Macular Degeneration: De Juan E

Pieramici DJ, De Juan E, Fujii GY, Reynolds SM, Melia M, Humayun MS, Schachat AP, Hartranft CD. · Wilmer Ophthalmological Institute, The Johns Hopkins Hospital, Baltimore, Maryland 21287, USA. · Am J Ophthalmol. · Pubmed #11024414 No free full text.

Abstract: PURPOSE: To review a series of patients with age-related macular degeneration undergoing limited macular translocation for the treatment of subfoveal choroidal neovascularization, to determine short-term visual acuity outcomes, to measure amounts of attainable retinal movement, and to identify prognostic factors.METHODS: A retrospective review was conducted on a consecutive series of patients undergoing inferior limited macular translocation with scleral imbrication for the treatment of subfoveal choroidal neovascularization secondary to age-related macular degeneration. The main outcome measures investigated were distance of macular translocation, visual acuity at 3 and 6 months after surgery, change in visual acuity from baseline, and the development of intraoperative and postoperative complications. Univariate and multivariate analyses of a number of potential prognostic factors were undertaken.RESULTS: Macular translocation was achieved in all 102 eyes (101 patients) included in this study. The range of movement varied from 200 to 2,800 microm with a median movement of 1, 200 microm. Nearly 33% of the study group achieved a visual acuity better than 20/100 at 3 months, and 49% achieved this vision at 6 months. At 3 and 6 months, 37% and 48% of the study group, respectively, experienced 2 or more lines of improvement on visual acuity testing, and by 6 months 16% experienced greater than 6 lines of visual improvement. Good baseline vision, achieving the desired amount of macular translocation, a greater amount of macular translocation, and recurrent choroidal neovascularization at baseline were associated with better visual acuities at 3 and 6 months. Poor preoperative vision and the development of complications were associated with worse vision at 3 and 6 months. CONCLUSIONS: Limited macular translocation is a technically feasible procedure that can lead to significant visual improvement and good visual acuity in some patients presenting with subfoveal choroidal neovascularization associated with age-related macular degeneration. A randomized prospective clinical trial of this surgical technique is warranted.

Lakhanpal RR, Javaheri M, Ruiz-Garcia H, De Juan E, Humayun MS. · Microsurgery Advanced Design Laboratory, Doheny Retina Institute, Doheny Eye Institute, Department of Ophthalmology, Keck School of Medicine, University of Southern California, Los Angeles 90033, USA. · Retina. · Pubmed #15805902 No free full text.

Abstract: PURPOSE: To evaluate a new technique, 25-gauge transvitreal limited arteriovenous-crossing manipulation without vitrectomy (LAM), for the treatment of branch retinal vein occlusion (BRVO) complicated by macular hemorrhage and/or macular edema recalcitrant to grid laser photocoagulation. METHODS: Twelve eyes of 12 patients underwent LAM for BRVO performed by a single surgeon (M.S.H.) using the 25-gauge nitinol flexible-extendable blunt pick. The presence or absence of intraoperative reperfusion visualization, pre- and postoperative visual acuity, macular thickness as measured by optical coherence tomography, intraocular pressure, and lens status were evaluated. RESULTS: Restoration of blood flow was noted in all patients and was based on intraoperative reestablishment of a red column of erythrocytes through the previously closed vessel. Mean visual acuity improved from 20/200 (logarithm of the minimal angle of resolution [LogMAR] +/- SD, 1.00 +/- 0.32) preoperatively to 20/70 (LogMAR +/- SD, 0.56 +/- 0.28) (P = 0.0003) at the final visit. Eleven (92%) of 12 eyes had >or=2 lines of visual improvement. Five eyes (45%) had final visual acuity of 20/50 or better. Mean macular thickness +/- SD improved from 401.0 +/- 73.2 to 178.7 +/- 19.6 microm (P < 0.0001) at the final visit. No statistically significant difference was noted in cataract progression or intraocular pressure. Mean follow-up +/- SD was 49.9 +/- 19.6 weeks. All patients were observed for at least 12 weeks. CONCLUSION: LAM may achieve outcomes comparable with those of arteriovenous adventitial sheathotomy for complicated BRVO.

