Retina shift restores sight
Duke Eye Center performs surgery to help people
with macular degeneration see again

By SARAH AVERY, Staff Writer

DURHAM -- There is no cure for macular degeneration, but that's a bit of hairsplitting if you ask Alice Haynes.

The eye disease, the leading cause of blindness among older Americans, robbed Haynes of central sight in her left eye and was quickly going after her right. On the advice of a friend, she went to Duke Eye Center for radical surgery.

Now, at 69, the Chapel Hill grandmother of nine is back to driving, and golfing, and reading -- things she thought she'd never do again.

"People will say to me, 'My God, this is a miracle,' " Haynes said. "And it really is."

The surgery is called macular translocation, and it offers hope to people who have lost sight in one eye and are beginning to lose it in the other.

The two-phase procedure involves moving the macula -- the center of the retina that contains specialized cells for fine vision -- away from a diseased area underneath, restoring vision.

Dr. Robert Machemer, emeritus chairman of the Duke Eye Center, was a pioneer in the surgery in the early 1990s, but it is only now gaining momentum. His successors at the center have fine-tuned the process with advanced techniques and tools.

Dr. Cynthia Toth, associate professor of ophthalmology, said she was initially skeptical that the procedure was safe and effective.

"I thought it was too extreme," Toth said. But she had experience with macular degeneration, having watched her grandmother lose her sight to it. And she was compelled by the results, with many patients regaining enough central vision to read again.

She began performing the surgery at Duke in 1996 and has done more than 230 operations. She also teaches the technique to other eye surgeons.

"People can get their vision back," she said. "It just blows you away."

But it's not for everyone. Because of potential complications, a patient is considered for the operation only if he has already lost sight in one eye and is in the early stages of losing it in the other. Complications include such problems as double vision or tilted vision.

The alternative, however, is the certainty that central vision will deteriorate, taking with it many of the activities essential to independent living.

Age-related macular degeneration afflicts 1.6 million Americans in their later years, according to the National Eye Institute. While its cause is unknown, how it works is better understood.

When macular degeneration strikes, deposits form behind the macula, creating a cloudy hole in the central vision. The most common form of the disease, striking 85 percent of the time, is the "dry" form, which refers to the bloodless way the deposits develop.

A less common "wet" form occurs when blood vessels behind the retina begin to leak, creating a bulge that lifts the macular part of the retina away from the eye wall.

Brief opportunity

In both cases, the macula eventually thins and dies, leading to permanent damage. Duke's surgery capitalizes on that brief period -- perhaps six months -- when the macula is still healthy but vision is deteriorating as a result of the abnormal growth under the retina.

The first surgery is an exacting procedure that relies on an operating microscope. Enlarged images of the interior of the eye are projected onto a video screen. Toth and a surgical resident sit at the patient's head, peering into the microscope or at the video screen as they work with tiny instruments inside the eye.

The patient, under local anesthesia, is awake, and Toth chatters amiably to offer updates and explanations of the work. As she enters the eye, Toth sets about removing the vitreous gel that fills the eyeball. Then she injects a fluid under the retina to loosen it from the abnormal cells.

Using a tool devised by Machemer, she gently cuts the retina, a fine filament that has the consistency of wet tissue paper, to separate it from the eye wall and rotate it away from the damaged area.

In a recent case, she carefully lifted the deposit that had caused the macular degeneration, much like lifting a scab from skin.

Then, donning special goggles, Toth fired a laser at the edges of the retina so that it would implant back along the eye wall. Finally, she filled the eye with a silicone oil to hold the retina in place. The procedure lasted about two hours.

Haynes, who had the surgery in January 2001, said the first procedure was not painful but required a two-week regimen in which she had to keep her head in certain positions for 12 hours a day -- four hours with her head resting on a table, four hours lying on each side. The positioning was to assure that the retina healed in its new location.

"Friends came and talked with me and brought me tapes to listen to," she said. "It wasn't that bad. I felt that the end result was far worth the inconvenience."

Second round

Because the center of vision is shifted, patients have a tilted perspective from that eye, and Haynes said this was disconcerting, as if everything was tipped to the side. The second surgery is designed to correct this tilt.

At Duke, the second operation is performed eight weeks later by another team of eye surgeons led by Dr. Sharon Freedman. The eye itself is rotated, and the muscles are adjusted to hold the new focus. Haynes said she recovered quickly from the second surgery, although her vision remains slightly tipped at about 5 degrees.

That has created problems only for her golf game, she said: "I have trouble reading the greens."

But Haynes is back to participating in her book club, driving around Chapel Hill, even threading sewing needles. She was so proud of the latter feat, in fact, that she carried her threaded needle to Toth as a testimony to the surgery's success.

Toth sports it on the lapel of her white coat.

Staff writer Sarah Avery can be reached at 829-4882 or savery@newsobserver.com

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Dr. Cynthia Toth, right, a Duke eye surgeon, and associate Prithvi Mruthyunjaya operate on a patient with macular degeneration.

Toth uses a microscope during macular translocation surgery on a patient with macular degeneration.
Staff Photos by John Rottet