk for late CNV formation originating from the edges of the excision side of the CNV and growing peripheral to the graft.

Reliability testing of the Dutch version of the Radner Reading Charts.

Purpose. To statistically analyze the test-retest and inter-chart reliability of the newly developed actual logarithmically scaled Dutch Radner Reading Charts in an older population affected by macular disease. These Dutch Radner Reading Charts are developed according to the strict principles of sentence construction of the originally German language Radner Reading Charts. Methods. Thirty-six subjects aged 50 years or older and affected with a macular disease monocularly read the three charts of the Radner Reading Charts in a randomized order twice with 1 month in between. The subjects were divided into three groups according to their distance logMAR visual acuity (group 1, ≥0.1; group 2, 0.12 to 0.4; and group 3, 0.42 to 0.8). Reading acuity (logRAD, the reading equivalent of logMAR), logRAD score, maximum reading speed, critical print size, and logRAD/logMAR ratio were measured. Variance component analysis was used to determine the sources of variability. Results. The test-retest and inter-chart reliability was high for all visual acuity groups and variables. For all groups together the chart accounted for maximal 5% of the total variability for all measurements. The individual subject did have the largest influence on the measurements (88 to 98% of the variability). Conclusions. The Dutch version of the Radner Reading Charts provided high reliable test-retest and inter-chart measurements of reading performance in a heterogeneous group of subjects with subnormal to low vision. This study also showed that the strict principles of sentence construction of the originally German Radner Reading Charts may also be successfully used for other languages.

Retinal pigment epithelium (RPE)–choroid graft translocation in the treatment of an RPE tear: preliminary results

Aim: To investigate whether retinal pigment epithelium (RPE)–choroid translocation would be a suitable treatment for RPE tears, which have a poor prognosis and are encountered more often since the introduction of anti-(vascular endothelial growth factor (VEGF)) therapy for exudative age-related macular degeneration (AMD). Methods: Prospective interventional case series of six eyes of six patients with AMD with an RPE tear treated with an RPE–choroid translocation. The RPE tear occurred in a vascularised pigment epithelium detachment in four patients and after treatment in the other two. Preoperative and postoperative evaluation included ETDRS visual acuity (VA) and fixation testing. The follow-up period ranged from 6 months to 2 years. Results: The mean preoperative VA was 20/160 (range 20/400–20/80). The mean VA at the last examination after surgery was 20/80 (range 1/60–20/50). One of the six patients had a preoperative VA of ⩾20/80, and four had a VA of 20/80 or better at their last examination. Foveal fixation on the graft was present in five of the six eyes up to the last examination. Conclusion: These preliminary data show that an RPE–choroid translocation may be a treatment option for patients with an RPE tear.

Histological evidence for revascularisation of an autologous retinal pigment epithelium–choroid graft in the pig

Background: Translocation of a free autologous graft consisting of retinal pigment epithelium (RPE), Bruch’s membrane, choriocapillaris and choroid in patients with exudative age-related macular degeneration is currently being evaluated in clinical practice. Angiographic studies in these patients suggest that their grafts become revascularised. Aim: To investigate the histological evidence of revascularisation of the graft in a porcine model. Methods: In 11 pigs (11 eyes), an RPE–choroid graft was translocated from the mid-periphery to an intact or an intentionally damaged RPE and Bruch’s membrane at the recipient site. The eyes were enucleated 1 week or 3 months after surgery. Tissue sections were evaluated using immunohistochemistry. Results: Bridging vessels between recipient layer and graft were identified from 1 week to 3 months after surgery. This reconnection occurred regardless of whether the Bruch’s membrane of the recipient site was left intact or intentionally damaged at the time of transplantation. The vasculature of the graft appeared open and perfused. Vessels with transcapillary pillars and conglomerates of small new vessels were present in the graft. Conclusions: This study showed histological evidence for revascularisation by angiogenesis of a free autologous RPE–choroid graft.

