Epiretinal Membranes, CME and Macular Holes Laura S. Gilmore, MD Grand Rounds November 14, 2003 Texas Tech University HSC Lubbock, TX

History Chief Complaint: VA OD “fading away” x 6-8 months HPI: 81yo male referred for evaluation of chronic CME OD s/p CE 3 years ago PMH: newly diagnosed DM with BS 120s-140s. HTN. Hypothyroidism. Arthritis. Hypercholesterolemia. Ocular History: CE OD 99; KNOWN CME x 3 years FH: diabetes, sister SH: no alcohol. Quit smoking >30 years ago

Physical Exam VS: BP 115/79, P 74 VA: OD 20/50 -1+2PH NI, OS 20/50 -1+1PH 20/40-2; VF FTFC OU x small central scotoma; AMSLER normal IOP: OD 10, OS 14 PCIOL OD, 3+ NSC OS Anterior segment clear, without pupil distortion, PSC, synechiae, lens dislocation DFE: OD-ERM; macular hole with flap of retinal tissue; multicystic CME; cryo scar supero-nasally; PVD with Weiss ring. OS-appears flat

Additional History 1978: blunt trauma OD-champagne cork vs eye Resultant RD, per patient Treated in San Diego VA Hospital with cryotherapy, pneumatic retinopexy? Still awaiting records from San Diego

Note dragging of vessels, tortuosity, color changes

Dragging, tortuosity

Cystic spaces evident in this incidence

Cystic rupture in another incidence

Hypotheses Senile macular hole Blunt trauma caused retinal tear and/or detachment, and hole directly or indirectly CME with ruptured cyst Vitreofoveal traction syndrome 1st, then ERM ERM 1st, leading to 1) tractional macular hole or 2) CME from ERM traction, then hole

Unlikely Choices Typical senile hole- not likely, since usually shows early hyperfluorescence Direct result of trauma in 1978? symptoms would have appeared within 6-12 months CME with ruptured cyst Not likely result of CE, or symptoms would have been evident within 6-8 months post-op. CE was over 3 years ago.

Most Likely Choice RD repair/cryo, with resultant ERM 1st, leading to 1) tractional macular hole or 2) CME from ERM traction, then hole

Macular Dysfunction Caused by Epiretinal Membrane Contraction Distortion Intraretinal edema, CME Degeneration of underlying retina

Classification by Distortion Grade 0: Cellophane Maculopathy-translucent with no distortion of retina; cellophane light reflex Grade 1: Crinkled Cellophane Maculopathy-irregular retinal folds and light reflex, radiating retinal folds; no to mild VA c/o, 20/40 at worst, +/-metamorphopsia, insidious onset Grade 2: Macular Pucker-grayish membrane; marked retinal crinkling and puckering of macula; PVD in 90%; may see edema, retinal heme, CWS, SRD, leakage by FA; VA 20/200 or less, insidious to sudden onset, usually with metamorphopsia

ERM Following Retinal Tear/Detachment Repair Grade 1 or 2 frequently seen s/p RT/RD repair usually occurs 8-16 weeks post-op VA in 20% of pts improves due to relaxation or partial peeling of ERM and resolution of intraretinal edema Traction on macula can lead to hole or CME

Clinical Features of CME Visual acuity is reduced according to severity and duration Longstanding cases usually result in coalescence of fluid-filled microcysts into large cystic spaces Lamellar holes form at fovea, causing irreversible damage to central vision SLE shows loss of foveolar depression, thickening of retina, and multiple cysts in sensory retina

Signs of Macular Hole Watzke-Allen-beam on foveola appears broken round, red spot in the center of the macula, 1/3 to 2/3 DD, surrounded by a gray halo lose foveolar depression; yellow spot in macula. Small, yellow precipitates in hole subretinally retinal cysts at the margin of the hole or a small operculum above the hole, anterior to the retina (stage 4) or both May be caused by vitreous or epiretinal membrane traction on the macula, trauma, or cystoid macular edema

Fluorescein Angiography CME-Dye accumulates in outer plexiform layer; Dye leaks into parafoveal region during the arteriovenous phase, coalesces into flower-petal pattern in late AV phase; hyperfluorescence from dye pooling in microcystic spaces persists through late phase Macular/lamellar holes-EARLY hyperfluorescence ERM-diffuse leakage of capillaries around FAZ; what we see

Summary ERM following RD repair tractional macular hole vs. CME from ERM traction, then hole

Proposed Treatment in this Case Surgery at 20/50? F/U this week, 20/25 OD No metamorphopsia, no Amsler symptoms just small central scotoma No; will follow. If VA decreases (at least 20/60) or pt has intolerable distortion, proceed with PPVx, membrane peeling

Gass, J. Donald M. Stereoscopic Atlas of Macular Diseases, Diagnosis and Treatment, Volume II, 4th Edition. 903-916, 938-954. Kanski, Jack J. Clinical Ophthalmology. 4th Edition. 424-425.