Surgical Treatment of Acute Submacular Hemorrhages and Advanced Exudative Age-related Macular Degeneration

__Abstract__ Located behind the cornea, iris and lens, the vitreous is a clear gel in the center of the eye (figure 1). The inner surface of the eye is lined with retina, a multi-layered sensory tissue. In the retina the photoreceptors, rods and cones, are capable of phototransduction; light is converted into signals that will stimulate neuronal impulse transmission.1 The nerve impulses then travel through axons of the retinal ganglion cells, via the optic nerve to the visual cortex of the brain where these signals are processed. Under the retina are the retinal pigment epithelium (RPE) and Bruch’s membrane. The RPE is a monolayer of highly pigmented hexagonal cells which forms the outer blood-retinal barrier of the eye. The RPE is highly specialized in nutrient and waste transport, and in the synthesis and secretion of the proteins needed for retinal function.2 The retina is also protected from light damage by the RPE, as the RPE melanosomes absorb excess incoming light.1 The basement membrane of the RPE is the innermost layer of the five layers of Bruch’s membrane, and the basement membrane of the choriocapillaris forms the bottom layer of Bruch’s membrane. Bruch’s membrane further consists of fine collagen and elastic fiber layers through which nutrients pass from the choriocapillaris to the RPE, and through which cellular waste products pass from the RPE to the choriocapillaris.3 The choroid, which contains the choriocapillaris, supplies oxygen to the outer layers of the retina, whereas the retinal vessels supply the inner retina. The outermost layer of the eye is the sclera, which gives support and protects the eye, and to which the eye musculature is attached

Visual acuity of 20/32, 13.5 years after a retinal pigment epithelium and choroid graft transplantation

Purpose: To present the 13.5-year-survival of an autologous retinal pigment epithelium (RPE) and choroid graft transplantation with good visual acuity results. Observations: A 72-year old patient presented with a 5-weeks-old visual acuity deterioration to excentric finger counting at half a meter. Fundoscopy showed a fibrotic macular scar, a large subretinal hemorrhage, partly recent, combined with intraretinal fluid, blood, and hard exudates. RPE-choroid graft surgery was performed, and visual acuity improved to 20/32, and maintained up until 13.5 years postoperative. Microperimetry performed at the same time revealed a 3.4 dB sensitivity, with fixation on the graft. During the postoperative years glaucoma developed, an uveitis anterior was treated, and to treat a small Coats' like lesion; one bevacizumab injection was administered. Conclusions and importance: A best corrected visual acuity of 20/32 could be achieved and maintained up to 13.5 years after an RPE-choroid graft transplantation, despite an unfavorable preoperative presentation and some early and late complications. This case is a proof of principle that an RPE-choroid graft harvested from the midperiphery can support the macular metabolism up to 13.5 after surgery in a patient with severe exudative AMD. It also represents a rationale for pursuing stem cell derived RPE replacement. Anti-vascular endothelial growth factor injections are nowadays the mainstay of therapy for choroidal neovascularization and/or small hemorrhages and offer good results. Nevertheless, selected patients that cannot benefit from this therapy may profit from an autologous RPE-choroid graft transplantation