Influence of intraoperative course on visual outcome after an RPE-choroid translocation

PURPOSE In a previous study, preoperative variables were correlated with postoperative visual outcome after the translocation of a free RPE-choroid graft. The present study was conducted to investigate whether the intraoperative course was an independent factor influencing visual outcome in these patients. METHODS This was a prospective interventional case series of 48 patients with exudative AMD treated with an RPE-choroid translocation. Preoperative and postoperative evaluation included ETDRS visual acuity (VA) and fixation testing by a masked examiner. Four critical surgical steps were evaluated, and the intraoperative course was graded from 0 (uncomplicated surgery) to 5 (most complicated surgery). The relationship between intraoperative course adjusted for preoperative delay/lesion composition and visual outcome at 3 months and 1 year after surgery was analyzed with multivariate analysis. RESULTS The mean VA (logMAR) improved slightly from 0.99 before surgery to 1.00, 0.94, 0.89, and 0.91 after 3, 6, 9, and 12 months, respectively. Foveal fixation on the graft was present in 34 (71%) of the eyes at 1 year after surgery. The intraoperative course was statistically significantly associated with the DeltaVA (logMAR) at 3 months (P = 0.037) and at 1 year after surgery (P = 0.020) and if measured as gain or loss of > or =2 ETDRS-lines (odds ratio [OR] 1.8, 95% confidence interval [CI] 1.7 to 2.8, P = 0.027) and > or =3 ETDRS lines (OR, 2.2, 95% CI 1.9-3.5, P = 0.003); better surgery was associated with visual gain whereas eventful surgery was associated with visual loss. CONCLUSIONS The intraoperative course adjusted for preoperative variables had a statistically significant influence on postoperative visual outcomes in patients treated with a free RPE-choroid translocation. Refining the surgery could improve results.

Effect of gravity in long-term vitreous tamponade: in vivo investigation using perfluorocarbon liquids and semi-fluorinated alkanes

Purpose In order to investigate whether gravity is the reason for retinal degeneration in long-term vitreous tamponade, perfluorohexyloctane (F6H8), perfluorodecalin (PFD), and a mixture of F6H8/PFD were compared.

Angiographic evidence for revascularization of an rpe-choroid graft in patients with age-related macular degeneration.

Purpose: To study graft perfusion using fluorescein angiography (FA) and indocyanine green angiography (ICG) after the translocation of an autologous retinal pigment epithelium (RPE)-choroid graft in patients with exudative age-related macular degeneration (AMD). Methods: Retrospective observational case series of 31 patients with AMD who had FA and/or ICG performed after an RPE-choroid graft translocation. The FAs (n = 25) and ICGs (n = 23) were assessed by an independent masked reader for the presence of early fluorescence of the graft in FA, and for perfusion of the choroidal vessels of the graft and recipient bed in ICG. Results: Early fluorescence of the graft was present in 23 of the 25 FAs. Perfusion of the graft vasculature was observed in 12 of the 23 ICGs. The two grafts that lacked early fluorescence in FA also had no signs of choroidal perfusion of the graft and the recipient bed with ICG. Conclusion: Revascularization of the RPE-choroid graft was observed in all but 2 of the 31 patients either by early fluorescence of the graft by FA or by identification of perfused choroidal graft vessels with ICG from 1 week up to 3 years after surgery. For assessment of revascularization of the graft evaluation of the early phase of the FA is recommended.

Threshold Amplitude and Frequency for Ocular Tissue Release from a Vibrating Instrument:An Experimental Study

PURPOSE During retinal pigment epithelium (RPE) and choroid graft translocation in the treatment of patients with exudative age-related macular degeneration, the adhesion of the graft to the translocation instrument complicated its submacular release. Vibration of the instrument improved the release of the graft. This study was conducted to validate the effectiveness of the principle of vibration and to determine the threshold amplitude and frequency required for development of an optimized instrument. METHODS An experimental in vitro model with fresh porcine RPE-choroid grafts was used. Release of the graft was studied by a masked observer for amplitudes in the range of 0.05 to 1.2 mm and frequencies in the range of 25 to 200 Hz in the horizontal plane. RESULTS The minimum threshold amplitude required to release the graft was approximately 0.15 mm from a frequency of 100 Hz and higher. CONCLUSIONS This study confirmed the clinical experience that vibration of an instrument induces the release of the RPE-choroid graft. The minimum threshold amplitude and frequency needed for optimum tissue release were estimated.

There is no relation between the occurrence of proliferative vitreoretinopathy and the location of the donor site after transplantation of a free autologous retinal pigment epithelium–choroid graft

Purpose:  A free autologous retinal pigment epithelium (RPE)–choroid graft can be harvested during transplantation surgery from a 6 or 12 o’clock site in the midperiphery. This study evaluated whether proliferative vitreoretinopathy (PVR) occurs more frequently in patients with an inferior donor site retinotomy, which is not closed by the tamponade and is in contact with the hydrophilic, pro‐inflammatory and fibrotic environment, than in patients with a superior donor site retinotomy.