Surgical treatment of low vision

John Gorfinkel, MD, CM, FRCSC

ABSTRACT • RÉSUMÉ
Recent advances in technology are driving a renewed search to find surgical solutions for low vision
rehabilitation. The scope of surgery is now being pushed beyond the initial goal of repairing existing
anatomical structures. Today, the goal for vision rehabilitation is no less than replacing damaged ocular
tissues with artificial ones. Surgical management of low vision may be subdivided into two categories,
those procedures aimed at restoring ultrastructural visual function and those aimed at enhancing visual
acuity of the residual retina with various levels of magnification. This paper briefly reviews advances in
ultrastructural restoration by repair and considers in more detail enhanced acuity through magnification
or replacement.

Les progrès récents de la technologie suscitent un renouveau dans la recherche de solutions chirurgicales
en réadaptation visuelle. On pousse maintenant la chirurgie à aller au-delà des objectifs du début qui
étaient de réparer les structures anatomiques existantes. Aujourd’hui, la réadaptation visuelle n’a pour
but rien de moins que de remplacer le tissu oculaire endommagé par de l’artificiel. Le traitement
chirurgical de la malvoyance se répartit en deux catégories : les procédures qui ont pour objet de
restaurer la fonction visuelle ultrastructurale et celles qui ont pour objet d’améliorer l’acuité de la rétine
résiduelle par divers degrés de grossissement. Le présent article examine une brève revue des progrès
en restauration ultrastructurale et plus en détails l’amélioration de l’acuité par grossissement.

TRADITIONAL EYE SURGERY replacing nonfunctional tissue. One can attempt to

T raditional eye surgery attempts to restore ocular
microstructure with the understanding and hope
that such procedures will restore visual function.
Cataract surgery, retinal detachment surgery, procedures
to peel retinal membranes, and subretinal surgery all
restore structures within the eye to bring back visual
function. The direct surgical treatment of age-related
macular degeneration (AMD), the most common cause
of low vision in patients over 75 years of age,1 includes
submacular membranectomy of central neovascular
membranes, pneumatic displacement of submacular
blood, and translocation of the macula to locations of
healthier retinal pigment epithelium (RPE).
Unfortunately, the results of surgery for exudative AMD
over the last 15 years have not greatly increased visual
acuity outcome.2 Macular translocation surgery and dis-
placement of submacular blood, however, have been
shown to improve vision in selected patients.2,3
LOW VISION REHABILITATION SURGERY
The surgical management of low vision is aimed not
at repairing ocular damage but at enhancing the resolu-
tion acuity of the residual retina or even at bypassing or
achieve this either by the surgical introduction of
devices that produce magnification or by the surgical
introduction of electronic structures.
Koziol et al4 presented one such approach by using a
teledioptric lens system in a study of 50 patients with
cataract and AMD. In their study, an intraocular lens
(IOL) implant with a diameter of 6.5 mm and a high
minus-power centre with a diameter of 1.9 mm pro-
duced a ×2.5 magnified image when coupled with high
plus-power spectacles, but created a normal, pseudopha-
kic image when used without these glasses. Although a
visual field 2.6 times wider than that formed with an
external telescope was achieved with the high plus-
power spectacles, visual acuity was improved in only
22% of patients in the study at one year. This approach
offers the unique choice of 2 optical systems, one with
the high plus-power spectacle that magnifies and one
without such glasses that provides more peripheral
vision, but a drawback is the decrease in image contrast
caused by the simultaneous production of 2 image foci
on the retina.
Recently another surgical option for low vision
patients was introduced by Balestrazzi et al5 with a 2-IOL

From the Department of Ophthalmology, University of Toronto, Correspondence to: John Gorfinkel, MD, 340 College St., Ste. 310,
Toronto, Ont. Toronto ON M5T 3A9; fax (416) 924-0329.

Originally received Sep. 5, 2005 This article has been peer-reviewed.

