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

62/M C.C.) Decreased visual acuity (OD) Past history onset)2months ago DM/HBP(-/-) Ocular trauma/op(-/+) : 2010.3. cat op(OD) at local clinic

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

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

M-OCT

Macular Epiretinal Membrane Review Macular Epiretinal Membrane

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

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

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%

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

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

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

Clinical findings Cellophane retinopathy : translucent Macular pucker : opaque

Clinical findings Pseudohole : elliptical shape and surrounding ERM

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

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

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

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

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

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

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

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

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

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