scanning laser ophthalmoscope fundus perimetry after surgery for choroidal neovascularization

Scanning Laser OphthalmoscopeFundus Perimetry After Surgery

for Choroidal Neovascularization

ANAT LOEWENSTEIN, MD, JANET S. SUNNESS, MD, NEIL M. BRESSLER, MD,MARTA J. MARSH, MS, AND EUGENE DE JUAN, JR, MD

● PURPOSE: Submacular surgery is under investi-gation for the treatment of subfoveal choroidalneovascularization secondary to age-related macu-lar degeneration, ocular histoplasmosis syndrome,and other causes. The aims of this study were todetermine whether the macular area from whichchoroidal neovascularization was removed surgi-cally remained functional and whether there wasany qualitative difference between eyes with dif-ferent disease conditions or between eyes ofyounger and older patients.● METHODS: Our study included 19 patients (19eyes) with choroidal neovascularization, sevencases caused by age-related macular degenerationand 12 caused by ocular histoplasmosis syndrome,pathologic myopia, or idiopathic causes. All testswere performed at least 6 months after surgicalremoval of choroidal neovascularization. All pa-tients underwent fundus perimetry with the scan-ning laser ophthalmoscope for evaluation of denseand relative scotomas and fixation site.● RESULTS: After submacular surgery in 19 pa-tients, 10 patients (one with age-related macular

degeneration and nine with pathologic myopia,ocular histoplasmosis syndrome, or an idiopathiccause of choroidal neovascularization) fixated withinan area that ophthalmoscopically and angiographi-cally was an area of retinal pigment epithelial dis-turbance occupied by choroidal neovascularizationpreoperatively. Of 12 patients without age-relatedmacular degeneration, seven of eight patientsyounger than 50 years of age compared with two offour patients 50 years or older fixated within thearea of retinal pigment epithelial disturbance.● CONCLUSIONS: Our data suggest that in patientswithout age-related macular degeneration who un-dergo submacular surgery, the surgically disturbedarea previously occupied by choroidal neovascular-ization can remain functional postoperatively. Fur-thermore, occasionally a patient with age-relatedmacular degeneration undergoing submacular sur-gery still can fixate in the area from which thechoroidal neovascularization was removed. (AmJ Ophthalmol 1998;125:657–665. © 1998 byElsevier Science Inc. All rights reserved.)

S UBMACULAR SURGERY FOR THE REMOVAL OF

choroidal neovascularization and submacularhemorrhage is currently being investigated as a

potential treatment in the management of age-related macular degeneration, ocular histoplasmosis,and other disease conditions.1-13 Preliminary evi-dence in small groups of patients with limitedfollow-up suggests that surgery can be accomplishedin a wide range of lesions and may be beneficial. Amulticenter investigation, the Submacular SurgeryTrials, currently is evaluating the feasibility of

Accepted for publication Sept 23, 1997.From The Wilmer Ophthalmological Institute, Johns Hopkins Hos-

pital, Baltimore, Maryland. Statistical support was funded by core grantEYO1765 from the National Institutes of Health, Bethesda, Maryland.The work with the scanning laser ophthalmoscope was supported inpart by the Harry and Jeanette Weinberg Foundation, Baltimore,Maryland; the Morris Rodman Philanthropic Foundation, Rockville,Maryland; the Altsheler-Durell Foundation, Louisville, Kentucky; TheGrousbeck Family Foundation, Boston, Massachusetts; and the MaculaFoundation, New York, New York.

Reprint requests to Eugene de Juan, Jr, MD, The Wilmer Ophthal-mological Institute, The Johns Hopkins Hospital, Maumenee 738, 600N Wolfe St, Baltimore, MD 21287; fax: (410) 614-9315; e-mail:[email protected]

© 1998 BY ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED.0002-9394/98/$19.00 657PII S0002-9394(98)00014-2

submacular surgery for the treatment of choroidalneovascularization.14 From the information reportedin retrospective studies, there appears to be a differ-ence in visual prognosis between patients withocular histoplasmosis syndrome and patients withage-related macular degeneration. Very few patientswith age-related macular degeneration experience amarked improvement in central visual acuity aftersurgery compared with as many as 40% of patientswith ocular histoplasmosis syndrome. The reasonsfor this difference are not completely clear. It hasbeen proposed that the choroidal neovascularizationsecondary to ocular histoplasmosis syndrome oftenlies between the neurosensory retina and the retinalpigment epithelium, allowing removal with mini-mal disruption to the Bruch membrane and theretinal pigment epithelium, whereas in age-relatedmacular degeneration, the retinal pigment epithe-lium usually is incorporated within the choroidalneovascularization.15-21