Accepted for publication Mar. 14, 2006
Can J Ophthalmol 2006;41:319–21

Surgical treatment of low vision—Gorfinkel 319

Surgical treatment of low vision—Gorfinkel
implant used to create a telescope. Balestrazzi was able
to improve vision in 16 patients with low vision by
implanting 2 IOLs, one in the bag and one in the ante-
rior chamber, to create a Galilean telescopic system
without reduction of peripheral visual field and with
×1.3 magnification. Best-corrected visual acuity (BCVA)
improved from a mean of 20.67 letters on the Early
Treatment Diabetic Retinopathy Study (ETDRS) chart
to 33.24 letters, and near BCVA from a mean of 3.50
Jaeger (J) to 1.83 J.
A similar, but nonsurgical, approach using a negative
contact lens and positive spectacles to create a contact-
lens telescope (CLT) was found to improve visual acuity
in various studies.6,7 Moreover, the visual field was
improved from 22° with a conventional telescope to
52.1° with a CLT. However, the CLT causes a mismatch
between head movement and image movement on the
retina like that of a conventional telescope because of its
effect on the vestibulo-ocular reflex (VOR). There is a
trade-off with these telescopes between the benefit of
increased visual acuity and the disadvantages of
restricted visual field and uncompensated retinal-image
movement by the VOR.
Clinical trials are currently taking place in the United
States to assess the risks and benefits of implanting a
miniature intraocular telescope in patients with AMD.
In a study of 40 eyes in 40 patients with dry AMD, the
implantable miniature telescope (IMT) improved dis-
tance visual acuity from 0.9 logMAR to 0.6 logMAR
and near acuity from 0.8 logMAR to 0.6 logMAR at
one year.8 On the other hand, the device is somewhat
bulky, extending 4.4 mm from the posterior segment
through the pupil to a distance 2 mm behind the cornea
and thus increasing the risk of corneal complications.9,10
This device magnifies in the same way as the familiar,
external Galilean telescope composed of a minus-power
eyepiece lens and a plus-power ocular lens. The main
claim for an IMT is that it improves mobility by restor-
ing the degree of eye movement required to compensate
for head movement, to a ratio of one, so that the VOR
may keep objects on the fovea while ambulating.10 If
one were to use a 3× external telescope, the VOR would
rotate the eye to compensate only for the degree of head
movement, but not for the degree of image movement on
the retina, which is 3 times as great. In other words, the
VOR would require a ratio, or gain, of 3 rather than 1.
Such adaptability has not been demonstrated. Another
advantage of an IMT requiring a VOR gain of 1, the
same as that of the other eye, is the potential to use the
telescope for magnification in the first eye, and to use
the other eye for a wider field of vision. The patient is
trained to alternate between the use of each eye.10 The
320 CAN J OPHTHALMOL—VOL. 41, NO. 3, 2006
advantage of the IMT over the external telescope
accrues from this effect on the VOR rather than from
any effect on loss of a ring of visual field, or ring
scotoma, which is intrinsic to both IMTs and external
telescopes. In the example of a 3× telescope with a field
of view of 5°, the ring scotoma would extend from an
inner angle of 5° to an outer one—3 times as large—of
15°. The 5° of object space seen through the telescope
occupies 15° of image space on the retina, and meets up
with unmagnified image space beyond the 15°, thereby
causing a 10° ring of field to disappear. This leads to
another undesirable effect of telescopic vision, the Jack-
in-the-box phenomenon, which occurs when objects
appear to vanish into or jump out of the ring scotoma.11
A recent editorial in this journal12 argued that an
implantable intraocular telescopic device would cause a
permanent loss of peripheral fields of vision, which is
critical for mobility, orientation tasks, and the ability to
use preferred retinal loci (PRLs) for intermittent spot-
ting purposes.
As a result of these trade-offs, other surgeons have
tried a moderate degree of magnification in an attempt
to balance the beneficial and detrimental effects of tele-
scopes. In this way, a surgical approach was used to
create a telescopic effect in 3 patients by pairing a low-
power IOL with a plus-power spectacle lens.13 Such a
low-power IOL functions as the minus eyepiece of a
Galilean telescope when combined with the plus-
correcting spectacle lens. The low-power IOL was used
to generate an end spectacle refraction of approximately
+6 dioptres, which resulted in a moderate magnification
of 12%. We are now involved in a study at the University
of Toronto to evaluate the use of such a strategy.14 A key
advantage to this approach is the use of existing IOL
technology with its known and well-controlled risks.
Indirect surgical treatment of low vision with elec-
tronic devices is now possible because of advances in
microchip technology. In retinitis pigmentosa (RP) and
AMD, photoreceptor function is replaced with subreti-
nal or epiretinal implants consisting of silicon micro-
chips that bypass the damaged photoreceptors by
directly stimulating the ganglion cells.15 The device
tested in a recent study consisted of a 16-electrode, plat-
inum stimulating array on the epiretinal surface; an
extraocular electronic implant in the temporal area of
the skull to generate the electrical impulses; and an
external unit (made of a small camera worn in the
glasses and connected to a visual processing unit worn
on a belt) to acquire, process, and transmit images for
use by the extraocular implant.16 The subject in this
study, blind from retinitis pigmentosa, was able to
detect ambient light and the motion of a dark object

and to recognize simple shapes. Subjects perceive the
world as a crude grid of light spots known as phosphene
vision.
Phosphene vision is also possible in patients who have
lost eyes from trauma by placing electrode arrays on the
visual cortex as shown by Dobelle and group in the
1970s.17 In an effort to improve perception beyond that
of phosphene vision, engineers at the University of
Pennsylvania have electronically copied, or “morphed”,
the structure of the retina in neuromorphic microchips
consisting of electronic components that mimic the
function of all 5 layers of the retina.18 The chip, named
Visio1, replicates responses of the retina’s 4 major types
of ganglion cell, and should provide near-normal vision
with an output of 3 600 ganglion cells. In this scenario,
the eye itself would function as the camera, and the
intraocular implant as the retina. Before such an
implant becomes a reality, however, further refinement
of biocompatible encapsulation materials and stimula-
tion interfaces will be needed. Nonetheless, this tech-
nology has the potential to provide vision where no
functioning retina exists, unlike the image-magnifying
devices described previously.
CONCLUSION
In summary, the evolution of surgical methods to
treat patients with low vision is leading to promising
outcomes. Retinal surgery, surgical methods to provide
telescopic magnification for low vision patients, and
retinal microchip implants where no retinal function
exists are now a reality, and we can look forward to
further improvement in materials and techniques.
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Key words: low vision, surgery, implants, telescope
CAN J OPHTHALMOL—VOL. 41, NO. 3, 2006 321