nw2010 epiretinal membrane
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Epiretinal MembraneEpiretinal Membrane
Nawat WatanachaiRamathibodi Hospital
Mahidol University
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Epiretinal membrane (ERM)Epiretinal membrane (ERM)
An avascular fibrocellular membrane that proliferates on the inner surface of the retina to produce various degrees of macular dysfunction
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Common synonymsCommon synonyms
Cellophane maculopathy Macular pucker Premacular fibrosis/ gliosis Surface wrinkle retinopathy Epimacular membrane
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Epidemiology and pathogenesisEpidemiology and pathogenesis
Idiopathic ERMSecondary ERM
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Epidemiology and pathogenesisEpidemiology and pathogenesis
Idiopathic ERM6% in > 50 yrs oldF>MBilat 20-30%
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Epidemiology and pathogenesisEpidemiology and pathogenesis
Idiopathic ERMPVD 90%
Retinal glial cells migrate through defects in the ILM probably create at the time of vitreous separation
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Epidemiology and pathogenesisEpidemiology and pathogenesis
SecondaryAfter repair of RRD : 4-8%–Risks : older age, preop VH, macular
detachment, preop sign of PVR, large RB, use of cryo, multiple Sx
–RPE cells that liberated into the vit cavity and proliferate
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Epidemiology and pathogenesisEpidemiology and pathogenesis
SecondaryAfter prophylactic treatment of peripheral break : 1-2%Trauma, vit inflam condition, retinal vascular dis, long-standing VH
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Ocular manifestationsOcular manifestations
Depend on its thickness and the extent (occlusion) to which it has undergone shrinkage or contraction (traction)
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Ocular manifestations: thin ERM, Cellophane maculopathy
Ocular manifestations: thin ERM, Cellophane maculopathy
thin and transparent Abnormal glistening light reflex from the inner
retinal surface Mostly asymptomatic
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Ocular manifestation: thick ERM, puckerOcular manifestation: thick ERM, pucker Inner retinal striae radaite from edge of ERM White-gray/ white translucent membrane, may
obscure visualization of the retinal vessels
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Ocular manifestation: thick ERMOcular manifestation: thick ERM
More severe degree of macular dysfunctionMacular distortion, folding, puckeringMacular edema, pre-retinal/ intraretinal hemorrhageFoveal ectopia, macular pseudoholeTRD, RB, RRD
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ERM with Foveal ectopiaERM with Foveal ectopia
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Ocular manifestation: thick ERMOcular manifestation: thick ERM
Vision loss Metamorphopsia central photopsia binocular diplopia macropsia
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Ocular manifestation : pseudo or true macular holeOcular manifestation : pseudo or true macular hole
PseudoholeWrinkle of inner retinal surfaceRetinal tissue at the base of pseudoholeAbsence of characteristics of true hole: yellow pigment deposits in the base, halo of neural detachment. Overlying operculum/ pseudooperculum
Equivocal cases : OCT, FFA
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PseudoholePseudohole
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Diagnosis and ancillary testingDiagnosis and ancillary testing
Clinical, based on biomicroscopic observation Examination/ photography with Red-free light Watzke-Allen test OCT FFA: retinal vascular distortion that underlies an
ERM
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Diagnosis and ancillary testingDiagnosis and ancillary testing
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Diagnosis and ancillary testingDiagnosis and ancillary testing
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DDXDDX
VMT syndrome Combined RPE and retinal hamartoma Prominent macular light reflex in the young CME Optic disc swelling (juxtapapillary ERM) Idiopathic MH
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PathologyPathology
ERM consists of avascular fibrocellular sheetNative vitreousNewly synthetic collagenFragment of ILM
Myofibroblastic Cells : RPE cells, fibrous astrocytes, macrophages
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TreatmentTreatment
ERM with minimal symtoms : no treatment but observation
Treat in cases ofSignificant visual lossMetamorphopsiaIntolerable binocular diplopia
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Goal of treatmentGoal of treatment
Reduce or eliminate most common mechanisms of visual loss, including macular distortion, TRD, foveal ectopia, membrane that cover the fovea, retinal vascular leakage with macular edema, traction-induce obstruction of axoplasmic fold
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Surgical proceduresSurgical procedures Pars plana vitrectomy +/- staining Engage the edge of
ERM with a retinal pick/ forceps/ sharp bent-tip needle
Peel the membrane with forceps
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stainingstaining
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peelingpeeling
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Course and outcomesCourse and outcomes
Most pts who have ERM experience little or no symptom progression after dx
10-25% of eyes show a decline in VA in mths/ yrs
Rarely spontaneous separate from retina
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Course and outcomesCourse and outcomes
After Sx, resolute within days/ wksVA improve 2 or more snellen lines in 60-
85% of eyes and may continue for 6-12 mths after Sx
2-15% of eyes have worse VA postop Visual function rarely returns to normal
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Cases with minimal benefit Cases with minimal benefit
Patients who have symptoms that has lasted longer than 1 yr
Findings that suggest long-standing casesAtrophic/ hypertrophic RPE alterationsIntraretinal lipid/ hard exudatesMicrovascular changes such as microaneurysms
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ComplicationsComplicationsProgressive sclerotic cataract (MC)
60-70% in 2 yrs Peripheral retinal breaks RRD Posterior retinal breaks Photic maculopathy Endophthalmitis Recurrence 5%
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Thank youThank you