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Epiretinal Membrane

  • Author: Kean Theng Oh, MD; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Apr 30, 2016
 

Background

An epiretinal membrane (ERM) is a collection of collagenous cells that occurs on the inner surface of the central retina. These membranes have contractile properties and can lead to visual changes and metamorphopsia because of their effect on the underlying retina. See the image below.

Very dense epiretinal membrane with associated mac Very dense epiretinal membrane with associated macular distortion.

This ocular pathology was first described by Iwanoff in 1865, and it has been shown to be a relatively common entity, occurring in about 7% of the population. Epiretinal membranes have been called various names, including epimacular membranes, cellophane maculopathy, preretinal macular gliosis, preretinal macular fibrosis, macular pucker, preretinal vitreous membranes, epiretinal astrocytic membranes, surface wrinkling maculopathy, internoretinal fibrosis, and silk-screen retinopathy; all of which pertain to clinico-anatomic descriptions of pathologic findings produced by  epiretinal membranes of varying severity and differing morphologic characteristics.

Epiretinal membranes can be associated with various ocular conditions, such as posterior vitreous detachments (PVD), retinal tears, retinal detachments, retinal vascular occlusive diseases, ocular inflammatory diseases, and vitreous hemorrhage. However, a large proportion of cases do not occur in the context of any associated disease or known history and therefore are classified as idiopathic epimacular membranes (IEMM). Idiopathic and postdetachment membranes are the most common epiretinal membranes and, as such, are the focus of this article.

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Pathophysiology

Epiretinal membranes are avascular, fibrocellular membranes that proliferate on the surface of the retina and can lead to varying degrees of visual impairment. These cells, once in contact and attached to the retina, may proliferate and form sheets of membranes over the surface of the retina. Through their contractile properties, the underlying retina is, in turn, distorted. The effect on vision is variable and determined by the severity of the distortion, the location, and other secondary effects on the retina.

The source of the cells producing these membranes has been the source of great debate. Earlier reports proposed that glial cells (primarily fibrous astrocytes) from the inner layers of the neurosensory retina proliferated through breaks in the internal limiting membrane (ILM) produced after a retinal tear or a posterior vitreous detachment. Modern vitrectomy specimens have shown that epiretinal membranes comprise glial cells, retinal pigment epithelial cells, macrophages, fibrocytes, and collagen cells. These cells are found in varying proportions in accordance with the etiology of the membrane. Membranes associated with retinal breaks, previous retinal detachments, or cryopexy are composed mainly of dispersed RPE cells, while cells of glial origin predominate in the IEMM. Furthermore, these cells also possess the ability to change into cells with similar appearance and function.

The incidence of associated PVD in cases of IEMM range from 75-93%, and PVD is present in virtually all eyes with retinal breaks or retinal detachments and subsequent epiretinal membrane formation. It has been suggested that PVD may contribute to epiretinal membrane formation in many ways. PVD can lead to retinal breaks that may liberate RPE cells that initiate membrane formation. Small breaks in the ILM after PVD also may provide retinal astrocytes access to the vitreous cavity, where they may subsequently proliferate. Finally, vitreous hemorrhage, inflammation, or both associated with a PVD also may stimulate epiretinal membrane formation.

Epiretinal membrane formation without PVD may predispose patients to vitreomacular traction syndrome (VMT). Chang et al evaluated patients with VMT using a spectral-domain ocular coherence tomography (SD-OCT) and ultrastructural correlation using samples obtained during surgery.[1] They were able to document fibrocellular proliferation between the inner surface of the retinal and posterior surface of the vitreous, resulting in increased vitreoretinal adhesion.[1]

Bovey and Uffer observed a phenomenon of ILM tearing associated with epiretinal membrane.[2] They hypothesize that the presence of ILM tears and folds are more likely when the epiretinal membrane forms prior to a posterior vitreous detachment, resulting in the subsequent cleavage plane being between the ILM and the inner retina rather than at the ILM surface.[2]

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Epidemiology

Frequency

United States

The frequency at which epiretinal membranes occur varies according to the underlying disease. The idiopathic variety of epiretinal membranes has been shown to be present in up to 7% of the population. Bilateral cases have been seen in as much as 30% of the population. A 2016 examination of the Beaver Dam Eye Study cohort using OCT suggested a higher prevalence of epiretinal membrane in the population (34.1%).[3]

Clinically significant epiretinal membranes occur in 3-8.5% of eyes after successful primary retinal detachment surgery. Patients noted to be at the greatest risk for epiretinal membranes are those with preoperative signs of proliferative vitreoretinopathy, including rolled retinal edges, star folds, and equatorial ridges.

