An A to Z guide on Epiretinal Membranes (ERMs) Paris Tranos PhD,ICO,FRCS OPHTHALMICA Vitreoretinal & Uveitis Department
Types of ERM Natural history OCT prognostic factors ERM with co-existing pathology Indications for surgery Treatment dilemmas
Introduction Accumulations of contractile fibrous tissue on the surface of the retina 2%-6.4% of general population Cellophane maculopathy vs macular packer Sjaarda RN, Michels RG. Macular pucker. In: Ryan S, ed. Retina. Vol 3. St. Louis: Mosby, 1994:2301
67 yr old woman Referred for RE ERM metamorphopsia++ VA RE 4+/10
Primary (70-80%) PVD Secondary Vascular disease Uveitis Trauma PVR Appiah AP, Hirose T, Kado M. A review of 324 cases of idiopathic premacular gliosis. Am J Ophthalmol. 1988;106:533 5.
Natural history of ERM Idiopathic epiretinal membranes: 1. Always progress 2. The majority of ERMs remains stable 3. More than half will convert to symptomatic macular pucker 4. A large proportion of ERMs regress 5. They are more common in phakic than preudophakic patients
Natural course (5 yrs) Progression in 29% 10% of cellophane ERMs progress to macular pucker 13% ERM in fellow eye New ERM after phaco 9% vs 5% Stable in 39% Regression in 26% Frase-Bell S Five-year cumulative incidence and progression of epiretinal membranes: the Blue Mountains Eye Study. Ophthalmology 2003 Jan;110(1):34-40.
63 yr old man NO metamorphopsia VA 10/10 25% regress 4 yrs later
18 yr old female B/L Intermittent Uveitis VA 6/6 RE 6/18 LE Vitritis +1 Snowballs++ Disc swelling ERM
Systemic steroids 2/12 later RVA 6/6 LVA 6/18
Observation vs PPV + Peel? other
2/12 later LVA 6/12
5/12 later LVA 6/6
67 yr old man C/O reduced RVA, metamorphopsia++ VA RE 3/10 PPV/ERM peel
Baseline 3/10 3 weeks 4/10 79 yr VA RE 3+/1 0 3 months 6/10 6 months 8/10 6 weeks 6/10 1 year 2 years 9/10 9/10
73 yr old man C/O reduced RVA, metamorphopsia++ VA RE 3/10 PPV/ERM peel
6 weeks 3/10 6 months 3/10
1 st case 2nd case 6 weeks 3/10 Baseline 3/10 Baseline 3/10 6 months 3/10 6 months 8/10 6 months 8/10
Optical Coherence Tomography
Optical Coherence Tomography Vitreoretinal interface
Optical Coherence Tomography Vitreoretinal interface Type of ERM-Retinal adhesion Jae Suk Kim et al, Retinal Adherence and Fibrillary Surface Changes Correlate with Surgical Difficulty of Epiretinal Membrane Removal. Am J Ophthalmol. 2012 April ; 153(4): 692 697
Optical Coherence Tomography Vitreoretinal interface Type of ERM-Retinal adhesion Contour of retinal surface
Optical Coherence Tomography Vitreoretinal interface Type of ERM-Retinal adhesion Contour of retinal surface Inner retina Outer retina
Inner retina predictors Inner retinal thickness - VA Inner Nuclear Layer thickness - metamorrphopsia Takabatake M et al Postoperative changes and prognostic factors of visual acuity, metamorphopsia, and aniseikonia after vitrectomy for epiretinal membrane. Retina 2017 Watanabe A.Correlation between metamorphopsia and epiretinal membrane optical coherence tomography findings. Ophthalmology 2009 Koo HC et al Morphologic and functional association of retinal layers beneath the ERM with SD-OCT in eyes without photoreceptor abnormality. Graefes Arch Clin Exp Ophthalmol. 2012
Outer retina predictors COST PROS length Shiono A et al Photoreceptor Outer Segment Length: A Prognostic Factor for Idiopathic Epiretinal Membrane Surgery.Ophthalmology 2013 Jan
Shiono A et al Photoreceptor Outer Segment Length: A Prognostic Factor for Idiopathic Epiretinal Membrane Surgery.Ophthalmology 2013 Jan Outer retina predictors COST PROS length Outer Foveal Thickness (OFT)
Inoue M, et al. Inner segment/outer segment junction assessed by spectral-domain optical coherence tomography in patients with idiopathic epiretinal membrane.am J Ophthalmol 2010; 150:834 9. Shimozono M,et al. The significance of cone outer segment tips as a prognostic factor in epiretinal membrane surgery. Am J Ophthalmol 2012;153:698 704. Outer retina predictors COST PROS length Outer Foveal Thickness (OFT) Integrity of ELM, ellipsoid/interdigitation zone
OCT prognosticators Incidence of EMM rip is 4.5% Type 1 if rip <500μ from the fovea Type 2: extrafoveal Type 1: worse baseline and postop visual acuity
59 yr old man C/O LE Misty vision, difficulty driving at night, glare VA RE 8/10 LE 3+/10 What causes the symptoms? 1. Cataract 2. Epiretinal membrane 3. Age related macular degeneration 4. All the above LE phaco LVA 8/10 Symptoms improved
62 yr old woman C/O LE blurred vision for months, mild distortion LE VA RE 9/10 LE 5/10 LE phaco LVA 8/10 Symptoms improved
Epiretinal membrane in combination with macular disorders. When do we operate?