In most of the previously mentioned studies, thevariables used to measure outcome of submacularsurgery include visual acuity and anatomic successrates (absence of recurrent choroidal neovascular-ization). However, the size of the central scotoma(blind spot) and the relation of the fixation site tothe surgically disturbed area, including the areaoccupied by choroidal neovascularization preopera-tively, have not been studied in detail, to ourknowledge. These variables may be critical, both forunderstanding the postoperative healing processand for determining visual performance in readingand other tasks.22 Scanning laser ophthalmoscopefundus perimetry can determine the relationshipsbetween anatomic and functional changes in themacula and thus contribute greatly to our under-standing of the mechanism and potential for visualrecovery after submacular surgery.22-32 To ourknowledge, only two studies have been publishedpreviously in which scanning laser ophthalmoscopemacular perimetry was used for visual functionassessment of submacular surgery; each of themreported the results in four to six eyes.12,13

The aims of the present study were to determineto what degree the macular area from which cho-roidal neovascularization was removed during sub-macular surgery remained functional as assessed byscanning laser ophthalmoscope perimetry and to

determine whether there was any qualitative differ-ence between eyes with different disease conditionsor between eyes of younger and older patients.

PATIENTS AND METHODS

WE IDENTIFIED ALL THE PATIENTS WHO HAD SUB-

macular surgery performed by a single surgeon (E. deJ.) at the Wilmer Ophthalmological Institute fromJanuary 1994 until February 1996. Of the 49 pa-tients identified, 19 (12 women and seven men)were included in the present study. Among the 30patients who were excluded from the study were onepatient who had died; three patients who could notbe reached; eight patients who could not come forevaluation during the time the study was performed;15 patients who participated in the ongoing multi-center Submacular Surgery Trials, in which scan-ning laser ophthalmoscope fundus perimetry is notpart of the study protocol; and three patients inwhom final visual acuity was considered to be toopoor (hand movement or light perception only) tohave a scanning laser ophthalmoscope examination.In the latter three patients, the postoperative courseafter submacular surgery was complicated by a vit-reous hemorrhage or a retinal detachment.

Of the 19 patients who were included in thepresent study, seven had choroidal neovasculariza-tion caused by age-related macular degeneration,and 12 patients had choroidal neovascularizationcaused by conditions other than age-related maculardegeneration (pathologic myopia in six patients,ocular histoplasmosis syndrome in five patients, andidiopathic causes in one patient). The mean age ofthe patients with age-related macular degenerationwas 70.7 years (median, 72 years; range, 64 to 75years). The mean age of the patients with choroidalneovascularization not caused by age-related macu-lar degeneration was 44.6 years (median, 42.5 years;range, 18 to 68 years).

A complete pars plana vitrectomy was performedusing a standard three-port technique. Then aretinotomy site was created with a soft-tipped can-nula. No diathermy was used before the retinotomywas made. The leading edge of the fibrovasculartissue was identified and gently pulled using subreti-nal forceps. A fluid-air exchange completed the

AMERICAN JOURNAL OF OPHTHALMOLOGY658 MAY 1998

procedure. Patients were instructed to maintain aface-down position postoperatively as long as a largeair bubble was present in the eye.

Preoperatively, all patients underwent stereo-scopic color fundus photographs and fluoresceinangiography. At least 6 months postoperatively, thepatients underwent a complete ocular examination,including best-corrected visual acuity using a back-lit Early Treatment Diabetic Retinopathy Study(ETDRS) chart, color fundus photography, andscanning laser ophthalmoscope perimetry to evalu-ate macular function. The visual acuities wereconverted to a logMAR scale for analysis but arereported as Snellen visual acuity equivalents.

