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Sections Epiretinal Membrane
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Presentation

History

The type and degree of symptoms experienced by an individual with epiretinal membrane (ERM) depends largely on the thickness of the membrane, the degree of retinal distortion it causes, the location of the wrinkling, and the presence or the absence of retinal detachment or edema.^[5]

The usual symptoms caused by epiretinal membranes run the spectrum from no symptoms at all to severe visual dysfunction.

Early on, epiretinal membranes cause little or no visual disturbance.

As the membrane progresses, the visual disturbance is often vague and difficult for the patient to describe.

Mild distortion or blurring is the most common symptom.

Vision better than 20/50 is present in 78-85% of cases, while 56-67% have vision better than 20/30. Only 2-5% have vision poorer than 20/200.

In more advanced cases, metamorphopsia, micropsia, or Amsler Grid abnormalities may be present.

In contrast, vision is markedly reduced in patients with epiretinal membranes associated with retinal detachment. Vision is 20/60 or better in only 7% of cases and 56% have vision poorer than 20/200 after successful retinal reattachment surgery.

In a 2016 preferred practice guideline for epiretinal membranes, the authors reported that, over a 5-year period, 29% of epiretinal membranes progressed, 26% regressed, and 39% remained stable.^[3]

Use of spectral domain ocular coherence tomography (SD-OCT) has correlated inner nuclear layer thickness with the symptom of metamorphopsia. Ichikawa et al suspect that tangential retinal displacement distorting Muller cells results in metamorphopsia.^[6]

Physical

The clinical findings in epiretinal membranes vary according to the degree of severity of the membrane. Gass formulated a classification system based on the appearance of the membrane and the underlying retinal tissue and vessels. This grading system is not typically used in clinical practice, but it is interesting from a historical perspective.

Grade 0 membranes

Grade 0 epiretinal membranes are translucent membranes not associated with any retinal distortion.

These epiretinal membranes also are known as cellophane maculopathy owing to the cellophanelike sheen coming from the inner retinal surface as it is seen ophthalmoscopically.

Grade 1 membranes

Membranes causing an irregular wrinkling of the inner retinal surface are classified as grade 1 epiretinal membranes.

The crinkled cellophane appearance is caused by the gathering of the inner retinal layers into folds following the contraction of the overlying membrane.

Fine, superficial, radiating folds extend outward from the margins of the contracted membrane.

Wrinkling may be sufficient to produce tortuosity of the paramacular vessels pulling them toward the fovea.

Cystoid macular edema, retinal hemorrhage, exudates, and RPE disturbances are typically absent.

Grade 2 membranes

Membranes, especially those that develop after retinal detachment surgery, have an opaque, thick appearance.

Gross, full-thickness puckering of the macula may be present along with retinal edema, small hemorrhages, cotton-wool spots, and, infrequently, a localized detachment of the retina.

These membranes are labeled macular puckers or grade 2 membranes.

Pseudoholes

A pseudohole is depicted in the image below.

Grade 2 epiretinal membrane causing striations in the retinal surface. Note the presence of a pseudohole.

View Media Gallery

Causes

See Pathophysiology.

Differential Diagnoses

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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
Ichikawa Y, Imamura Y, Ishida M. Inner Nuclear Layer Thickness, a Biomarker of Metamorphopsia in Epiretinal Membrane, Correlates With Tangential Retinal Displacement. Am J Ophthalmol. 2018 Jun 8. 193:20-27. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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Rahman R, Stephenson J. Early surgery for epiretinal membrane preserves more vision for patients. Eye (Lond). 2014 Apr. 28(4):410-4. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
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Media Gallery

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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Author

Kean Theng Oh, MD

Kean Theng Oh, MD is a member of the following medical societies: 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 Founder and CEO of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine

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

Chief Editor

Douglas R Lazzaro, MD, FAAO, FACS Chairman, Professor of Ophthalmology, The Richard C Troutman, MD, Distinguished Chair in Ophthalmology and Ophthalmic Microsurgery, Department of Ophthalmology, State University of New York Downstate Medical Center; Chief of Ophthalmology, Director of Cornea, Director of Surgical Training, Kings County Hospital Center

Douglas R Lazzaro, MD, FAAO, FACS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Society of Cataract and Refractive Surgery, Association for Research in Vision and Ophthalmology, Association of University Professors of Ophthalmology, Brooklyn Ophthalmological Society, Cornea Society, New York Society for Clinical Ophthalmology, Ophthalmic Laser Surgical Society

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.