Removal Of Choroidal Neovascularization Research Articles

Choroidal neovascularization removal with photo-mediated ultrasound therapy.

Age-related macular degeneration (AMD) is a major cause of irreversible central vision loss. The main reason for lost vision due to AMD is choroidal neovascularization (CNV). In the clinic, current treatments for CNV include photodynamic therapy, laser photocoagulation, and anti-vascular endothelial growth factor (VEGF) therapy. This study evaluates a novel treatment technique combining synchronized nanosecond laser pulses and ultrasound bursts, namely photo-mediated ultrasound therapy (PUT) as a potential treatment method for CNV, for its efficacy and safety in the treatment of CNV via the experiments in a clinically-relevant rabbit model in vivo. CNV was created by subretinal injection of Matrigel and vascular endothelial growth factor (M&V) in 10 New Zealand white rabbits. Six rabbits were used in the PUT group. In the control groups, two rabbits were treated by laser-only, and two rabbits were treated by ultrasound-only. The treatment efficacy was evaluated through fundus photography and fluorescein angiography (FA) longitudinally for up to 4weeks. Rabbits were sacrificed for histopathology 3 months after treatment to examine the safety of PUT. The fluorescein leakage on FA was quantified to longitudinally evaluate treatment outcome. Compared with baseline, the relative intensity index was reduced by 26.57%±8.66% at 3 days after treatment, 27.24%±6.21% at 1week after treatment, 27.79%±2.61% at 2weeks after treatment, and 32.12%±3.23% at 4weeks after treatment, all with a statistically significant difference of p<0.01. The comparison between the relative intensity indexes from the two control groups (laser-only treatment and ultrasound-only treatment) did not show any statistically significant difference at all time points. Safety evaluation at 3 months with histopathology demonstrated that the PUT did not result in morphologic changes to the neurosensory retina. This study introduces PUT for the first time for the treatment of CNV. The results demonstrated good efficacy and safety of PUT to treat CNV in a clinically-relevant rabbit model. With a single session of treatment, PUT can safely reduce the leakage of CNV for at least 1 month after treatment.

Evaluation of Transplanted Autologous Induced Pluripotent Stem Cell-Derived Retinal Pigment Epithelium in Exudative Age-Related Macular Degeneration

To report the results after 4 years of follow-up in a previously presented first case of induced pluripotent stem cell (iPSC)-derived retinal pigment epithelium (RPE) sheet autologous transplantation using multimodal imaging. Follow-up of a single case. A patient with exudative age-related macular degeneration and polypoidal choroidal vasculopathy. Transplantation of an autologous iPSC-derived RPE cell sheet after removal of choroidal neovascularization (CNV) in September2014. The function of the graft was assessed 4 years after surgery by color fundus photography, spectral-domain (SD) OCT, fluorescein angiography, indocyanine green angiography, and an adaptive optics (AO) retinal camera. At the 4-year follow-up, the transplanted autologous iPSC-derived RPE sheet had survived beneath the retina with slight expansion of the pigmented area and no adverse events. The outer nuclear layer above and adjacent to the graft showed acceptable thickness and an organized structure. Fluorescein angiography and SD OCT suggested the presence of vessel-like structures confined to the grafted area associated with the remaining trunk vessel of preoperative polypoidal choroidal vasculopathy but with no exudative changes. Visual acuity has been stable with no additional injections of anti-vascular endothelial growth factor agent. The choroidal volume at the graft site is relatively preserved when compared with the volume outside this site without RPE after removal of the CNV. Indocyanine green angiography revealed a preserved choriocapillaris around the iPSC-derived RPE sheet. Dark cell-like structures with a predominantly hexagonal arrangement were observed by AO imaging in an area located near the margin of the graft sheet. The average intercell distance was found to be stable over time. Thus far, the grafted iPSC-derived RPE sheet has survived for 4 years and seems to support photoreceptors and choroidal vessels. The morphologic characteristics of the RPE are observed at the transplant site.