Albini TA, Rao NA, Li A, Craft CM, Fujii GY, De Juan E. · Doheny Eye Institute, University of Southern California, Los Angeles, California, USA. · Ophthalmology. · Pubmed #15177973 No free full text.

Abstract: OBJECTIVE: To illustrate the histopathologic findings in a patient who underwent limited macular translocation. DESIGN: Observational case report. METHODS: The patient underwent limited macular translocation for subfoveal choroidal neovascularization resulting from age-related macular degeneration. Thirty-one months after surgery, the patient had died and both eyes were obtained at autopsy. Serial sections through both maculas were obtained. Immunohistochemistry of the foveas with C10C10 and hCAR/LUMIf antibodies for rods and cones, respectively, was performed. MAIN OUTCOME MEASURES: Histopathologic changes in the operated eye as compared with the fellow eye. RESULTS: There was no morphologic difference in the subfoveal retinal pigment epithelium, Bruch's membrane, or choriocapillaris, but there was a decreased cone density in the translocated fovea as compared with the fellow eye. CONCLUSIONS: In this patient, the fovea was translocated without causing apparent change in the underlying retinal pigment epithelium, Bruch's membrane, or choriocapillaris. Although there may be some photoreceptor loss, the excellent visual recovery suggests that the retinal pigment epithelium underlying the translocated fovea is functionally adequate.

Fujii GY, De Juan E, Humayun MS, Sunness JS, Chang TS, Rossi JV. · Doheny Retina Institute, Doheny Eye Institute, University of Southern California, Keck School of Medicine, Los Angeles, California 90033, USA. · Am J Ophthalmol. · Pubmed #14644217 No free full text.

Abstract: PURPOSE: To evaluate the effects of subfoveal choroidal neovascularization secondary to age-related macular degeneration on functional parameters obtained by scanning laser ophthalmoscope microperimetry. DESIGN: Retrospective observational case series and cross-sectional study. METHODS: At the Doheny Retina Institute and Wilmer Eye Institute a consecutive series of 179 eyes of 175 patients with subfoveal choroidal neovascularization secondary to age-related macular degeneration was studied. The onset of visual symptoms, best-corrected visual acuity, fluorescein angiography, evaluation of fundus microperimetry and fixation pattern using the Rodenstock scanning laser ophthalmoscope were obtained for each patient. The main outcome measures were central retinal sensitivity and fixation pattern (fixation location and fixation stability) in eyes with subfoveal choroidal neovascularization and their relationship to the length of disease, type and characteristics of choroidal neovascularization, and visual acuity. RESULTS: Of 179 eyes, 135 (75%) had central fixation, 27 (15%) had poor central fixation, and 17 (9%) had predominantly eccentric fixation. Seventy-six eyes (42%) had stable fixation, 70 eyes (39%) had relatively unstable fixation, and 33 eyes (18%) had unstable fixation. In 50 eyes (28%) a dense central scotoma was noted. Eighty-nine of 100 eyes (89%) with length of symptoms of less than 3 months had predominantly central fixation and 58 (58%) had stable fixation; 14 of 34 eyes (41%) with length of symptoms of more than 6 months had predominantly central fixation, and 5 eyes (15%) had stable fixation. In 15 eyes of patients who elected not to receive treatment, successive scanning laser ophthalmoscope microperimetry were obtained over time (follow-up of 18 months after onset of symptoms). Three months or less after the onset of symptoms, 13 eyes (87.7%) had predominantly central fixation and 9 eyes (60%) had stable fixation. More than 3 months and 6 months or less after the onset of symptoms, 10 eyes (66.7%) had predominantly central fixation and 7 eyes (46.7%) had stable fixation. This trend was further demonstrated in eyes more than 6 months after the onset of symptoms. CONCLUSIONS: We conclude that the sequence of events leading to visual function deterioration appears to involve an initial mild decrease in central retinal sensitivity and visual acuity followed by progressive fixation instability and, ultimately, development of an absolute central scotoma with totally eccentric fixation. Increased length of disease is associated with worse fixation pattern and retinal sensitivity deterioration as assessed by scanning laser ophthalmoscope microperimetry. A better understanding of the characteristics of visual loss assessed by fixation pattern evaluation and microperimetry in age-related macular degeneration may help optimize timing, patient selection, and treatment options in eyes with this condition.