The location of the fovea was defined withoutreference to the scanning laser ophthalmoscope, usinglandmarks such as perifoveal capillaries and xantho-phyll. When these landmarks were not visible, thelocation of the foveal avascular zone was approxi-mated by measuring 3.0 mm from the temporal edgeof the disk horizontally and measuring 0.5 mm downfrom the center of the disk vertically.31

A transparent template of Macular Photocoagu-lation Study (MPS) disk areas was used, where 1MPS disk area equals approximately 2.5 mm2 on theretina, assuming a camera magnification of 2.5. Todetermine the size of the choroidal neovasculariza-tion preoperatively and the size of the surgicallydisturbed area postoperatively, we placed the trans-parent template on a frame of the preoperative andpostoperative angiogram or color fundus photographin which the boundaries of the lesion were clearlydemarcated.

A prototype Rodenstock scanning laser ophthal-moscope (G. Rodenstock Instrument GmbH, Mu-nich, Germany) was used. The fundus was imagedon a video monitor using an infrared laser. Thestimuli were generated using a helium-neon redlaser with an acousto-optic modulator, allowing theintensity of the beam to be changed pixel by pixel,with resolution of 2 minutes of arc (10 mm). Afixation cross of 1 degree in size was used. Thestimulus was a 0.4-second flash of 10 minutes of arc(50 mm) in size. The maximum stimulus intensity,used for detecting scotomas, was approximately70,000 trolands. The sites of fixation and scotomawere determined on the scanning laser ophthalmo-scope using a technique called landmark-driven

fundus perimetry, which has been described indetail previously.31 To summarize briefly, thismethod allows for making a plan to uniformly testthe central retinal area. The test uses a circular gridof five concentric circles centered on fixation, each1 degree apart, with 12 meridians tested for eachcircle, for a total of 60 points, and additional pointsof specific interest are added. The order of stimuluspresentation is randomly selected. This techniqueprovides reproducible and retinally correct testingby using the change in position of a retinal land-mark to drive the presentation of the stimulus to thedesired retinal location. The area of dense scotomawas measured from a printed copy of the scanning laserophthalmoscope results. In two cases, the scotoma wastoo large to be seen in the scanning laser ophthalmo-scope field. Several fields were then tested to encom-pass the whole area of visible retinal pigment epithelialdisturbance. A dense, or absolute, scotoma was definedas consistent absence of response to the brighteststimulus presented by the scanning laser ophthalmo-scope. Maps of the scotoma were made, and the size ofthe scotoma was measured.

The patients also underwent testing of letter andword reading. Letters or words appeared one at atime in the center of the scanning laser ophthalmo-scope screen. The patient was instructed to readeach letter or word.

The location of the foveal center was estimatedusing preoperative and postoperative fluoresceinangiograms and fundus photographs that were avail-able. The fixation site as identified by scanning laserophthalmoscope evaluation was mapped onto thefundus photograph, and the distance between thefoveal center and the fixation site was measuredusing a reticle.

The location of fixation relative to the scar and tothe estimated foveal center was determined byinstructing the patient to look directly at the cross(maintaining steady fixation as much as possible)while the observer noted the location. The locationof fixation was characterized in two ways. First,fixation was characterized in terms of whether it waswithin the area of the surgically disturbed area. Thesurgically disturbed area was the clearly defined areaof retinal pigment epithelial absence, atrophy, ordepigmentation seen postoperatively, which did notexist preoperatively (Figures 1 and 2, top right).

SCANNING LASER OPHTHALMOSCOPE FUNDUS PERIMETRYVOL. 125, NO. 5 659

This area consistently showed a transmission defecton the early phase of a fluorescein angiogram but noleakage in the late phase. If the fixation site was notwithin this surgically disturbed area, then the dis-tance of the fixation site from the edge of thesurgically disturbed area was determined. Second,fixation was characterized in terms of whether it wasin the fovea. If the fixation was determined not tobe foveal, the distance of the fixation from the foveawas determined. Fixation stability was assessed qual-itatively by observing the placement of the fixationcross on the retina, and quantitatively as the aver-age absolute deviation in position of the landmarkfor all stimulus presentations during testing for a

dense scotoma. This technique has been describedpreviously.31 Most sessions were videotaped.

Differences in fixation location were analyzedwith the Fisher exact test. The Wilcoxon rank sumtest was used for comparing the distributions of theother measures.33 A P value less than or equal to0.05 was considered statistically significant.