Surgical removal of subfoveal choroidal neovascularization in pathologic myopia: a 12-year follow-up study

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 45.8years, high myopia (>6D) and classic subfoveal CNV. They were treated with pars plana vitrectomy and surgical removal of CNV. All patients were followed up every 3months for 2years, with visual acuity (VA), fundus examination, and fluorescein angiography and then every year for 5years. 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 12years of follow-up, the mean VA did not significantly change over time, with a mean gain of 0.22 logMAR at 1year, and 0.18, 0.12 and 0.05 at 2, 5 and 12years, respectively. The anatomical evolution was characterized by a significant enlargement of the lesion size at 5years. This study showed that final VA after surgical treatment with 12years 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.

Surgical Treatment of Age-Related Macular Degeneration

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.

Implications of bevacizumab on vascular endothelial growth factor and endostatin in human choroidal neovascularisation

Aim:To evaluate the implications of intravitreal bevacizumab on proangiogenic vascular endothelial growth factor (VEGF) with regard to the endogenous angiogenesis inhibitor endostatin in human choroidal neovascularisation (CNV) secondary to age-related...

Postoperative Assessment of Retinal Function Using a Multifocal Electroretinogram After the Removal of Subfoveal Choroidal Neovascularization Secondary to Age-Related Macular Degeneration

To assess retinal function in a macular lesion with multifocal electroretinography (mfERG) after successful surgical removal of choroidal neovascularization (CNV). We prospectively studied 15 patients (15 eyes) who underwent surgical removal of subfoveal CNV secondary to age-related macular degeneration. Three and 6 months after surgery, retinal thickness in the parafoveal lesion and the size of the serous retinal detachment (SRD) were measured. The mfERG was also recorded, and the data from each of six concentric ring annuli were averaged. After surgery, the parafoveal retinal thickness significantly decreased compared with the preoperative value, and SRD was not recognized in any patient. The change in the amplitude of the P1-wave within 2 degrees to 15 degrees in diameter positively correlated with the decrease in the parafoveal retinal thickness. Additionally, amplitude within 8 degrees to 24 degrees in diameter positively correlated with the size of the preoperative SRD. mfERG is helpful to quantitatively and objectively assess the effect of the surgical removal of CNV on retinal function, not only in the fovea but also in the entire macular area.

Expression of VEGF and PEDF in Choroidal Neovascular Membranes Following Verteporfin Photodynamic Therapy

To examine the impact of photodynamic therapy (PDT) on pigment epithelium derived factor (PEDF) expression in human choroidal neovascularization (CNV) membranes with regard to vascular endothelial growth factor (VEGF) expression. Interventional case series. Retrospective review of interventional case series of 42 patients (42 eyes) who underwent removal of CNV. CNV was secondary to age-related macular degeneration (AMD) in all cases. Fifteen patients were treated with PDT, 3 to 246 days before surgery. CNV were stained for CD34, CD105, cytokeratin 18, VEGF, and PEDF. Twenty-seven CNV without previous treatment were used as control. Specimens without pretreatment disclosed varying degrees of vascularization, VEGF, and PEDF expression by different cells. Specimens treated by PDT, three days previously showed mostly occluded vessels lined with damaged endothelial cells (EC). In contrast, specimens excised at later time points after PDT were highly vascularized with healthy EC. This chronology was associated with an impressive VEGF immunoreactivity increased considerably in retinal pigment epithelial cells as well as significantly reduced PEDF expression in EC and stroma. PDT induces a selective vascular damage in CNV. The effectiveness of PDT, however, seems to be jeopardized by a rebound effect initiated by an enhanced VEGF and reduced PEDF expression in CNV.

