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Macular translocation for neovascular age-related macular degeneration

  • Review
  • Intervention

Authors


Abstract

Background

Macular translocation has been proposed by vitreoretinal surgeons to displace the neuroretinal tissue onto healthy retinal pigment epithelium and choroid when the macula has been invaded by subretinal neovascularisation.

Objectives

This review aims at assessing the effectiveness of macular translocation for preserving or improving vision in patients with neovascular age-related macular degeneration (AMD).

Search methods

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE and Caribbean Literature on Health Sciences (LILACS). There were no language or date restrictions in the search for trials.The electronic databases were last searched on 21 July 2008.

Selection criteria

We included randomised or quasi randomised controlled trials comparing macular translocation with any other treatment or observation.

Data collection and analysis

Two authors independently extracted the data. The risk ratio (RR) of visual loss and visual gain was estimated at one year after treatment.

Main results

Only one small unblinded study on 50 people compared full macular translocation with photodynamic therapy (PDT) in AMD patients with predominantly classic subfoveal choroidal neovascularisation (CNV). At the last examination, performed in most of the cases after one year, there was no difference in the rate of visual loss of 3 or more lines (translocation versus PDT: RR 0.56, 95% confidence interval (CI) 0.22 to 1.43), as well as in the mean change of contrast sensitivity (1 letter favouring translocation; 95% CI -3.51 to 5.51) and the rate of recurrence of CNV (translocation versus PDT: RR 1.56, 95% CI 0.83 to 2.91). Other outcomes significantly favoured translocation, such as the gain of 3 or more ETDRS lines (RR 21, 95% CI 1.30 to 340.02), the mean change of visual acuity (mean difference (MD) 14.60, 95% CI 5.39 to 23.81) and the mean change of near visual acuity score (MD 17.80, 95% CI 3.98 to 31.62) which is obtained with an algorithm. Serious complications reported after macular translocation were retinal detachment in 6/25 patients and diplopia requiring prismatic correction in 5/25 patients.

Authors' conclusions

There is insufficient evidence from randomised controlled trials on the effectiveness of macular translocation, which is also not free of important risks. Furthermore, this technique is difficult to perform and a long surgical training is required. Future studies might include patients with small neovascular lesions that failed to respond to current pharmacological therapies and are willing to accept the risks associated with surgery to try to improve visual acuity.

摘要

背景

黃斑部轉位術用於新生血管的老年性黃斑退化

玻璃體視網膜外科醫師建議,當黃斑被視網膜下的新生血管侵入時可使用黃斑部轉位術來置換神經視網膜組織到健康的視網膜色素上皮細胞與脈絡膜。

目標

這篇回顧的重點在於評估黃斑部轉位術對於保存或改善新生血管的老年性黃斑退化患者視力的效果。

搜尋策略

我們檢索考科藍圖書館的the Cochrane Central Register of Controlled Trials (CENTRAL),MEDLINE,EMBASE及Caribbean Literature on Health Sciences (LILACS)。檢索試驗的條件不限制語言或日期。電子資料庫最近一次的更新是在2008年7月21日。

選擇標準

我們納入比較黃斑部轉位術與任何其他治療或觀察法的隨機或類隨機對照試驗。

資料收集與分析

兩名作者分別摘錄資料。估計治療後一年視力喪失與獲得的相對風險(risk ratio (RR))。

主要結論

只有一篇小型非盲目的研究,包含50人,比較全黃斑部轉位術與光動力療法(photodynamic therapy (PDT))治療主要為典型的中心窩下脈絡膜新血管生成(choroidal neovascularisation (CNV))的AMD患者。最近一次的評估發現,一年後大部分的病例其3行或以上視力喪失的比率(轉位術對照PDT:RR為0.56,95% confidence interval (CI)為0.22至1.43),以及對比敏感度的平均改變量(一個字母的結果偏好轉位術;95% CI為−3.51至5.51)及CNV復發的比率(轉位術對照PDT:RR為1.56,95% CI為0.83至2.91)沒有差異。其他的結果顯著偏好轉位術,如獲得3行或以上的ETDRS(RR為21,95% CI為1.30至340.02),視力的平均改變量(平均差(mean difference (MD))為14.60,95% CI為5.39至23.81)及由算數取得之近距離視力評分的改變量(MD為17.80,95% CI為3.98至31.62)。黃斑部轉位術後的嚴重併發症有6/25的患者視網膜剝離且5/25的患者其複視需要稜鏡矯正。

作者結論

隨機對照試驗沒有提供關於黃斑部轉位術效果的足夠證據,且也不能避免重要的風險。再者,這種技術不容易進行且需要長期的手術訓練。未來的研究可以納入小病灶的新生血管病人,其曾以目前的藥物治療失敗,並願意承受與手術相關的風險以嘗試改善視力。

翻譯人

本摘要由高雄榮民總醫院金沁琳翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

黃斑部轉位術用於老年性黃斑退化:目前不清楚是否黃斑部轉位術可以改善濕型AMD患者的視力,這種老年性黃斑退化的形成是因為在視網膜中央稱為黃斑有異常生長新的血管而形成。老年性黃斑退化會導致視野中央的失明點,且其為西方國家老年人法定失明最常見的原因。黃斑部轉位術是一種手術方式,其包括視網膜剝離並將黃斑移至損傷較少的區域。有些眼科醫師認為這種手術有助於改善病患的視力。我們發現一篇小型的研究認為視力可能會獲得改善,但在視網膜位移的過程可能會出現嚴重的併發症。因此,大部分已取得治療的濕型AMD病患不考慮使用黃斑部轉位術。

Plain language summary

Macular translocation for age-related macular degeneration

It is unclear if macular translocation can improve vision in patients with wet AMD, the form of age-related macular degeneration (AMD) caused by the abnormal growth of new blood vessels in the region of the central retina called macula. Age-related macular degeneration leads to the development of a blind spot in the centre of the visual field and is the most common cause of legal blindness among the elderly in the western world. Macular translocation is a surgical procedure that involves the detachment of the retina which includes the macula into a less-damaged area. Some ophthalmologists have suggested that this surgery can help patients improve vision. We found a small study suggesting that vision might improve, but severe complications can arise during the process of retinal displacement. Thus, macular translocation might not be considered for most patients with wet AMD given the treatment options already available.