1. Macular Epiretinal membrane
Case
Macular Epiretinal membrane
AP. 박영훈/ R2 이용은

2. 62/M C.C.) Decreased visual acuity (OD) Past history onset)2months ago
DM/HBP(-/-)
Ocular trauma/op(-/+) : cat op(OD) at local clinic

3. Ocular exam (2010.11.01) VA OD 0.63(0.8 x +0.75Ds = -0.50Dc Ax 90)
OS 0.8(n-c)
IOP OD 10 mmHg
OS 12 mmHg at 10:00AM
Lid OU no swelling
Conjunctiva OU not injected
Cornea OU Clear
AC OU deep & cell(-)
Pupil OU Round and normal sized LR(+/+)
Lens OD PCL in situ
OS mild cortical opacity

4. Ocular exam (2010.12.02) C.C.) Metamorphopsia (OD) VA OD (0.63)
OS (0.8)
Fd OD thin ERM c PVD
Plan
M-OCT(OD)
Tagen 3C#3 and Lacure
F/U in 1month

5. M-OCT

6. Macular Epiretinal Membrane
Review
Macular Epiretinal Membrane

7. Macular epiretinal membrane
Definition : Cell proliferation and connective tissue deposition above the ILM of macula
Pathology : Glial cell at ILM defect → Fibrous astrocytes,myofibroblasts, hyalocytes, RPE, macrophages → Clinically significant ERM

8. Etiology Idiopathic : related to PVD
Retinal vascular occlusive disease DM
Inflammatory disease
Intraocular tumor
After ocular surgery
RD surgery
Cataract operation
Laser or cryotherapy

9. Epidemiology 2% of eyes at age 50 20% of eyes at age 75
Macular pucker : 3~8.5% of eyes after RD surgery
Bilaterality : 20~30%

10. Symptoms Asymptomatic Blurred vision and mild distortion Diplopia
Macropsia
Metamorphopsia
67%, VA > 20/60
F/U for 2years → 10~25% lose 1 or 2 lines of vision

11. Gass Classification Grade 0 : Cellophane maculopathy : transparent ERM
: normal visual acuity, no symptoms
Grade 1 : Crinkled cellophane maculopathy
: fine retinal folds
: vessel tortuosity
: symptoms of metamorphopsia

12. Gass Classification Grade 2 : Macular pucker
: marked retinal distortion and wrinkling
: associated with intraretinal hemorrhages, retinal edema, cotton-wool spots, localized serous detachment, PVD
: VA less than 20/400 in severe cases

13. Clinical findings Cellophane retinopathy : translucent
Macular pucker : opaque

14. Clinical findings
Pseudohole : elliptical shape and surrounding ERM

15. FAG Retinal vascular tortuosity Macular leakage DDx. with macular hole
To find associate disease

16. Treatment Observation because VA remain quite stable
If vision worsens, the possibility of other disease (cataract, AMD, etc)

17. Treatment
Visual acuity less than 20/50 and accompanying diplopia or metamorphopsia
Pucker after RD surgery; within 2 months
For eyes with idiopathic ERM, when vision has decreased significantly

18. Preoperative evaluation
Is the membrane the definite cause of decreased vision?
Associated macular hole
Choroidal neovascularization
Macular edema
Cataract
Partial PVD associated with VMT

19. Surgical prognosis Poor prognostic factor Good prognostic factor
Poor preoperative visual acuity(VA)
CME
RPE atrophy associated leakage
RPE disruption from any etiology
ERM after RD surgery
Good prognostic factor
Preoperative VA more than 20/60
Short duration
Thin ERM

20. Surgical procedure Pars plana vitrectomy
MVR blade and fine-tipped intraocular FB forceps
Memorize the area over which the ERM has been removed
“Area within the vascular arcades should be free of traction”
After ERM removal, indirect ophthalmoscopic exam to detect the peripheral retinal breaks(6%) → cryotherapy or endolaser

21. Surgical procedure Removing ERM often simultaneously removes ILM
Stain ILM
- ICG dye : ILM not ERM
-Trypan blue : ERM > ILM, no toxicity
-Triamcinolone : only FDA approved for use in the eyes

22. Surgical Results
Visual acuity usually gradually recover during 2 months to 1 year
Patients note improvement in metamorphopsia during the 1st month after surgery
Wrinkles do not disappear in many cases
Idiopathic ERM : 80~90% VA gain 2 or more Snellen lines

23. Surgical Complications
Cataract → combined surgery
Retinal breaks : 1~6% (check before FAE)
RD : 1~7%
Visually significant recurrent ERM : 0~5%
Endophthalmitis

24. Reference
Retina, 4th edition , Stephen J. Ryan 형광안저촬영