Iris Pigment Epithelial Translocation in the Treatment of Exudative Macular Degeneration

To report the functional and anatomical outcome of 20 patients who underwent surgical removal of choroidal neovascularization combined with transplantation of autologous iris pigment epithelial cells to the subretinal space 3 years after treatment. Freshly isolated autologous iris pigment epithelial cells were translocated to the subretinal space in 20 patients after membrane extraction. Patients were followed up by funduscopy, angiography, microperimetry, and visual acuity testing. After a follow-up of 3 years, 1 patient showed improved visual acuity, 13 patients retained stable visual acuity, and 3 patients had reduced visual acuity. No macular edema or recurrent choroidal neovascularization was apparent at any time during the follow-up. Transplanted autologous iris pigment epithelial cells were well tolerated for 3 years and stabilization of visual acuity was achieved in most patients. These results suggest that iris pigment epithelial cells may serve as a substitute for retinal pigment epithelial cells after choroidal neovascularization removal in patients with exudative macular degeneration; however, whether these cells will be of any value for the restoration of vision and possible protection against choroidal neovascularization recurrence awaits further clinical observation and additional research.

Longterm results in surgical removal of subfoveal choroidal neovascularization in age‐related macular degeneration

This study aimed to analyse visual outcome, surgical complications and recurrence rates 3 years after removal of subretinal choroidal neovascularization (CNV) in patients with age-related macular degeneration (AMD). The study involved a retrospective analysis of 50 eyes of 50 patients who underwent surgical removal of CNV in AMD between February 1996 and June 1998. The minimum follow-up period was 36 months. Improvement or worsening of visual acuity (VA) was defined as a change of more than two lines. The mean reduction in VA was 2.2 +/- 6.9 lines. Visual acuity improved in 12 eyes, remained stable in 16 eyes and worsened in 22 eyes. Recurrence of CNV occurred in three eyes. After surgical excision of age-related subfoveal CNV, VA improved or stabilized in a large group of patients. Considering the development of VA and the low recurrence rate, surgical treatment seems to be beneficial compared to the natural course of CNV over a longterm follow-up of more than 3 years.

SURGICAL REMOVAL OF PERIPAPILLARY CHOROIDAL NEOVASCULARIZATION ASSOCIATED WITH OPTIC NERVE DRUSEN

To assess the anatomical and functional results after surgical removal of peripapillary choroidal neovascularization (CNV) associated with optic nerve head drusen. A retrospective study was carried out on four eyes (four patients) undergoing vitrectomy, retinotomy, and removal of CNV associated with optic disk drusen. CNV was preoperatively demonstrated by fluorescein angiography in all cases. In three cases, the CNV had a subfoveal extension, and a serous-hemorrhagic retinal detachment was the cause of the central vision disturbance in the remaining one. Optic nerve head drusen were bilateral and were confirmed with computed tomography scan. Visual acuity (VA) improved in all cases after a follow-up ranging from 12 to 42 months. Preoperative VA was 20/200, 20/200, 20/50, and count fingers and final VA was 20/50, 20/25, 20/25, and 20/30, respectively. There was no evidence of CNV recurrence during the follow-up period. The results of surgical removal of peripapillary CNV with macular involvement associated with optic nerve head drusen are very encouraging, especially if we consider the variable outcome of the natural course in these cases.

Surgical Removal of Choroidal Neovascularization in Angioid Streaks

All the studies so far on surgical removal of choroidal neovascularization (CNV) in angioid streaks(AS) were conducted on a small number of cases. Therefore, a definitive evaluation of the surgical method was not available. The present study aimed to evaluate this surgical modality. We performed surgical removal of foveal CNV accompanied by AS. Eighteen eyes of seventeen patients were available for follow-up of over 12 months. Surgical indications included foveal CNV, fluorescence leakage from the CNV in late-phase fluorescein angiography, and visual acuity of 0.3 or lower. The best visual acuity was improved in 44% and unchanged in 44%. The final visual acuity was improved in 33% and unchanged in 39%. 22% had a preoperative visual acuity of 0.2 or above; and 44% and 17% achieved best and final visual acuity, respectively, of 0.2 or above. Since all cases developed atrophy of the choriocapillaris in the fovea, none of the cases were capable of fixation within atrophy. The fixation point was localized outside atrophy in 56% and fixation was poor in 44%. The diameter of postoperative atrophy of choriocapillaris was significantly greater (p < 0.05) than the preoperative CNV diameter. CNV recurred in 8 eyes(44%), 88% of which occurred within one year. Surgical removal of CNV in AS is an effective method to maintain preoperative visual acuity.

