Sight-Saving Surgery Shows Promise, but Not Without Risk

From the WebMD Archives

Feb. 23, 2000 (Atlanta) -- Until she got something in her good eye, Margaret Brill never noticed that her other eye was going blind. "I'd look at a clock and see just the outside of it but not the hands, or I'd look at my husband and there was just a black hole where his face should be," she tells WebMD. "It was scary."

Unable to read the big 'E' on the eye chart with her failing eye -- 20/400 vision -- Brill was found to have the rare, "wet" form of age-related macular degeneration (AMD). While only 10% of AMD patients get the wet type, it causes 80% of the legal blindness associated with the condition. Faced with these statistics, Brill chose to undergo a risky surgical technique known as limited macular translocation. Today the 75-year-old Milwaukee resident has 20/40 vision in the eye -- good enough to read large type and to continue her hobby, quilting.

"If other people's vision is as bad as mine was in that eye, I would recommend it," she says. "Even if the surgery was not a success, [the eye] couldn't have got much worse, I think."

AMD occurs when a new bunch of blood vessels begins to grow under the retina, the eye's movie screen at the back of the eye. In other areas of the eye, ophthalmologists use laser surgery to burn away these blood vessels, leaving a hole in the retina and a blind spot. But when the blood vessels grow right in the middle of the retina -- an area called the macula that enables people to see clearly -- simple laser surgery leaves patients without the ability to see straight ahead.

About 15 years ago, Duke University researcher Robert Machemer, MD, began exploring ways to move the macula out of the way of these blood vessels. These efforts led to the surgical technique known as full macular translocation, which involves cutting the retina all the way around its borders and rotating it. Eugene de Juan Jr., MD, who worked with Machemer over the past five years, has pioneered a less risky technique -- limited macular translocation.

"Full macular translocation had been done in a few places around the world for a few cases, but it took five or six hours, it was associated with a lot of complications, and it was just not a very satisfying procedure -- but it proved that the concept of moving the retina was a good one," de Juan, professor of ophthalmology at Johns Hopkins University in Baltimore, tells WebMD. "I think what I've done is come up with a particular technique of macular translocation. It is the first to be relatively safe and it can be done by the majority of [retinal eye] surgeons."

Brill's surgeon, Judy E. Kim, MD, tells WebMD that while the operation is performed on an outpatient basis, it still carries many risks. "We deal not only with the eye situation, we have to gauge patients' health and social situation when recommending this procedure," says Kim.

Kim, assistant professor at the Eye Institute of the Medical College of Wisconsin in Milwaukee, says the new technique uses an injection of salt solution to gently detach the retina. "We try to move the retina downward so the macula no longer sits over the blood vessel," she says. "[Then we] just sort of twist the whole thing [the macula] around like a turntable or a pizza. The center is held in place and you just spin it around." A few days later, the blood vessels are treated with the laser. "It is not a risk-free procedure and is labor intensive, but when it works, vision improvement can be intense in patients with no other options."

But few patients do quite as well as Brill. "It depends on what you start with, but going from 20/400 to 20/40 is extremely rare," says de Juan, who has performed the procedure more than 400 times. "Only 20% of patients [will improve significantly]." Of the other patients, he says about 40% have less, but still significant, improvement and another 40% will have worsening of their vision.

According to de Juan, eye surgeons are getting better at identifying which patients would benefit the most from the procedure since this would not work for all patients with AMD. In the future, he predicts this will allow for a more aggressive approach to AMD treatment in the appropriate patient.

Levent Akduman, MD, of The Retina Center in St. Louis, tells WebMD that with greater experience, even full macular translocation is becoming an attractive option. "With new techniques, in the next year or two we will have a success rate of about 50% with full translocation," he predicts. He says the procedure, for some, "offers hope of regaining legal-driving vision. ... I definitely emphasize to patients that this is extensive surgery that may take six hours to do and may result in losing the eye. But the patients know it is the only chance for better vision in their eye. Again, we have come really quite a long way since 1996 when I started doing this. This surgery has a lot better chance than it did four or five years ago."

De Juan can be seen performing a limited macular translocation in a real-time video on the Internet at