One study noted no significant difference in the frequency of epiretinal membranes in eyes that underwent subretinal fluid drainage compared to those that had nondrainage procedures. The possible risk of epimacular development in eyes that have undergone cryotherapy or laser photocoagulation for retinal tears is difficult to quantify because it is almost impossible to determine whether the cellular dispersion was caused by the retinal tear itself or the subsequent therapy for it.

The incidence of epiretinal membrane formation associated with other ocular pathologies, such as retinal vascular occlusive disease, ocular inflammation, or vitreous hemorrhage, is unknown.

Mortality/Morbidity

The visual loss depends on the severity of the distortion of the retina, the location of the wrinkling of the retina, and any other secondary effects of the membrane on the retina (eg, edema, hemorrhage).

Sex

Both sexes appear to be affected in relatively equal percentages.

Age

Epiretinal membranes occur more frequently in the older population, with postmortem studies showing 2% prevalence in individuals aged 50 years and as much as 20% prevalence in individuals aged 75 years.

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Contributor Information and Disclosures
Author

Kean Theng Oh, MD Consulting Staff, Associated Retinal Consultants, PC

Kean Theng Oh, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Society of Retina Specialists, Association for Research in Vision and Ophthalmology, Michigan Society of Eye Physicians & Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

John H Drouilhet, MD, FACS Clinical Professor, Department of Surgery, Section of Ophthalmology, University of Hawaii, John A Burns School of Medicine

John H Drouilhet, MD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Steve Charles, MD Director of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine

Steve Charles, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Macula Society, Retina Society, Club Jules Gonin

Disclosure: Received royalty and consulting fees for: Alcon Laboratories.

Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

V Al Pakalnis, MD, PhD Professor of Ophthalmology, University of South Carolina School of Medicine; Chief of Ophthalmology, Dorn Veterans Affairs Medical Center

V Al Pakalnis, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, South Carolina Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Bradley M Hughes, MD Assistant Professor, Department of Ophthalmology, Retina and Vitreous Service, University of Arkansas for Medical Sciences

Bradley M Hughes, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Ophthalmology

Disclosure: Nothing to disclose.

Sherman O Valero, MD Consulting Staff, Department of Ophthalmology, Makati Medical Center, Philippines

Disclosure: Nothing to disclose.

References
  1. Chang LK, Fine HF, Spaide RF, et al. Ultrastructural correlation of spectral-domain optical coherence tomographic findings in vitreomacular traction syndrome. Am J Ophthalmol. 2008 Jul. 146(1):121-7. [Medline].

  2. Bovey EH, Uffer S. Tearing and folding of the retinal internal limiting membrane associated with macular epiretinal membrane. Retina. 2008 Mar. 28(3):433-40. [Medline].

  3. Folk JC, Adelman RA, Flaxel CJ, Hyman L, Pulido JS, Olsen TW. Idiopathic Epiretinal Membrane and Vitreomacular Traction Preferred Practice Pattern(®) Guidelines. Ophthalmology. 2016 Jan. 123 (1):P152-81. [Medline].

  4. Karacorlu M, Ozdemir H, Senturk F, Karacorlu SA, Uysal O. Correlation of retinal sensitivity with visual acuity and macular thickness in eyes with idiopathic epimacular membrane. Int Ophthalmol. 2010 Jun. 30(3):285-90. [Medline].

  5. Rouvas A, Chatziralli I, Androu A, Papakonstantinou S, Kouvari MS, Alonistiotis D, et al. Long-term anatomical and functional results in patients undergoing observation for idiopathic nontractional epiretinal membrane. Eur J Ophthalmol. 2016 Apr 12. 26 (3):273-8. [Medline].