Retinal pigment epithelium translocation after choroidal neovascular membrane removal in age-related macular degeneration

PurposeTo test the feasibility of a new surgical technique and to assess visual function over the translocated retinal pigment epithelium (RPE) cells in patients operated on for subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration (ARMD). DesignRetrospective, noncomparative, interventional case series. ParticipantsNine patients with previously untreated exudative ARMD underwent surgical excision of the subfoveal CNV with RPE translocation and were observed for 12 to 32 months. MethodsThe surgery consisted of a standard three-port pars plana vitrectomy, excision of the CNV, and RPE translocation. Pre- and postoperative ocular examination included best-corrected visual acuity measurement, fundus color stereo photography, and fundus fluorescein angiography. Optical coherence tomography and confocal laser scanning ophthalmoscopy (cLSO) were performed after surgery. A crossfixation target and a single-point flashing light were projected on different areas of the posterior pole using a cLSO. Photopic 10 to 2 perimetry, photopic fine matrix mapping, and cLSO microperimetry were also performed after surgery in six patients. Main outcome measuresOptical coherence tomography cross-sectional scans and cLSO RPE autofluorescence were recorded to detect the presence of viable translocated RPE. Visual acuity, fixation, photopic 10 to 2 perimetry, photopic fine matrix mapping, and cLSO microperimetry were used to test central visual function. ResultsRetinal pigment epithelium was translocated successfully at the time of CNV removal from the edge of the RPE defect to a subfoveal location in seven of nine patients. One patient experienced proliferative vitreoretinopathy, but significant hemorrhage was not a feature. Optical coherence tomography showed the translocated RPE as an area of increased optical reflectivity with optical shadowing external to it. Confocal laser scanning ophthalmoscopy showed autofluorescence of the translocated RPE. The crossfixation target was seen when projected on the translocated RPE. During eccentric fixation, the patients could see a flashing point-target projected on the translocated RPE. Photopic 10 to 2 perimetry, photopic fine-matrix mapping, and cLSO microperimetry showed the presence of central visual function. ConclusionsThe authors propose that translocation of RPE at the time of CNV removal, from the edge of the RPE defect to a subfoveal location, may have a role in the surgical management of ARMD.

Surgical treatment of subfoveal neovascularization in myopia: macular translocation vs surgical removal

PURPOSE: To compare the visual outcome of two different surgical approaches for subfoveal neovascularization in degenerative myopia: macular translocation and surgical removal of choroidal neovascularization (CNV). DESIGN: Interventional case series. METHODS: Retrospectively, 32 eyes with degenerative myopia (axial length over 26 mm or refraction over −6 diopters) and subfoveal CNV of 32 consecutive patients operated on by either surgical removal of CNV or limited macular translocation were reviewed. Surgical removal of CNV was performed in 18 eyes and limited macular translocation with a twofold suture in 14 eyes. The main outcome measurements were best-corrected visual acuity (BCVA) and findings from fluorescein angiography. Postoperatively, mean ± SD follow up was 14 ± 15 months (range, 6–48 months) in the removal group and 11 ± 4 months (range, 6–24 months, P = .37) in the translocation group. RESULTS: In both groups, there was no significant difference in preoperative age, sex, refractive error, or BCVA. The average of postoperative BCVA was statistically better after macular translocation (10 ETDRS lines or 20/100) than after surgical removal (6 lines 10/125, P = .019). Visual acuity improved by 3.8 lines after macular translocation and was unchanged after surgical removal (−0.7 line, P = .011). Macular translocation was successful in shifting the CNV to an extrafoveal location in 11 out of 14 eyes. Mean foveal displacement of all 18 translocated eyes was 695 ± 426 μm (range, 100–1520 μm). Recurrence of CNV occurred in seven eyes (39%) after surgical removal and in two eyes (14%) after translocation. Retinal detachment occurred in two eyes in each group. CONCLUSION: In this retrospective study, eyes with degenerative myopia and subfoveal neovascularization treated with limited macular translocation had better visual acuity recovery than eyes treated with surgical removal of the choroidal neovascularization. Further studies are required to confirm these results.