Kent DL, Fujii GY, Pieramici DJ, Reynolds SM, Melia M, Rossi JV, Humayun MS, Caffey S, De Juan E. · Vitreoretinal Service, Wilmer Institute, Johns Hopkins University, Baltimore, Maryland, USA. · Retina. · Pubmed #12707592 No free full text.

Abstract: PURPOSE: To review in a standardized fashion pre- and postoperative fluorescein angiographic characteristics in patients undergoing limited macular translocation (LMT) with scleral imbrication to treat subfoveal choroidal neovascularization (SFCNV) secondary to age-related macular degeneration (AMD). The current study was undertaken to assess any potential effects of the translocation procedure on altering the angiographic characteristics of SFCNV before laser photocoagulation. METHODS: A consecutive series of patients undergoing LMT for AMD was identified retrospectively. The pre- and postoperative fluorescein angiograms were reviewed in a masked fashion. Angiographic characteristics evaluated included pre- and postoperative lesion components, stability of lesion, and the amount of retinal translocation obtained. RESULTS: Eighty-eight patients (90 eyes) had angiograms of adequate quality to permit evaluation. Time between the preoperative and the prelaser angiogram ranged from 2 to 84 days (median 7.5 days). Neovascular complexes remained unchanged or decreased in size in 79% of patients. There was no statistically significant difference in lesion size between the pre- and postoperative periods (P = 0.34). Retinal movement ranged from 160 microm to 3,320 microm (median 960 microm), with 61% of cases undergoing effective translocation (i.e., the fovea was moved away from the neovascular complex). None of the lesion components or demographic factors evaluated affected the amount of translocation obtained. Larger lesions were more likely to remain subfoveal following translocation (P = 0.004). CONCLUSION: The size and lesion characteristics appear relatively stable following translocation. Amount of retinal movement is not associated with angiographic lesion characteristics. Only size was associated with achievement of desired translocation in the final model, with large lesions being less likely to achieve desired translocation. In our study group, the amount of retinal translocation was variable with 61% of cases undergoing effective translocation.

Fujii GY, De Juan E, Zarbin MA, Humayun MS, Au Eong KG, Phillips S. · Wilmer Ophthalmological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21287-9277, USA. · Retina. · Pubmed #11508889 No free full text.

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Fujii GY, Pieramici DJ, Humayun MS, Schachat AP, Reynolds SM, Melia M, De Juan E. · Wilmer Ophthalmological Institute, The Johns Hopkins Hospital, Baltimore, Maryland 21287-9277, USA. · Am J Ophthalmol. · Pubmed #11124294 No free full text.

Abstract: PURPOSE: To report the ocular complications associated with the limited macular translocation procedure. METHODS: Retrospective review of 153 consecutive eyes of 151 patients that had the limited macular translocation procedure for subfoveal choroidal neovascularization between April 1996 and February 1999. The major study variables investigated included the incidence of specific ocular complications and their impact on visual acuity at 3 months after the surgery. In addition, baseline patient characteristics and operative factors were evaluated to determine whether they were significant risk factors for the development of an ocular complication. The existence of a surgical procedure learning process was investigated. RESULTS: One hundred forty-one (92.15%) of 153 eyes achieved at least 3-month follow-up. At least one complication occurred in 53 of 153 eyes (34.6%) and in 51 of these 53 eyes (96. 22%) the complications occurred before 3 months of postoperative follow-up. The intraoperative and postoperative complications included retinal detachment (17.4%), retinal breaks (13.4%), macular holes (7.8%), macular fold (4.6%), and intraocular hemorrhage (vitreous, subretinal, or choroidal; 9.2%). Eyes that developed retinal detachment, subretinal hemorrhage, and macular fold had significantly more loss of visual acuity than eyes without each of these complications (P =.0001, P =.038, and P =.027, respectively). The presence of predominantly classic choroidal neovascularization, the occurrence of an intraoperative retinal break, any intraocular hemorrhage, or macular fold formation were significantly associated with retinal detachment (P =.021, P =.025, P =.013, and P =.014, respectively). The incidence of any complication, retinal detachment, and hemorrhage significantly decreased during the study period, suggesting a learning process (P =.03, P =.006, P =.027, respectively). CONCLUSIONS: A variety of ocular complications can occur during or after limited macular translocation, and some are associated with reduced postoperative visual acuity. Improved surgical techniques and experience may significantly reduce the incidence of these complications.

