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Case Reports and Small Case Series
November 1998

Traumatic Foveal Relocation With Good Visual Acuity

Arch Ophthalmol. 1998;116(11):1536-1537. doi:

Neovascular age-related macular degeneration is a major cause of visual loss in elderly patients.1 Treatment options are limited for most of these patients. Surgical relocation of the foveal retina to an area of healthy retinal pigment epithelium (RPE) has been described.26 We report a case of traumatic foveal relocation with good visual acuity.

Report of a Case

An 18-year-old man suffered a bottle rocket injury with resultant trauma to his left eye. His right eye was not injured and had an uncorrected visual acuity of 20/20. Left eye evaluation revealed light perception visual acuity without associated light projection. A 50% hyphema and corneoscleral laceration were present. The laceration extended 2 mm posterior to the limbus at the 9- and 12-o'clock positions, involved the superonasal corneal quadrant, and extended to the center of the visual axis. Repair of the laceration with excision of prolapsed iris was performed the day of the injury by the referring physician.

The patient was seen at our institution 4 days following his injury. Left eye visual acuity was light perception, intraocular pressure was 10 mm Hg, and an ophthalmic examination showed an intact corneal wound. Corneal edema, disrupted lens material, and a hemorrhage precluded a view to the retina. Ultrasonography revealed a possible superonasal retinal detachment.

A vitrectomy was performed 18 days after his injury, removing the traumatically disrupted lens and hemorrhagic vitreous. The corneal clarity had improved adequately to proceed without a temporary keratoprosthesis.

The retina was tractionally elevated in a ridge extending from the optic disc to the 11-o'clock position periphery where depressed examination revealed retinal incarceration in the original rupture site. The borders of the ridge had a concave appearance and no evidence of a break was found. The macula was attached, but rotated superiorly. The vitreous base was trimmed 360° with scleral indentation and a 3.5-mm circumferential buckle was placed to support the vitreous base. No gas or silicone oil was used.

The subretinal fluid beneath the tractional retinal elevation resolved, resulting in a dry fold postoperatively (Figure 1). His remaining retina remained attached. His fovea was found to be rotated superiorly 43° with the darker RPE of the central macula visible beneath the retina adjacent to the inferotemporal arcade vessels. Fine spiral folds were seen at the superotemporal disc margin (Figure 2). He fixated reliably on the area of foveal relocation and had a corrected visual acuity of 20/60 OS at 6 weeks. The visual acuity was obtained despite vascularization of the corneal wound and corneal sutures within the visual axis. He reported excyclorotation of images in his left eye.

Figure 1.
Dry retinal fold extending from the optic disc to the 11-o'clock position.

Dry retinal fold extending from the optic disc to the 11-o'clock position.

Figure 2.
Superior foveal relocation. Darker macular retinal pigment epithelium is superior to the inferotemporal arcade vessels (solid arrow). Fovea is rotated 43° counterclockwise (open arrow).

Superior foveal relocation. Darker macular retinal pigment epithelium is superior to the inferotemporal arcade vessels (solid arrow). Fovea is rotated 43° counterclockwise (open arrow).

Comment

Therapy for neovascular age-related macular degeneration is limited. Photocoagulation of choroidal neovascularization is useful for a small percentage of patients. Surgical removal of choroidal neovascularization has limited success in improving vision.1

In age-related macular degeneration many components of the complex of macular RPE, Bruch's membrane, and choriocapillaris are dysfunctional. Surgically relocating the fovea to an area of healthy RPE that may preserve foveal function has been proposed. Different surgical methods have been described to accomplish foveal relocation.26

The macular area is characterized by the greatest density of RPE melanin pigmentation7 and a lobular choroidal angioarchitecture that allows for extremely fast circulation.8 The ability of extramacular RPE and choriocapillaris to support good foveal function is relatively unknown.

Our patient demonstrates good visual acuity following foveal relocation to an area of extramacular RPE. Assuming comparatively good extramacular RPE function in patients with age-related macular degeneration, foveal relocation may offer a surgical alternative to the limited treatment options available to those with subfoveal choroidal neovascularization.

BackExtra

Supported in part by an unrestricted grant from Research to Prevent Blindness, Inc, New York, NY.

Corresponding author: Dean P. Hainsworth, MD, Mason Eye Institute, One Hospital Dr, Columbia, MO 65212 (e-mail: dean_hainsworth@muccmail.missouri.edu).

References
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