Changes in fluorescein angiogram early after surgical removal of choroidal neovascularization in age-related macular degeneration.

Retinal pigment epithelial (RPE) defects inevitably occur in surgical removal of choroidal neovascularization (CNV) in age-related macular degeneration (AMD). RPE can proliferate and cover the denuded area, but the healing process has not been investigated in humans. To understand the RPE wound-healing process, we estimated the changes in fluorescein angiograms early after CNV removal. Ten consecutive patients with exudative AMD underwent CNV removal without gas tamponade. Fluorescein angiography was performed within 4 days of surgery and again 1 or 2 weeks postoperatively. Areas of leakage were measured using a computer-assisted image analyser. The decreasing rate of leakage was calculated as the change in disc areas of leakage per day (DA/day). The rates of decreasing leakage ranged from 0 to 0.42 DA/day (mean, 0.24 +/- 0.15 DA/day; median, 0.26 DA/day). The rate of decreasing leakage correlated with changes in visual acuity (r = 0.642, P = 0.0456). The retinal pigment epithelial wound after surgical removal of choroidal neovascularization may heal at the rate of 0.24 disc areas/day based on the blood retinal barrier function in patients with age-related macular degeneration. A faster rate of decreasing leakage may be associated with better visual prognosis.

New Examination Methods for Macular Disorders: Application of Diagnosis and Treatment