RESULTS

CHARACTERISTICS AND RESULTS FOR THE 19 PA-

tients (19 eyes) are outlined in Table 1. The mediantime 6 SD between surgery and scanning laser

FIGURE 1. (Top left) Patient 15. Preoperative early-phase fluorescein angiogram shows diffuse hyperfluo-rescence from classic choroidal neovascularization in apatient with ocular histoplasmosis. (Top right) Postop-erative fundus photograph. The fixation site (arrow),determined by the scanning laser ophthalmoscope pe-rimetry (bottom left), is within the surgically disturbedarea (arrowheads) previously occupied by choroidalneovascularization. (Bottom left) Scanning laser oph-thalmoscope perimetry. The fixation target (whitecross, not visible because of the whiteness of the scar inthe background) is positioned at the arrow. The blackcross is used for generating the stimulus and is not seenby the patient. There is a dense scotoma in most of theregion inferior to fixation, but the portion of thesurgically disturbed area (arrowheads), including fixa-tion and superior to it, is functional. Open symbols 5areas of dense scotoma, solid symbols 5 visually unaf-fected retinal areas.


ophthalmoscope perimetry was 374 6 260 days(range, 184 to 1,139 days).

The patients were analyzed in two groups, accord-ing to their primary diagnosis. The first groupincluded only patients with age-related maculardegeneration (n 5 7); the second group included all

the other patients who had choroidal neovascular-ization resulting from pathologic myopia, ocularhistoplasmosis syndrome, or idiopathic causes (n 512). Results of visual acuity and scotoma size in thetwo groups are listed in Table 2. Postoperatively, themean change in visual acuity in the first group, was

FIGURE 2. (Top left) Patient 6. Preoperative fluorescein angiogram in the midphase shows hyperfluorescence fromclassic (straight arrows) and occult (curved arrows) choroidal neovascularization in a patient with age-related maculardegeneration. (Top right) Postoperative fundus photograph shows the fixation site (black arrow), determined by thescanning laser ophthalmoscope perimetry (bottom right), and the surgically disturbed area (arrowheads). (Bottomleft) Postoperative fluorescein angiogram in the late phase shows no leakage from the surgically disturbed area orfixation site (arrow) determined by scanning laser ophthalmoscopy perimetry. (Bottom right) Scanning laserophthalmoscopy perimetry. The white cross indicates the site of fixation. The black cross is used for generating thestimulus and is not seen by the patient. Fixation is superior to the surgically disturbed area (arrowheads) and isslightly more than 1 disk area from the superotemporal vessels. There is a dense scotoma corresponding to thesurgically disturbed area. Open symbols 5 areas of dense scotoma, solid symbols 5 visually unaffected retinal areas.


12.7 logMAR (a loss of almost 3 lines). In thesecond group, the mean change was 20.01 logMAR(an improvement of less than 1 letter).

The results of scanning laser ophthalmoscopeperimetry are outlined in Table 3. Ten (53%) of the19 patients fixated within the area of surgicallyinduced retinal pigment epithelial change. One(14%) of the seven eyes with age-related maculardegeneration fixated within the surgically disturbedarea, whereas nine (75%) of the 12 eyes withoutage-related macular degeneration fixated within thesurgically disturbed area. The difference betweenthese two groups was significant by the Fisher exacttest (P 5 .02). All of the eyes with choroidalneovascularization stemming from ocular histoplas-mosis syndrome or idiopathic causes as well as threeof the six myopic eyes fixated within the surgicallydisturbed area. When patients without age-relatedmacular degeneration were analyzed by age, seven of

eight patients younger than 50 years compared withtwo of four patients over 50 years could fixate withinthe area of surgically induced retinal pigment epi-thelial change. Figure 1 illustrates fixation withinthe surgically disturbed area for a patient withocular histoplasmosis syndrome. Figure 2 illustratesfixation outside the surgically disturbed area for apatient with age-related macular degeneration. As-sessment of fixation stability confirmed the localiza-tion of fixation in all cases.

The patients with age-related macular degenera-tion had statistically significant larger choroidal neo-vascularization sizes preoperatively. Postoperatively, allbut one patient with age-related macular degenerationhad surgically disturbed areas of 6 or more disk areas;one patient with macular degeneration fixated withina surgically disturbed area that measured 3 disk areas.All patients without macular degeneration had surgi-cally disturbed areas smaller than 6 disk areas.