  6. Hosoda Y, Ooto S, Hangai M, Oishi A, Yoshimura N. Foveal Photoreceptor Deformation as a Significant Predictor of Postoperative Visual Outcome in Idiopathic Epiretinal Membrane Surgery. Invest Ophthalmol Vis Sci. 2015 Oct. 56 (11):6387-93. [Medline].

  7. Gupta P, Sadun AA, Sebag J. Multifocal retinal contraction in macular pucker analyzed by combined optical coherence tomography/scanning laser ophthalmoscopy. Retina. 2008 Mar. 28(3):447-52. [Medline].

  8. Rahman R, Stephenson J. Early surgery for epiretinal membrane preserves more vision for patients. Eye (Lond). 2014 Apr. 28(4):410-4. [Medline]. [Full Text].

  9. Kofod M, Christensen UC, la Cour M. Deferral of surgery for epiretinal membranes: Is it safe? Results of a randomised controlled trial. Br J Ophthalmol. 2016 May. 100 (5):688-92. [Medline].

  10. Gupta OP, Ho AC, Kaiser PK, et al. Short-term outcomes of 23-gauge pars plana vitrectomy. Am J Ophthalmol. 2008 Aug. 146(2):193-197. [Medline].

  11. Gupta OP, Weichel ED, Regillo CD, et al. Postoperative complications associated with 25-gauge pars plana vitrectomy. Ophthalmic Surg Lasers Imaging. 2007 Jul-Aug. 38(4):270-5. [Medline].

  12. Mura M, Barca F, Dell'Omo R, Nasini F, Peiretti E. Iatrogenic retinal breaks in ultrahigh-speed 25-gauge vitrectomy: a prospective study of elective cases. Br J Ophthalmol. 2015 Dec 23. [Medline].

  13. Yonekawa Y, Mammo DA, Thomas BJ, Wolfe JD, Hassan TS. A Comparison of Intraoperative Dexamethasone Intravitreal Implant and Triamcinolone Acetonide Used During Vitrectomy and Epiretinal Membrane Peeling: A Case Control Study. Ophthalmic Surg Lasers Imaging Retina. 2016 Mar 1. 47 (3):232-7. [Medline].

  14. Charles S. Epimacular Membranes. Guyer DR, Yannuzzi LA, Chang S, et al. Retina-Vitreous-Macula. Philadelphia, Pa: WB Saunders Co; 1999. Vol 2: 230-7.

  15. Haritoglou C, Gandorfer A, Gass CA, et al. The effect of indocyanine-green on functional outcome of macular pucker surgery. Am J Ophthalmol. 2003 Mar. 135(3):328-37. [Medline].

  16. Casparis H, Bovey EH. Surgical treatment of lamellar macular hole associated with epimacular membrane. Retina. 2011 Oct. 31(9):1783-90. [Medline].

  17. Hillenkamp J, Saikia P, Herrmann WA, et al. Surgical removal of idiopathic epiretinal membrane with or without the assistance of indocyanine green: a randomised controlled clinical trial. Graefes Arch Clin Exp Ophthalmol. 2007 Jul. 245(7):973-9. [Medline].

  18. Garweg JG, Bergstein D, Windisch B, et al. Recovery of visual field and acuity after removal of epiretinal and inner limiting membranes. Br J Ophthalmol. 2008 Feb. 92(2):220-4. [Medline].

  19. Liu H, Zuo S, Ding C, Dai X, Zhu X. Comparison of the Effectiveness of Pars Plana Vitrectomy with and without Internal Limiting Membrane Peeling for Idiopathic Retinal Membrane Removal: A Meta-Analysis. J Ophthalmol. 2015. 2015:974568. [Medline].

  20. Ripandelli G, Scarinci F, Piaggi P, Guidi G, Pileri M, Cupo G, et al. Macular pucker: to peel or not to peel the internal limiting membrane? A microperimetric response. Retina. 2015 Mar. 35 (3):498-507. [Medline].