Majji AB, Cao J, Chang KY, Hayashi A, Aggarwal S, Grebe RR, De Juan E. · Wilmer Ophthalmological Institute, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA. · Invest Ophthalmol Vis Sci. · Pubmed #11053297 links to  free full text

Abstract: PURPOSE: To investigate age-related changes in the retinal pigment epithelium (RPE), Bruch's membrane, and choriocapillaris in the senescence-accelerated mouse (SAM). METHODS: The external and eyecup features and light and electron microscopic findings were examined in three male and two female mice of a senescence-prone mouse strain (SAM P(8)) monthly for 12 months. These results were compared with those in age-matched mice of similar background but senescence resistant (SAM R(1)). Choroidal vascular casts were prepared at 12 months in seven mice each of the SAM P(8) and SAM R(1) strains. Quantitative analysis of area of choriocapillaris was performed by automated image analysis, and the results were analyzed by paired Student's t-test. RESULTS: We found in the SAM P(8) strain that hair loss, coarseness of hair texture, and ulceration of skin appeared and increased as the age advanced (at approximately 5-9 months). Eyecup examination showed no differences. Light and electron microscopy revealed progressively more prominent abnormalities in the RPE and Bruch's membrane mice older than 10 months. Two of the five SAM P(8) mice older than 11 months showed what appeared to be intra-Bruch's membrane choroidal neovascularization. The RPE and Bruch's membrane appeared normal in the SAM R(1) strain. In the SAM P(8), vascular casts of the choriocapillaris showed a mild but significant decrease in vascular area when compared with the SAM R(1) strain at 12 months (P = 0.011). CONCLUSIONS: Senescence accelerated mice develop progressive age-related changes in the RPE-Bruch's-choriocapillaris complex that have features that may be relevant in the study of age-related macular changes in humans.

Weisz JM, Humayun MS, De Juan E, Del Cerro M, Sunness JS, Dagnelie G, Soylu M, Rizzo L, Nussenblatt RB. · Department of Ophthalmology, Wilmer Ophthalmological Institute, Johns Hopkins Medical Institutes, Baltimore, Maryland 21287, USA. · Retina. · Pubmed #10606456 No free full text.

Abstract: PURPOSE: To test the hypothesis that healthy fetal retinal pigment epithelium (RPE) can rescue the remaining viable RPE and choriocapillaries and thereby the photoreceptors in non-neovascular age-related macular degeneration (ARMD) (geographic atrophy [GA]). METHODS: A 65-year-old legally blind woman with non-neovascular ARMD underwent fetal RPE transplantation. Best-corrected visual acuity testing, detailed fundus examination, fundus photography, fluorescein angiography, scanning laser ophthalmoscope macular perimetry, and humoral and cellular immune response testing were performed. A suspension of RPE was infused into the subretinal space through a retinotomy along the superotemporal arcade at the edge of the area of GA. The patient did not take systemic immunosuppressants. RESULTS: The patient's vision remained unchanged for 5 months after the surgery. Fluorescein angiography after transplantation showed leakage and staining at the level of the outer retina. There was progressive subretinal fibrosis in the area of the transplant. Immune response studies showed a weakly positive mixed lymphocyte response against phosducin and rhodopsin. CONCLUSION: Although it is surgically feasible to transplant fetal RPE to the subretinal space of patients with GA, such an allogenic RPE transplant without immunosuppression leads to leakage on fluorescein angiography and eventual fibrosis. A very weak immune response against proteins associated with photoreceptors is also of concern.