TABLE 1. Patient Characteristics and Individual Patient Results

Patient No.,

Age (yrs),

Sex Diagnosis

Visual Acuity*

CNV Size

(DA)†

Time Between

Surgery and

SLO (days)

SDA

(DA)

Size of Dense

Scotoma (DA)

Fixation Relative

to SDA

Distance of

Fixation

From

Fovea

(mm)Preoperative

Postoperative

ETDRS

Postoperative

(Letter) Acuity

on SLO

1, 64, F AMD 20/200 20/250 20/132 6 204 6.0 6.0 Nasal 0.8

2, 75, F AMD 20/400 20/400 20/400 1 (16) 794 9.0 8.5 No fixation NA

3, 72, M AMD 20/100 20/100 20/132 6 762 9.0 8.7 Edge 0

4, 65, M AMD 20/1280 20/1280 ND 9 184 9.0 9.0 Nasal to disk 4.5

5, 72, F AMD 20/150 20/1280 20/280 9 1,139 9.0 4.0 No fixation NA

6, 73, F AMD 20/80 20/320 20/72 6 689 9.0 9.0 Edge 3.2

7, 74, F AMD 20/100 20/160 20/210 6 387 3.0 3.0 Within 2.0

8, 40, F Myopia 20/200 20/30 20/32 1 400 0.25 0.25 Within 0

9, 33, F Myopia 20/120 20/640 20/120 ND 588 ND 4.0 Nasal 3.0

10, 38, F Myopia 20/200 20/125 20/66 ND 317 ND 3.3 Within 0

11, 60, M Myopia 20/400 20/400 20/144 2 (4) 358 3.0 3.0 Superior 1.1

12, 60, M Myopia 20/100 20/100 20/160 ND 374 4.0 1.0 Within 0

13, 68, F Myopia 20/50 20/600 ND 1 593 2.0 8.0 Edge 1.0

14, 41, F OHS 20/70 20/25 20/34 2 (2.5) 237 3.0 2.5 Within 0

15, 46, F OHS 20/400 20/125 20/152 2 (2.5) 207 3.0 2.0 Within 0

16, 56, M OHS 20/100 20/100 20/72 1 516 1.0 0.3 Within 0

17, 31, M OHS 20/60 20/125 20/106 1 329 1.5 2.0 Within 2.5

18, 44, M OHS 20/100 20/80 20/40 2 (6) 192 2.0 1.75 Within 0

19, 18, F Idiopathic

causes

20/60 20/60 20/34 2 190 0.25 0.2 Within 0

AMD 5 age-related macular degeneration; CNV 5 choroidal neovascularization; DA 5 disk area; ETDRS 5 Early Treatment Diabetic

Retinopathy Study; NA 5 not applicable; ND 5 not done or not available; OHS 5 ocular histoplasmosis syndrome; SDA 5 surgically

disturbed area; SLO 5 scanning laser ophthalmoscope; VA 5 visual acuity.

*Postoperatively, best-corrected visual acuity was measured using the ETDRS chart, and letter visual acuity was measured on SLO.†Values in parentheses indicate total size when including blood.


The scanning laser ophthalmoscope letter visualacuity was within 3 lines of the postoperative visualacuity attained with the ETDRS chart for all pa-tients fixating within the surgically disturbed area.In contrast, four of seven eyes that did not fixatewithin the surgically disturbed area had at least a3-line improvement in scanning laser ophthalmo-scope visual acuity compared with the postoperativeETDRS visual acuity.

