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

2. 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

3. Physical Exam
VS: BP 115/79, P 74
VA: OD 20/ PH NI, OS 20/ PH /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

4. 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

5. Note dragging of vessels, tortuosity, color changes

6. Dragging, tortuosity

7. Cystic spaces evident in this incidence

8. Cystic rupture in another incidence

9. 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

10. 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.

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

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

13. 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

14. 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

15. 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

16. 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

17. 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

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

20. 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

21. Gass, J. Donald M. Stereoscopic Atlas of Macular Diseases, Diagnosis and Treatment, Volume II, 4th Edition , Kanski, Jack J. Clinical Ophthalmology. 4th Edition