epiretinal membrane update final - pacific university · 4.what are the expected outcomes of...
TRANSCRIPT
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Epiretinal Membrane
UpdateVictoria Conference 2018
James Kundart OD MEd FAAO FCOVD-A
Pacific University College of Optometry
Financial Disclosure: Nothing to Disclose
Images from Cirrus OCT
Learning Objectives
1. How is epiretinal membrane (ERM) best diagnosed?2. How is ERM differentially diagnosed from central serous
retinopathy and cystoid macular edema?3. Which ERM cases can be monitored, and which will need surgical
intervention?4. What are the expected outcomes of macular peel microsurgery
for ERM?5. Which symptoms are expected to remain after successful
surgery, and will need optical treatment?
Case Study #1, First Visit: Macular Cube OCT, 2014
-6.00 SE OD, OSBCVA 20/60 OD, OS
Images from Cirrus OCT
Case Study #1: Macular Cube OCT 2014
BP 175/113BMI 23
Images from Cirrus OCT
Case Study #1: 10-2 Matrix Visual Fields 2014
Images from Humphrey Matrix
Case Study #1, Second Visit: Macular Cube OCT 2015
Images from Cirrus OCT
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Case Study #15-Line Raster
OCT 2015
BP 166/84BMI 23
BCVA 20/50 OD, OS
Images from Cirrus OCT
Case Study #1, Third Visit: Macular Cube OCT Spring 2016
BCVA 20/60 OD and OS Images from Cirrus OCT
Case Study #1: Macular Cube OCT Spring 2016
Images from Cirrus OCT
Case Study #1: 5-Line Raster Macular OCT Spring 2016
Images from Cirrus OCT
Case Study #1:Macular Cube OCT Summer 2016
Images from Cirrus OCT
Case Study #1: Corneal Topography and 10-2 Matrix Visual Fields 2016
Images from Medmont Topographer and Humphrey Matrix
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Case Study #1: Before ERM Peel/Vitrectomy5-Line Raster OCRT 2017
BCVA 20/70 OD, OS
Images from Cirrus OCT
Case Study #1: Post-Op Peel OS
BCVA 20/50 OD, OS
Case Study #1: Post-Op Peel OS
BCVA 20/50 OD, OS
Case Study #1, Last Visit:10-2 Matrix Visual Fields and Summary
BP 130/88, BMI 22
Other Causes of ERM:Adult-Offset Coats’ Disease Pre-Op
• “(a) Color fundus photograph of the right eye of a 38-year-old man with epiretinal membrane along supertemporal arcade• (b) Ultra-wide-field color
photograph showing exudation and telangiectatic vessels in temporal periphery.”• The patient was 20/25 OD with
metamorphopsia OD
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5678313/
Other Causes of ERM: Adult-OffsetCoats’ Disease Post-Op (Peel/Vitrectomy)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5678313/
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Other Causes of ERM: Eales Disease
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5859602/
Other Causes of ERM: Eales Disease
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5859602/
• (a) Fundus photograph and (b) fluorescein angiogram of a 22-year-old male with Eales disease Stage 3A and best-corrected visual acuity 0.1 showing fibrovascular proliferation at the disc• (c) spectral domain optical coherence
tomography showed cystoid macular edema• (j) spectral domain optical coherence
tomography showed epiretinal membrane and macular edema
Epiretinal Membrane Differential Diagnoses:Cystoid Macular Edema (52 YOM and 13 YOF)
http://www.ojoonline.org/article.asp?issn=0974-620X;year=2012;volume=5;issue=3;spage=187;epage=188;aulast=Garoon
ERM DDx: Cystoid Macular Edema (CME) Using NSAIDs Post-Cataract Surgery
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5319126/
ERM DDx: Cystoid Macular Edema (CME)Do Steroids Help?