Macular edema or AMD with ERM Suboptimal response to intravitreal injections- frequent recurrences Poor visual outcome after intravitreal injections
81 yr old man NIDDM Good diabetic control B/L quiescent PDR Mild reduction of LVA RVA 1/20 LVA CF
RVA 1/60 2 YEARS LATER RVA 1/60
X3 LUCENTIS RVA 1/20 PPV/ERM peel
1/10 2/10 2/10
2/10 No more injections for 3 yrs
Management Pars plana vitrectomy 25g, 27g Surgical indications Metamorphopsia Visual acuity 0.3 0.5
Management VA: 0.7-0.8 Thompson JT Vitrectomy for epiretinal membranes with good visual acuity Trans am ophthalmol soc. 2004 december; 102: 97 106. R Rahman and J Stephenson Early surgery for epiretinal membrane preserves more vision for patients, Eye 2014.
Time Course of Changes in Visual Acuity, Metamorphopsia, Aniseikonia after ERM surgery Takabatake M et al Postoperative changes and prognostic factors of visual acuity, metamorphopsia, and aniseikonia after vitrectomy for epiretinal membrane.retina 2017 Kinoshita T et al Time Course of Changes in Metamorphopsia, Visual Acuity, and OCT Parameters after Successful Epiretinal Membrane Surgery IOVS 2012
Surgical dilemmas Epiretinal membrane (ERM) staining Internal limiting membrane (ILM) peel
Results 32 70 Tranos PG, et al. The role of internal limiting membrane peeling in epiretinal membrane surgery. A randomized controlled trial. British J Ophthalmol, 2017 Jun;101(6):719-724
Results Change in BCVA 0.25 (P) vs 0.26 (NP) P=>0.05 Tranos PG, et al. The role of internal limiting membrane peeling in epiretinal membrane surgery. A randomized controlled trial. British J Ophthalmol, 2017 Jun;101(6):719-724
Results Change in metamorphopsia 113 (P) vs 105 (NP) p>0.05 Tranos PG, et al. The role of internal limiting membrane peeling in epiretinal membrane surgery. A randomized controlled trial. British J Ophthalmol, 2017 Jun;101(6):719-724
Results Change in CRT 125 (P) vs 134 (NP) (p>0.05) peel No peel Tranos PG, et al. The role of internal limiting membrane peeling in epiretinal membrane surgery. A randomized controlled trial. British J Ophthalmol, 2017 Jun;101(6):719-724
Inadvertent removal of ILM during ERM surgery?
Methods OCT < 1month preop 3 types of ERM adhesion to inner retina Complete (>90%) Tranos P, et al. The role of membrane-inner retina adherence in predicting simultaneous internal limiting membrane peeling during idiopathic epiretinal membrane surgery.eye (Lond). 2017 Apr;31(4):636-642
Methods OCT < 1month preop 3 types of ERM adhesion to inner retina Complete (>90%) Partial (50-90%) Tranos P, et al. The role of membrane-inner retina adherence in predicting simultaneous internal limiting membrane peeling during idiopathic epiretinal membrane surgery.eye (Lond). 2017 Apr;31(4):636-642
Methods OCT < 1month preop 3 types of ERM adhesion to inner retina Complete (>90%) Partial (50-90%) Focal (<50%)
Methods Sup Temp 1000μ Nas Inf
Simultaneous ILM peel Results 80% 70% 60% 70 P=0.001 50% 40% 43 30% 20% 21 10% 0% COMPLETE BROAD FOCAL Type of ERM-inner retina adherence Tranos P, et al. The role of membrane-inner retina adherence in predicting simultaneous internal limiting membrane peeling during idiopathic epiretinal membrane surgery.eye (Lond). 2017 Apr;31(4):636-642
Conclusions Spontaneous ILM peel is common during ERM surgery The type of ERM-inner retina adherence is a significant predictor for simultaneous ILM peel during ERM removal Surgical removal of ILM should be avoided when there is complete ERM-inner retina attachment Tranos P, et al. The role of membrane-inner retina adherence in predicting simultaneous internal limiting membrane peeling during idiopathic epiretinal membrane surgery.eye (Lond). 2017 Apr;31(4):636-642
How much of the ERM should we remove? Remove the ERM over the entire macula Postop extrafoveal ERM edge in 36% Are extrafoveal ERM remnants significant? NO effect on visual function -foveal thickness Higher recurrence rate (42% vs 9%) Gaber R et al Characteristics of epiretinal membrane remnant edge by optical coherence tomography after pars plana vitrectomy. Retina. 2017
72 yr old man Metamorphopsia, reduction of VA LE Vity/Phaco Baseline 2/10 6m 6/10 3m 5/10 1 yr 8/10 4m 5/10
Summary ERM is a common finding that progresses to visual significance only in a minority of patients
Summary ERM is a common finding that progresses to visual significance only in a minority of patients Even patients with relatively good vision are good candidates for ERM surgery
Summary ERM is a common finding that progresses to visual significance only in a minority of patients Even patients with relatively good vision are good candidates for ERM surgery ILM peel does not alter the outcome
Summary ERM is a common finding that progresses to visual significance only in a minority of patients Even patients with relatively good vision are good candidates for ERM surgery ILM peel does not alter the outcome Meticulous assessment of OCT may facilitate more accurate prognosis
The future Apply Artificial Intelligence technology to identify new prognostic biomarkers