Imaging Studies

Fluorescein angiography

Performing an angiogram in cases of epiretinal membranes (ERMs) does not contribute anything significant in its diagnosis since the clinical picture is often specific enough. In less advanced cases, the angiographic picture is basically unremarkable. More significant findings, such as vessel tortuosity and macular edema, may be seen in more advanced cases.

Perform fluorescein angiography to rule out other lesions that may mimic epiretinal membranes.

Macular holes typically show early background fluorescence through the hole that disappears in the later phases.

Epiretinal membranes with pseudoholes typically do not exhibit this fluorescence since normal retinal tissue exists in the area.

An exudative macular degeneration also may mimic the appearance of an epiretinal membrane, but its angiographic picture of early fluorescence and leakage is easily distinguishable from epiretinal membranes.

Fluorescein angiograms of epiretinal membranes can reveal subtle leakage of the perifoveal capillaries or evidence of ischemia due to capillary dropout, which can assist with counseling for postoperative expectations. See the image below.

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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Ocular coherence tomography

Ocular coherence tomography (OCT) can elucidate the presence or absence of an epiretinal membrane.

OCT can objectively measure other effects of the epiretinal membrane on the retina, such as macular thickening, presence or absence of macular edema (eg, cystoid macular edema), and any associated vitreous traction on the retina.

Rouvas et al monitored patients with nontractional epiretinal membrane over time and demonstrated stability of visual acuity. They defined nontractional epiretinal membranes as membranes noted to have a tear or discontinuity on at least one line of the OCT scan. The mean follow-up period was 38.2 months, and 84.4% of patients were noted to have improvement or stabilization of visual acuity at the end of follow-up. The authors suggest that patients with nontractional epiretinal membranes may safely be monitored over follow–up, deferring surgery.^[7]

OCT allows the monitoring of the postoperative return of the normal retinal architecture as well as the presence of persistent traction or folds of the retina.

Evaluation of the inner-segment/outer-segment (IS/OS) junction on OCT appears to be correlated with postoperative visual acuity.^[3]Hosoda et al also identified that the degree of photoreceptor deformation was predictive of postoperative visual acuity. They described a "photoreceptor deformation index" based on characteristics on the OCT.^[8]

Gupta et al used combined OCT/scanning laser ophthalmoscopy (SLO) to evaluate 44 consecutive eyes with epiretinal membrane.^[9]Of the patients evaluated, 20 out of 44 demonstrated multiple foci of contracture within the epiretinal membrane. They subdivided epiretinal membrane into “simple puckers" and “complex puckers.” Complex puckers had a higher rate of intraretinal cysts and macular thickening than simple puckers. However, no difference in visual dysfunction existed between the two groups; the authors hypothesize that architectural differences in the retina may precede visual acuity loss.

Kromer et al correlated high preoperative retinal volumes on OCT with more benefit from surgical interval. They suggested that increased volumes were related to increased tractional components on the retina.^[10]

Treatment & Management

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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].
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. [QxMD MEDLINE Link].
Kromer R, Vogt C, Wagenfeld L, Spitzer MS, Stemplewitz B. Predicting Surgical Success in Patients with Idiopathic Epiretinal Membrane Using the Spectral-Domain Optical Coherence Tomography Segmentation Module for Single Retinal Layer Analysis. Curr Eye Res. 2018 Aug. 43 (8):1024-1031. [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 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 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.