Epiretinal MembraneEpiretinal Membrane

Nawat WatanachaiRamathibodi Hospital

Mahidol University

Epiretinal membrane (ERM)Epiretinal membrane (ERM)

An avascular fibrocellular membrane that proliferates on the inner surface of the retina to produce various degrees of macular dysfunction

Common synonymsCommon synonyms

Cellophane maculopathy Macular pucker Premacular fibrosis/ gliosis Surface wrinkle retinopathy Epimacular membrane

Epidemiology and pathogenesisEpidemiology and pathogenesis

Idiopathic ERMSecondary ERM

Epidemiology and pathogenesisEpidemiology and pathogenesis

Idiopathic ERM6% in > 50 yrs oldF>MBilat 20-30%

Epidemiology and pathogenesisEpidemiology and pathogenesis

Idiopathic ERMPVD 90%

Retinal glial cells migrate through defects in the ILM probably create at the time of vitreous separation

Epidemiology and pathogenesisEpidemiology and pathogenesis

SecondaryAfter repair of RRD : 4-8%–Risks : older age, preop VH, macular

detachment, preop sign of PVR, large RB, use of cryo, multiple Sx

–RPE cells that liberated into the vit cavity and proliferate

Epidemiology and pathogenesisEpidemiology and pathogenesis

SecondaryAfter prophylactic treatment of peripheral break : 1-2%Trauma, vit inflam condition, retinal vascular dis, long-standing VH

Ocular manifestationsOcular manifestations

Depend on its thickness and the extent (occlusion) to which it has undergone shrinkage or contraction (traction)

Ocular manifestations: thin ERM, Cellophane maculopathy

Ocular manifestations: thin ERM, Cellophane maculopathy

thin and transparent Abnormal glistening light reflex from the inner

retinal surface Mostly asymptomatic

Ocular manifestation: thick ERM, puckerOcular manifestation: thick ERM, pucker Inner retinal striae radaite from edge of ERM White-gray/ white translucent membrane, may

obscure visualization of the retinal vessels

Ocular manifestation: thick ERMOcular manifestation: thick ERM

More severe degree of macular dysfunctionMacular distortion, folding, puckeringMacular edema, pre-retinal/ intraretinal hemorrhageFoveal ectopia, macular pseudoholeTRD, RB, RRD

ERM with Foveal ectopiaERM with Foveal ectopia

Ocular manifestation: thick ERMOcular manifestation: thick ERM

Vision loss Metamorphopsia central photopsia binocular diplopia macropsia

Ocular manifestation : pseudo or true macular holeOcular manifestation : pseudo or true macular hole

PseudoholeWrinkle of inner retinal surfaceRetinal tissue at the base of pseudoholeAbsence of characteristics of true hole: yellow pigment deposits in the base, halo of neural detachment. Overlying operculum/ pseudooperculum

Equivocal cases : OCT, FFA

PseudoholePseudohole

Diagnosis and ancillary testingDiagnosis and ancillary testing

Clinical, based on biomicroscopic observation Examination/ photography with Red-free light Watzke-Allen test OCT FFA: retinal vascular distortion that underlies an

ERM

Diagnosis and ancillary testingDiagnosis and ancillary testing

Diagnosis and ancillary testingDiagnosis and ancillary testing

DDXDDX

VMT syndrome Combined RPE and retinal hamartoma Prominent macular light reflex in the young CME Optic disc swelling (juxtapapillary ERM) Idiopathic MH

PathologyPathology

ERM consists of avascular fibrocellular sheetNative vitreousNewly synthetic collagenFragment of ILM

Myofibroblastic Cells : RPE cells, fibrous astrocytes, macrophages

TreatmentTreatment

ERM with minimal symtoms : no treatment but observation

Treat in cases ofSignificant visual lossMetamorphopsiaIntolerable binocular diplopia

Goal of treatmentGoal of treatment

Reduce or eliminate most common mechanisms of visual loss, including macular distortion, TRD, foveal ectopia, membrane that cover the fovea, retinal vascular leakage with macular edema, traction-induce obstruction of axoplasmic fold

Surgical proceduresSurgical procedures Pars plana vitrectomy +/- staining Engage the edge of

ERM with a retinal pick/ forceps/ sharp bent-tip needle

Peel the membrane with forceps

stainingstaining

peelingpeeling

Course and outcomesCourse and outcomes

Most pts who have ERM experience little or no symptom progression after dx

10-25% of eyes show a decline in VA in mths/ yrs

Rarely spontaneous separate from retina

Course and outcomesCourse and outcomes

After Sx, resolute within days/ wksVA improve 2 or more snellen lines in 60-

85% of eyes and may continue for 6-12 mths after Sx

2-15% of eyes have worse VA postop Visual function rarely returns to normal

Cases with minimal benefit Cases with minimal benefit

Patients who have symptoms that has lasted longer than 1 yr

Findings that suggest long-standing casesAtrophic/ hypertrophic RPE alterationsIntraretinal lipid/ hard exudatesMicrovascular changes such as microaneurysms

ComplicationsComplicationsProgressive sclerotic cataract (MC)

60-70% in 2 yrs Peripheral retinal breaks RRD Posterior retinal breaks Photic maculopathy Endophthalmitis Recurrence 5%

Thank youThank you