Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Epiretinal Membrane Treatment & Management

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

Surgical Care

Isolate epiretinal membrane (ERM) as the main cause of a patient's visual impairment prior to planning a corrective procedure. Evaluate the patient carefully to rule out other pathologic conditions, such as macular holes, subfoveal choroidal neovascular membranes, cystoid macular edema, or retinal vascular occlusive disease, that may mimic the appearance of a true membrane.

Surgical treatment of epiretinal membrane is usually not an emergent procedure. Only when there is macular edema does it become a more urgent procedure.

Frequently, patients are referred for evaluation of an asymptomatic epiretinal membrane identified via OCT in primary care optometric and ophthalmologic practices. Thus, preoperative patient evaluation and counselling are important to identify surgical candidates and to set appropriate postoperative expectations. For such asymptomatic patients, the decision to intervene with surgery is not straightforward. Rahman and Stephenson demonstrated in a retrospective review that earlier intervention resulted in more rapid recovery and better final visual acuity.[8] However, Kofod et al evaluated early versus deferred surgery in epiretinal membrane and found that, while early surgery resulted in excellent vision, patients in the deferred surgery group did not lose 5 letters of ETDRS vision. Thus, they deemed surgery deferral a safe clinical decision.[9] Rouvas et al also recommended that nontractional epiretinal membranes may be monitored safely over time if the patient is not a good surgical candidate.[5]

Several surgical techniques exist for the treatment of epiretinal membrane. However, 3 basic stages of treatment exist.

Vitrectomy

Pars plana vitrectomy is performed to excise the posterior and central vitreous in phakic patients and the remainder of the anterior vitreous in aphakic and pseudophakic patients. This step is especially important in cases where marked adherence of the vitreous to the macula is present.

Lately, questions have been raised regarding the need for vitrectomy in epiretinal membrane peeling, especially in those cases where no significant PVR exists.

The main advantages of doing a vitrectomy are the prevention of vitreous contraction and elimination of vitreous traction on the macula. In addition, removal of the vitreous is believed by many to increase the safety of the mechanical aspects of the membrane removal.

The main disadvantages of vitrectomy include cataractogenesis and increased possibility of creating iatrogenic retinal breaks. Vitrectomy has been shown to increase the rate of cataract formation through unclear mechanisms.

Studies have shown that a 3-fold increase in the rate of significant cataract formation exists in patients that have undergone vitrectomy after a follow-up period of only 6 months.

Some surgeons feel that the effectiveness of membrane peeling is negated significantly by the cataract formation such that they have foregone vitrectomy in selected cases, opting to perform no-infusion/no-vitrectomy membrane peelings. The main disadvantage of this technique is the persistence of floaters postoperatively, which may be very bothersome to some patients. Furthermore, some surgeons have seen no significant difference in either cataractogenesis or development of retinal breaks/detachments in their series comparing vitrectomizing and nonvitrectomizing techniques.

Management of epiretinal membrane with vitrectomy is predisposed to smaller-gauge vitrectomies (25-gauge, 27-gauge).[10, 11, 12] These systems are transconjunctival with the potential to create self-sealing wounds. Complications appear low while affording the potential for more rapid surgical and visual recovery.

Use of intravitreal steroids such as triamcinolone or dexamethasone has been associated with a more rapid visual recovery and better final surgical outcomes.[13]

 

Epiretinal membrane peeling

From the time Machamer developed the concept of membrane peeling in the mid-1970s, several variations and refinements in both technique and instrumentation have been developed.

This procedure basically involves identifying the outer edge of the membrane and creating a dissection plane with the use of a blunt-tipped pick or a bent needle.

Once the edge of the membrane is seen, it may be gently lifted off the retinal surface with the use of a pick or fine forceps.

The membrane should be lifted in a tangential rather than an anteroposterior fashion so as not to pull on the underlying retina and create tears. This maneuver is relatively straightforward if the edge of the membrane is visible.

Charles developed a maneuver that approaches the membrane from inside out in cases where the edge is difficult to identify.[14] It involves creating a slit on the thickest part of the membrane with a straight microvitreoretinal blade and using this opening as the edge with which to start the peeling. The peeling is performed moving the forceps in a circular fashion similar to capsulorrhexis. The freed membrane should be removed either by pulling it out with the forceps through the sclerotomy or by using the vitreous cutter.

Internal limiting membrane (ILM) peeling

Removal of the ILM at the time of epiretinal membrane peeling is a current controversy, both for use of vital dyes and the necessity to peel the ILM in addition to the epiretinal membrane.

Vital stains, such as indocyanine green (ICG) dye and Trypan blue dye, have been used to assist ILM and epiretinal membrane peeling. Dyes that stain the ILM highlight foci of epiretinal membrane and potentially reduce the risk of recurrence or the persistence of symptoms.

Similar to its use in macular hole surgery, the use of ICG has proponents and detractors on the basis of its potential toxic effects. Haritoglou et al suggested that ICG-assisted ILM peeling may adversely affect the functional outcome of surgery for epiretinal membrane.[15, 16]

Hillenkamp et al prospectively evaluated the effect of ICG dye in the setting of epiretinal membrane surgery.[17] No difference or evidence of ICG toxicity was observed. Both visual function and macular morphology improved in patients with and without ICG dye use.

However, Garweg et al suggested that ILM peeling with ICG dye, but not with trypan blue dye, may result in loss of the central visual field over time.[18] No difference in visual acuity was noted. This study suggests that the ICG dye, not necessarily the ILM peeling, may have an adverse effect following epiretinal membrane surgery.

Liu et al performed a meta-analysis of epiretinal membrane surgery with and without ILM peeling and found that patients who underwent ILM peeling had better visual acuity at 12 months postsurgery. However, by 18 months postoperatively, the meta-analysis of two papers suggested that patients who had not undergone ILM peeling had marginally better visual acuity.[19]

Microperimetric analysis of patients undergoing ILM peeling versus no ILM peeling during epiretinal membrane surgery suggested a benefit to not peeling ILM. The sensitivity of the central 4° showed faster recovery and fewer absolute microscotomas in patients who did not undergo ILM peeling.[20]

Management of retinal breaks

Once the membrane is removed, it is imperative for the surgeon to look for any breaks in the retina, both in the posterior pole and in the periphery.

Any maneuvers completed to remove the membranes, no matter how elegant, become irrelevant if the retina detaches because of missed breaks.

Careful scleral depression of the anterior retina combined with indirect ophthalmoscopy should be performed to detect breaks in the periphery.

Breaks without subretinal fluid accumulation can be treated by laser retinopexy or cryoretinopexy.

The presence of significant amounts of subretinal fluid necessitates internal drainage under air, retinopexy, and gas tamponade.

 
 
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].

 
Previous
Next
 
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.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.