DISCUSSION

THE RESULTS DEMONSTRATE THAT IN SOME PATIENTS

undergoing submacular surgery for treatment ofchoroidal neovascularization, the surgically dis-turbed area can remain functional postoperatively,even in patients with age-related macular degener-ation. This preservation of function was noted moreoften in patients without macular degeneration.Patients without age-related macular degeneration,

on average, were younger than patients with age-related macular degeneration. The extent of retinalpigment epithelial disturbance was smaller in eyesthat fixated within the surgically disturbed area thanin eyes that fixated outside it. For the patients withage-related macular degeneration, the preservationof function or the size of the surgically disturbed areacould not be predicted from the size of the choroidalneovascularization preoperatively because only one ofthese patients fixated within the surgically disturbedarea. Because the scanning laser ophthalmoscope let-ter acuity was within 3 lines of the postoperative visualacuity attained with the ETDRS chart for all patientsfixating within the surgically disturbed area, we suspectthat patients actually are using this area for dailyactivities.22 In contrast, there were large differencesbetween visual acuity attained with the scanning laserophthalmoscope and ETDRS visual acuity in thegroup not fixating within the surgically disturbed area.These patients may have found the task of readingwith only one high-contrast letter displayed at a time

TABLE 2. Visual Acuity and Fluorescein Angiography Results

Variable All Patients (n 5 19) AMD (n 5 7) Non-AMD (n 5 12)

P

Value*

Preoperative visual acuity .28

Median 20/100 20/150 20/100 —

Range 20/50–20/1280 20/80–20/1280 20/50–20/400 —

Postoperative visual acuity .05

Median 20/125 20/320 20/125 —

Range 20/25–20/1280 20/100–20/1280 20/25–20/600 —

Change in visual acuity (no. [%]) .12

Within 1 line 9 (47) 4 (57) 5 (42) —

.1 line improvement 4 (21) 0 (0) 4 (33) —

.1 line worsening 6 (32) 3 (43) 3 (25) —

Preoperative size of CNV (DA)

(n 5 16)†.008

Median 2 (5) 6 (6) 2 (2) —

Range 1–9 (1–16) 1–9 (6–16) 1–2 (1–6) —

Postoperative size of surgically

disturbed area (DA) (n 5 17)

.001

Median 3 9 2 —

Range 0.25–9 3–9 0.25–4 —

Change in size after surgery (%)‡ .79

Median 0 0 0 —

Range 287.5 to 100 250 to 50 287.5 to 100 —

AMD 5 age-related macular degeneration; CNV 5 choroidal neovascularization; DA 5 disk area; SD 5 standard deviation.

*Wilcoxon rank sum test (AMD vs non-AMD).†Parenthetic values indicate size with blocked fluorescence.‡Preoperative size with blocked fluorescence.


to be simpler than localizing and reading a letter onthe visual acuity chart. Even with the scanning laserophthalmoscope, some of the patients had difficultyfixating on the letter outside the dense scotoma so thatthey could read it.

The factors that determine the retention of cen-tral vision in eyes undergoing submacular surgeryare not entirely clear. Removal of the choroidalneovascularization may arrest the enlargement ofthe choroidal neovascularization, preserve some ofthe neurosensory retina overlying the choroidal neo-vascularization, and allow photoreceptors adjacent tothe damaged retina to function normally. Retinalpigment epithelial cells adjacent to the treated areacan repopulate the area that was operated on as earlyas 1 week after surgery in monkeys,15 contributing tofunctional success. The visual recovery might be lim-ited by preoperative damage to the photoreceptorcells, retinal pigment epithelium, or choriocapillaris aswell as by intraoperative denudement of subfovealretinal pigment epithelium. In case of denudement ofsubfoveal retinal pigment epithelium, failure to restorea functional retinal pigment epithelium in the bed ofthe surgically excised choroidal neovascularizationmay compromise vital retinal pigment epithelium–mediated trophic factors that support the overlying

photoreceptors and the underlying choriocapillaris,thereby resulting in loss of photoreceptors and chorio-capillaris. Preliminary evidence suggests that the abil-ity of retinal pigment epithelial cells to regeneratemight be markedly greater in younger eyes.34

Even though this study was performed in a smallnumber of patients, the data suggest that in patientswithout age-related macular degeneration who un-dergo submacular surgery, the area of surgicallyinduced retinal pigment epithelial disturbance oc-cupied by choroidal neovascularization preopera-tively might have the potential to remain functionalpostoperatively. Furthermore, this study showedthat even a patient with choroidal neovasculariza-tion caused by age-related macular degenerationwho undergoes submacular surgery could fixate withinthe area from which the choroidal neovascularizationand, presumably, some retinal pigment epithelium andphotoreceptors were removed. The difference in prog-nosis for visual recovery after submacular surgery be-tween patients with age-related macular degenerationand those with ocular histoplasmosis syndrome re-ported in previous series might be explained, at least inpart, by age differences, with less ability of senescentretinal pigment epithelium to regenerate. Anotherpossibility would be that fewer retinal pigment epithe-lial cells or photoreceptors or both are removed duringsurgery for treatment of choroidal neovascularizationnot related to age-related macular degeneration. Theresults of our study suggest that the potential of thetreated area to function postoperatively may be asso-ciated, at least in part, with the patient’s age orunderlying disease entity.