To establish a diagnosis or evaluate the efficacy of treatment for macular disorders, we need methods to evaluate the anatomical and functional changes of these disorders. In this article, we describe several studies that we have conducted for 2 years. In section 1, we report our new methods for making a diagnosis and evaluating visual function in macular disorders. In section 2, we describe our trials of these examination methods in treatment. Here is the summary of our results. In section 1, to examine the structures of the macular area, we used a retinal thickness analyzer (RTA), a confocal scanning laser ophthalmoscope (Heidelberg Retina Tomograph, HRT), and optical coherence tomography (OCT) to measure retinal thickness and assess retinal microstructures. We compared retinal imaging analysis of various macular diseases obtained with these three instruments. With the RTA, we obtained good three-dimensional macular images displayed on a retinal thickness map, but the retinal thickness map did not demonstrate the thickened retina with dense retinal hemorrhages, and high backscattering from hard exudates might obscure the vitreoretinal interface. The HRT three-dimensional topographic image clearly showed the undulation of the retinal surface. However, it took a relatively long time to obtain the HRT image, and we sometimes could not obtain good topographic images because of fixation movement. Examination with the OCT allows confirmation of the retinal cross-sectional structures, such as retinoschisis or cystoid spaces and the vitreomacular interface, such as vitreous traction, that cannot be detected using other conventional methods with high resolution, but high reflectivity from dense hemorrhages obscured the deeper layers of the retinal structures. Measurement of retinal thickness obtained with both the RTA and OCT is highly reproducible, and there was significant correlation between the retinal thicknesses measured with the two instruments. We believe that these three instruments might contribute significantly to early, accurate diagnosis and better monitoring of the therapeutic effects of vitrectomy for macular diseases. In the future, if these fundus imaging analysis instruments can achieve higher resolution and can analyze three-dimensional retinal images, they will provide better information to clinically evaluate macular diseases. We demonstrated vitreous examination and examination from the retinal surface to the deeper retinal layer at the macular area using a scanning laser ophthalmoscope (SLO). The SLO examination with an argon laser and a large confocal aperture was useful for conducting kinetic examination of the vitreous opacity above the macula. With a diode laser and a ring aperture (dark-field mode), it was possible to examine the retina from the deeper retinal layer to the choroids. On the other hand, the SLO also allows us to conduct a functional examination of fixation. We demonstrated that the referred retinal locus of fixation may change during the follow-up period in patients whose central fixation is impaired due to macular disease, and we showed that the fixation behavior was related to the visual acuity. Therefore, the SLO is an ideal instrument for determining the visual field and the visual acuity before and after treatment in patients with macular disease, because of its precise localization of the examination point by directly observing the fundus and by monitoring fixation behavior. Our new program installed in the SLO allows us to complete the quantitative retinal sensitivity evaluation within 2 minutes, which is difficult to do using a conventional SLO program. Furthermore, we demonstrated for the first time that minute functional changes in the retina can be detected by the SLO under low background illuminance. Such changes cannot be detected under conventional conditions. In addition, the extrafoveal visual acuity of normal subjects and patients with macular disease was studied using this new SLO program. The iso-acuity lines could be illustrated by summarizing these results in normal subjects. The SLO acuity of the horizontal meridian is significantly better than that of the vertical meridian, and even in the nasal area adjacent to the optic disc, an acuity of better than 0.1 could be achieved. To evaluate macular function, we also investigated the blood flow of the choroid (CF), the retina (RF), and the choriocapillaris at the fovea (CCF). We investigated the CF in patients with age-related macular degeneration (AMD) using pulsatile ocular blood flow (POBF) measurements. In patients with exudative AMD, the POBF was significantly lower than in patients with nonexudative AMD or in control subjects. Decreased CF may play a role in the development of choroidal neovascularization in AMD. RF was measured using laser Doppler velocimetry (LDV). (ABSTRACT TRUNCATED)

Identification of ingrowth site of idiopathic subfoveal choroidal neovascularization by indocyanine green angiography

PurposeThis study aimed to determine whether indocyanine green (ICG) angiography is useful to identify the ingrowth site of idiopathic choroidal neovascularization (CNV), which can predict visual outcomes after surgical removal of idiopathic CNV. DesignConsecutive, observational case series. ParticipantsTwenty-six patients with idiopathic subfoveal CNV, of whom six underwent submacular surgery. InterventionIndocyanine green videoangiography with a scanning laser ophthalmoscope. Main outcome measuresWe studied ICG videoangiographic images of choroidal neovascular membranes from the early phase to the late phase with special attention to abnormal findings, which can indicate the ingrowth site of CNV. ResultsEarly ICG angiography demonstrated distinct neovascular vessels in 24 of the 26 patients (92%). Hypofluorescent rims continuously or intermittently surrounded neovascular membranes on late ICG angiograms in 21 of the 26 patients (81%). In 22 of the 26 patients (85%), ICG angiography demonstrated hypofluorescent areas within the CNV. These hypofluorescent areas frequently became ring shaped in the middle to late phase of the ICG angiography. In 14 of 16 patients (88%) with CNV larger than half a disc area, the filling of neovascular vessels appeared from the inside of the hypofluorescent areas and branched out toward the surrounding hyperfluorescent membrane in the early phase. In all six patients who underwent surgical removal of CNV, ICG videoangiography showed these hypofluorescent areas from which neovascular vessels emanated. Three of the four surgical patients, in whom hypofluorescent areas or central fluorescent areas surrounded by ring-shaped hypofluorescence were extrafoveal or juxtafoveal, had a best postoperative visual acuity of 20/60 or better. In contrast, both surgical patients with subfoveal hypofluorescent areas had a best postoperative visual acuity of 20/70 or worse. ConclusionsAlthough further observations are needed, ICG angiography may be a useful adjunct in the identification of the ingrowth site of idiopathic CNV, which can predict visual outcomes after surgery.

