RPE and Choroid Translocation in Geographic Atrophy

A major goal in surgery of geographic atrophy is the atraumatic creation of a submacular space by subretinal injection of BSS. Often the retinal-RPE-Choroid-adhesion is to tight, that water is insufficient. Then a spatula manoevre is advised with the tip of the spatula pointing to the RPE and choroid. Damage of Bruchs membrane is attempted to later on allow ingrowth of connecting vessels from the original choroid to the transplant.

The surgical steps are as follows:

Core vitrectomy, posterior vitreous separation, submacular fluid injection, eventually supported by a spatula manoevre, enlargement of a retinotomy temporal to the macula to allow the insertion of the transplant later on, laserdemarcation of the excision site, usually temporal inferior, laser disseminated between the excision site and the ora. Excision of the transplant, retina discarded, grabbing the transplant from the choroidal side near an edge. By using the edge of the retinotomy as a counter bearing the transplant is turned over so that the RPE side faces the photoreceptors in the subretinal space, positioning under the presseure of liquid perflurocarbon with a spatula underneath the transplant, exchange of liquid perfluorocarbon against heavy silicone.