  21. Chung SE, Kim KH, Kang SW. Retinal breaks associated with the induction of posterior vitreous detachment. Am J Ophthalmol. 2009 Jun. 147(6):1012-6. [Medline].

  22. Rush RB, Simunovic MP, Aragon AV 2nd, Ysasaga JE. Postoperative macular hole formation aftervitrectomy with internal limiting membrane peeling for the treatment of epiretinal membrane. Retina. 2013 Nov 8. [Medline].

  23. Dawson SR, Shunmugam M, Williamson TH. Visual acuity outcomes following surgery for idiopathic epiretinal membrane: an analysis of data from 2001 to 2011. Eye (Lond). 2014 Feb. 28(2):219-24. [Medline]. [Full Text].

  24. Gass JDM. Macular dysfunction caused by epiretinal membrane contraction. Stereoscopic Atlas of Macular Diseases: Diagnosis and Treatment. 4th ed. St. Louis, Mo: Mosby; 1997. Vol 2: 938-950.

  25. Haritoglou C, Gandorfer A, Schaumberger M, et al. Trypan blue in macular pucker surgery: an evaluation of histology and functional outcome. Retina. 2004 Aug. 24(4):582-90. [Medline].

  26. Marghero RR. Epiretinal macular membranes. Albert DM, Jakobiec FA, eds. Principles and Practice of Ophthalmology. Philadelphia, Pa: WB Saunders Co; 1994. Vol 2: 919-925.

  27. McDonald HR, Schatz H, Johnson RN. Introduction to epiretinal membranes. Ryan SJ, ed. Retina. 2nd ed. St. Louis, Mo: Mosby; 1994. Vol 2: 1819-1825.

  28. Russell SR, Crapotta JA. Macular epiretinal membranes. Ophthalmol Clin North Am. June 1993. 6(2):239-45.

  29. Sjaarda RN, Michels RG. Macular pucker. Ryan SJ, ed. Retina. 2nd ed. St. Louis, Mo: Mosby; 1994. Vol 3: 2301-2312.

  30. Ting FS, Kwok AK. Treatment of epiretinal membrane: an update. Hong Kong Med J. 2005 Dec. 11(6):496-502. [Medline].

  31. Wong JG, Sachdev N, Beaumont PE, et al. Visual outcomes following vitrectomy and peeling of epiretinal membrane. Clin Experiment Ophthalmol. 2005 Aug. 33(4):373-8. [Medline].

  32. Sheales MP, Kingston ZS, Essex RW. Associations between preoperative OCT parameters and visual outcome 3 months postoperatively in patients undergoing vitrectomy for idiopathic epiretinal membrane. Graefes Arch Clin Exp Ophthalmol. 2016 Mar 30. [Medline].

  33. Sandhu HS, Kim BJ. Combined hamartoma of the retina and RPE: A spectrum of presentation with epiretinal membrane masquerade. Can J Ophthalmol. 2016 Feb. 51 (1):e10-3. [Medline].

  34. Ota A, Tanaka Y, Toyoda F, Shimmura M, Kinoshita N, Takano H, et al. Relationship between variations in posterior vitreous detachment and visual prognosis in idiopathic epiretinal membranes. Clin Ophthalmol. 2016. 10:7-11. [Medline].

  35. Kim M, Park YS, Lee DH, Koh HJ, Lee SC, Kim SS. COMPARISON OF SURGICAL OUTCOME OF 23-GAUGE AND 25-GAUGE MICROINCISION VITRECTOMY SURGERY FOR MANAGEMENT OF IDIOPATHIC EPIRETINAL MEMBRANE IN PSEUDOPHAKIC EYES. Retina. 2015 Oct. 35 (10):2115-20. [Medline].

 
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Very dense epiretinal membrane with associated macular distortion.
Grade 2 epiretinal membrane causing striations in the retinal surface. Note the presence of a pseudohole.
Fluorescein angiogram demonstrating retinal vascular distortion. Note the leakage of the dye in the macular area, which represents secondary macular edema.
 
 
 
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