Macular rotation with and without counter-rotation of the globe in patients with age-related macular degeneration.

Macular rotation to treat exudative age-related macular degeneration (AMD) involves translocation of the fovea to a site with intact retinal pigment epithelium. To avoid the inevitable postoperative cyclotropia we combined this procedure with torsional muscle surgery. In 30 eyes the macula was rotated upward by 30-50 degrees following complete artificial retinal detachment and a 360 degrees retinotomy. Simultaneous torsional muscle surgery was not carried out in the first 8 eyes; in the remaining 22 eyes surgery of the oblique muscles was performed alone or in combination with surgery of two or four rectus muscles. Simultaneously or later, muscle surgery was performed on the fellow eye in 17 of these patients. Three of the eight patients who had no primary muscle surgery were operated on later. They had muscle surgery on the macular-rotated eye and on the fellow eye. Postoperatively, the silicone oil was removed from all but one eye and an intraocular lens implanted in all but two eyes. Five eyes developed a postoperative retinal detachment, three of them with proliferative vitreoretinopathy. Three other eyes developed a recurrence of the choroidal neovascularization. At last examination, 18 of the 30 eyes (60%) had a near vision of 0.4 or better, sufficient for the reading of normal newsprint. Six of the eight patients who did not undergo muscle surgery reported considerable disorientation caused by the postoperative diplopia and cyclotropia. The muscle operation, which has been performed in a total of 25 patients, conferred complete freedom from complaints in all but one patient. Macular rotation succeeded in restoring reading vision in about half of cases of exudative AMD, at least in the short term. The most serious complication was the development of a retinal detachment. The extremely disorienting side effects of diplopia and tilted image could be prevented or effectively treated by muscle surgery for counter-rotation of the globe, if need be also in the fellow eye.