REFERENCES

1. Thomas MA, Grand MG, Williams DF, Lee CM, Pesin SR,Lowe MA. Surgical management of subfoveal choroidalneovascularization. Am J Ophthalmol 1992;99:952–968.

2. Berger AS, Kaplan HJ. Clinical experience with the surgi-cal removal of subfoveal neovascular membranes: short-term postoperative results. Ophthalmology 1992;99:969–976.

3. Lambert HM, Capone A Jr, Aaberg TM, Sternberg P Jr,Mandell BA, Lopez PF. Surgical excision of subfovealneovascular membranes in age-related macular degenera-tion. Am J Ophthalmol 1992;113:257–262.

4. Russell SR, Crapotta JA, Zerbolio D Jr. Surgical removal offoveal neovascularization. Ophthalmology 1993;100:795–797.

TABLE 3. Results of Scanning LaserOphthalmoscope Perimetry

Variable

All Patients

(n 5 19)

AMD

(n 5 7)

Non-AMD

(n 5 12) P Value

Size of dense

scotoma (DA)

.003*

Median 3 8.5 2 —

Range 0.2–9 3–9 0.2–8 —

Fixating within

surgically disturbed

area (no. [%])

10 (53) 1 (14) 9 (75) .002†

Distance of fixation

from fovea

.08*

Within 500 mm 9 1 8 —

500–1,500 mm 3 1 2 —

1,501–3,000 mm 3 1 2 —

.3,000 mm 2 2 0 —

No stable fixation 2 2 0 —

AMD 5 age-related macular degeneration; DA 5 disk area.

*Wilcoxon rank sum test (AMD vs non-AMD).†Fisher exact test.


5. Ormerod LD, Puklin JE, Frank RN. Long-term outcomesafter the surgical removal of advanced subfoveal neovascu-lar membranes in age-related macular degeneration. Oph-thalmology 1994;101:1201–1210.

6. Thomas MA, Dickinson JD, Melberg NS, Ibanez HE,Dhaliwal RS. Visual results after surgical removal ofsubfoveal choroidal neovascular membranes. Ophthal-mology 1994;101:1384 –1396.

7. Capone A Jr, Sternberg P Jr. Advances in submacularsurgery. Am J Ophthalmol 1994;188:659–663.

8. Vander JF. Tissue plasminogen activator irrigation to facil-itate removal of subretinal hemorrhage during vitrectomy.Ophthalmic Surg 1992;23:361–363.

9. Sabates FN, Fletcher DC. Surgical excision of subfovealneovascular membranes in age-related macular degenera-tion. Am J Ophthalmol 1992;113:241–242.

10. Lewis H. Intraoperative fibrinolysis of submacular hemor-rhage with tissue plasminogen activator and surgical drain-age. Am J Ophthalmol 1994;118:559–568.

11. Ibanez HE, Williams DF, Thomas MA, et al. Surgicalmanagement of submacular hemorrhage: a series of 47consecutive cases. Arch Ophthalmol 1995;113:62–69.

12. Hudson HL, Frambach DA, Lopez PF. Relation of thefunctional and structural fundus changes after submacularsurgery for neovascular age-related macular degeneration.Br J Ophthalmol 1995:79:417–423.

13. Sabates NR, Crane WG, Sabates FN, Schuchard RA,Fletcher DC. Scanning laser ophthalmoscope macular pe-rimetry in the evaluation of submacular surgery. Retina1996;16:296–304.

14. Bressler NM. Submacular surgery: are randomized trialsnecessary? [editorial]. Arch Ophthalmol 1995;113:1557–1560.

15. Valentino TL, Kaplan HJ, Del Priore LV, Fang SR, BergerA, Silverman MS. Retinal pigment epithelial repopulationin monkeys after submacular surgery. Arch Ophthalmol1995;113:923–938.