Surgical removal of extensive peripapillary choroidal neovascularization associated with presumed ocular histoplasmosis syndrome

Objective This study aimed to report the visual outcome of surgical removal of extensive peripapillary choroidal neovascularization (CNV) due to presumed ocular histoplasmosis syndrome (POHS). Design Retrospective review of the records of all patients seen at the Barnes Retina Institute who underwent surgical removal of extensive peripapillary CNV associated with POHS and who had at least 12 months of follow-up. Participants Seventeen consecutive eyes (in 14 patients) undergoing surgical removal of extensive peripapillary CNV associated with POHS were studied. Intervention Pars plana vitrectomy and surgical removal of CNV were performed. Main outcome measurements Best-corrected Snellen visual acuity, funduscopic examination, and intravenous fluorescein angiography were obtained before surgery and at regular intervals after surgery. Results In 14 of 17 eyes, the peripapillary CNV was subfoveal, and in 3 eyes, it was extrafoveal. All three eyes with extrafoveal CNV were not eligible for laser treatment according to Macular Photocoagulation Study guidelines because treatment would have spared less than 1.5 contiguous clock-hours of retina temporal to the optic disc. Follow-up ranged from 17 to 57 months, with a median of 32 months. In eyes with subfoveal CNV, best-corrected preoperative Snellen visual acuity ranged from 20/25 to counting fingers at 2 feet with a median of 20/200, and best-corrected final Snellen visual acuity ranged from 20/25 to 20/200 with a median of 20/40. In 7 (50%) of 14 eyes, a final Snellen acuity of 20/40 or better was achieved, and in all cases except 1, visual acuity improved or did not change with surgery. In the three eyes with extrafoveal CNV, best-corrected preoperative Snellen visual acuity ranged from 20/20 to 20/400 with a median of 20/200, and best-corrected final Snellen visual acuity was 20/20 in all cases. In addition, visual acuity improved with surgery. Conclusions The data from this small retrospective study suggest that surgical removal may provide visual benefit in selected cases of extensive peripapillary CNV due to POHS.

Surgical Management of Subfoveal Choroidal Neovascularization

Subfoveal choroidal neovascularization (CNV) usually is associated with a poor visual prognosis. Laser photocoagulation of certain subfoveal membranes secondary to age-related macular degeneration (ARMD) appears preferable to observation based on recent Macular Photocoagulation Study (MPS) findings but is associated with decreased vision. The authors explored the use of vitreoretinal surgical techniques as an alternative method of eradicating subfoveal CNV. After vitrectomy, a small retinotomy technique was used to extract or disconnect from the choroidal circulation subfoveal CNV in 58 eyes. There were 33 eyes with ARMD, 20 eyes with presumed ocular histoplasmosis, and 5 eyes with miscellaneous etiologies. Five eyes also received subfoveal RPE patches. With limited follow-up, significant improvement in vision (defined as 2 Snellen lines) was achieved in 7 of 22 eyes with ARMD CNV removal (1 eye 20/20), 0 of 4 eyes with ARMD CNV removal and RPE patches, and 1 of 7 eyes with ARMD CNV disconnection. Significant improvement was achieved in 6 of 16 eyes with presumed ocular histoplasmosis removal and 0 of 4 eyes with presumed ocular histoplasmosis CNV disconnection. In 5 eyes with miscellaneous CNV, 2 improved (20/20 and 20/40). CNV recurred in 29%. Some patients with subfoveal CNV appear to benefit from surgical removal. Only rarely do eyes with ARMD improve. Longer-term follow-up and refined case selection are required before this approach can be widely recommended.