The surgical management of macular degeneration with the resection of choroidal neovascularization (CNV) had its heyday through the 1990’s. The procedure was originally introduced by Matthew Thomas and Henry Kaplan in 1991 (ncbi.nlm.nih.gov/pubmed?term=thomas%20ma%20kaplan%20hj). A fluffy of instruments and refinement in techniques followed for the next decade. Resection of CNV particularly in young patients with histoplasmosis or myopia would often have amazingly good visual results. Recurrence of the CNV was still a major problem, along with other surgically related complications. Results in age-related macular degeneration (AMD) were much more unpredictable. Finally, the procedure was put to the test with the multicenter, NIH sponsored Submacular Surgery Trials (SST). Its conclusions published in 2004 (ncbi.nlm.nih.gov/pubmed/15522362) concluded that surgical resection was not better than the natural history for AMD, and was not recommended. Surgery for histoplasmosis was also determined by the SST to have little to no benefit as well. (ncbi.nlm.nih.gov/pubmed/15534121). The conclusion of the SST and the advent of amazingly good visual results with anti-VEGF pharmacologic injection therapy with ranibizumab and bevacizumab have all but pushed submacular surgery permanently into the history books.
This video shows a case of ocular histoplasmosis with subfoveal CNV undergoing surgical resection in 1992. The case shows a recurrent neovascular membrane adjacent to a histo scar, and former laser scar. The first step was to cauterize the retina with an intraocular diathermy probe to allow entry with the subretinal instruments. As the technique evolved, it was found that this cautery step was unnecessary. An angle probe was then slid into the subretinal space and BSS injected to hydraulically elevate the macula. This technique was also later replaced by the development of a very slender 41 ga cannula (deJuan) that was used to balloon up the retina by direct infusion as a slender jet stream through the retina without creating a prior retinotomy. A long, slender “Thomas Pick” was then used to carefully dislodge the CNV complex from the RPE and histo/laser scar. Side gripping forceps were then brought in to remove the CNV from the subretinal space. In this video, conventional side gripping forceps were used as that was all that was available commercially in 1992. Over the next 5 years, a series of very elegant, slender submacular forceps as well as submacular scissors were developed to make this step more efficient and less damaging. After the CNV was removed from the eye, the retinotomy site was treated with endolaser. This laser step was also found to be unnecessary. This video shows a case of submacular surgery done in 1992 when the technique was in its infancy. Many of the steps were modified or eliminated, so that by the end of the 90’s it was a much quicker, safer and more elegant procedure. Just in time for the procedure to die, and be buried in the history books. Still the techniques have provided techniques and principles still useful today, particularly the ability to infuse fluid into the subretinal space with tiny cannulas, and the ability to create posterior retinal breaks without the need to seal them with endolaser.
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