16. Green WR, Enger C. Age-related macular degenerationhistopathologic studies. Ophthalmology 1993;100:1519–1535.

17. Lopez PF, Grossniklaus HE, Lambert HM, et al. Pathologicfeatures of surgically excised subretinal neovascular mem-branes in age-related macular degeneration. Am J Ophthal-mol 1991;112:647–656.

18. Grossniklaus HE, Martinez JA, Brown VB, et al. Immuno-histochemical and histochemical properties of surgicallyexcised subretinal neovascular membranes in age-relatedmacular degeneration. Am J Ophthalmol 1992;114:464–472.

19. Saxe SJ, Grossniklaus HE, Lopez PF, Lambert HM, Stern-berg P Jr, L’Hernault N. Ultrastructural features of surgi-cally excised subretinal neovascular membranes in theocular histoplasmosis syndrome. Arch Ophthalmol 1993;111:88–95.

20. Das A, Puklin JE, Frank RN, Zhang NL. Ultrastructural

and immunocytochemistry of subretinal neovascular mem-branes in age-related macular degeneration. Ophthalmol-ogy 1992;99:1368–1376.

21. Gass JDM. Biomicroscopic and histopathologic consider-ations regarding the feasibility of surgical excision ofsubfoveal neovascular membranes. Am J Ophthalmol 1994;118:285–298.

22. Sunness JS, Applegate CA, Haselwood D, Rubin GS.Fixation patterns and reading rates in eyes with centralscotomas from advanced atrophic age-related macular de-generation and Stargardt disease. Ophthalmology 1996;103:1458–1466.

23. Timberlake GT, Mainster MA, Webb RH, Hughes GW,Trempe CL. Retinal localization of scotomata by scanninglaser ophthalmoscopy. Invest Ophthalmol Vis Sci 1982;22:91–97.

24. Webb RH, Hughes GW, Delori FC. Confocal scanninglaser ophthalmoscope. Applied Optometry 1987;26:1492–1499.

25. Fletcher DC, Schuchard RA, Livingstone CL, et al. Scan-ning laser ophthalmoscope macular perimetry and applica-tions of low vision rehabilitation clinicians. OphthalmolClin N Am 1994;7:257–265.

26. Schuchard RA, Fletcher DC. Preferred retinal locus: areview with applications in low vision rehabilitation. Oph-thalmol Clin N Am 1994;7:243–256.

27. Schuchard RA. Validity and interpretation of Amsler gridreports. Arch Ophthalmol 1993;111:776–780.

28. Schuchard RA, Raasch TW. Retinal locus for fixation:pericentral fixation targets. Clin Vis Sci 1992;7:511–520.

29. Sjaarda RN, Frank DA, Glaser BM, Thompson JT, MurphyRP. Resolution of an absolute scotoma and improvement ofrelative scotomata after successful macular hole surgery.Am J Ophthalmol 1993;116:129–139.

30. Sunness JS, Bressler NM, Maguire MG. Scanning laserophthalmoscopic analysis of the pattern of visual loss inage-related geographic atrophy of the macula. Am J Oph-thalmol 1995;119:143–151.

31. Sunness JS, Schuchard RA, Shen N, et al. Landmark-driven fundus perimetry using the scanning laser ophthalmo-scope (SLO). Invest Ophthalmol Vis Sci 1995;36:1863–1874.

32. Chamberlin JA, Bressler NM, Bressler SB, et al. The use offundus photographs and fluorescein angiogram in the iden-tification and treatment of choroidal neovascularization inthe macular photocoagulation study. Ophthalmology 1989;96:1526–2534.

33. Armitage P. Statistical methods in medical research. NewYork: John Wiley & Sons, 1971.

34. Leonard DS, Zhang XG, Panozzo G, Sugino LK, ZarbinMA. Clinicopathologic correlation of localized retinalpigment epithelium debridement. Invest Ophthalmol VisSci 1997;38:1094–1109.

Authors InteractivetWe encourage questions and comments regarding this article via theInternet on Authors Interactivet at http://www.ajo.com/ Questions, com-ments, and author responses are posted.


scanning laser ophthalmoscope fundus perimetry after surgery for choroidal neovascularization

Documents