Optical coherence tomography images of cystoid macular edema (CME)• Top: Preoperative and postoperative
findings of definite CME• Middle: Preoperative and postoperative
findings of probable CME• Bottom: Preoperative and postoperative
(cataract surgery) findings of possible CME
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5636715/
Where ERM Comes From: Latanoprost, CME, and ERM
A. Optical coherence tomography of right eye before latanoprost administration. No pathology is detected.B. Seven months after treatment with preservative free latanoprost optical coherence tomography in right eye revealed cystoid macular edema with well-defined, intraretinal cystic areas of low reflectivity in the macula with serous retinal detachmentC. Two months after latanoprost discontinuation optical coherence tomography demonstrated complete resolution of cystoid macular edemaA subtle epiretinal membrane is noted
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ERM DDx: Does Latanoprost Cause CME?(after cataract surgery OD)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5360021/pdf/13104_2017_Article_2448.pdf
Niacin and CME
http://www.hindawi.com/journals/criopm/2013/713061/
ERM DDx: Microcystic Macular Edema
http://iovs.arvojournals.org/article.aspx?articleid=2190200
ERM DDx: Microcystic Macular Edema (MME)
• An example of a normal retina compared with the retina of a patient with MME. (A) A normal retina from a healthy control subject
• The pseudo-colored surface image is the infrared surface photo; the vertical stacked gray image an OCT B-scan
• (B) Optical coherence tomography image taken from a 76-year-old woman with a 3-year history of AMD, for which she received regular injections with ranibizumab and bevacizumab
• At time of imaging, her best corrected VA OS was 0.7 (20/30)
http://iovs.arvojournals.org/article.aspx?articleid=2190200
ERM DDx: Microcystic Macular Edema (MME)
http://iovs.arvojournals.org/article.aspx?articleid=2190200
• Representative OCT images of patients with MME from the clinical spectrum are shown
• The infrared surface photo and OCT image are presented to the left and the manually segmented INL to the right
(A) Microcystic macular edema in the right eye of a 70-year-old male patient with a history of proliferative diabetic retinopathy treated with panretinal photocoagulation (VA OD 0.3 or 20/60)(B) Optical coherence tomography image showing MME 8 months after occlusion of the vena temporalis superior OD in a 66-year-old female patient (VA OD 0.7 or 20/30)• Microcystic macular edema was located in the temporal
superior quadrant of the inner 3-mm EDTRS grid• However, INL thickening extended to the periphery. In addition,
hyperreflective spots were observed in all inner retinal layers
ERM DDx: Microcystic Macular Edema
http://iovs.arvojournals.org/article.aspx?articleid=2190200
• (D) Microcystic macular edema in a 58-year-old female patient with a newly diagnosed pucker in the right eye (VA OD 0.2 or 20/100)
• Again, there were multiple hyperreflective spots in the inner retinal layers
• (E) Microcystic macular edema 3 months after vitrectomy, in a 71-year-old female patient with a retinal detachment in the left eye (VA OS 0.05 or 20/400)
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ERM DDx: Microcystic Macular Edema
http://iovs.arvojournals.org/article.aspx?articleid=2190200
• Microcystic macular edema in a patient with multiple sclerosis and a history of optic neuritis and branch retinal vein occlusion in the right eye
• This 55-year-old female patient was diagnosed with clinical definite MS in 1992
• Magnetic resonance imaging showed multiple periventricular brain lesions, and spinal T2 hyperintense lesions
• In 2001, she experienced one episode of optic neuritis OD; coincidentally, an occlusion of the vena temporalis superior was found (VA 0.4 or 20/50)
ERM DDx: Microcystic Macular EdemaPropensity for the Nasal/Temporal Quadrants
http://iovs.arvojournals.org/article.aspx?articleid=2190200
• Most frequently, MME was observed in patients with ARMD (27.1%) followed by patients with preceding ophthalmic surgery (20.3%) or presence of an epiretinal membrane (18.8%)
Last ERM DDx: Case Study #2
• A 62-year-old male first reported to our clinic with a chief concern was a larger image size OS
• The patient had no history of eye surgery of any sort
• There was a history of blunt trauma to the right nasal canthus almost 40 years previously
• The patient reported that he was generally healthy with a history of hay fever
https://journals.lww.com/optvissci/Abstract/2018/03000/Retinal_Nerve_Fiber_Layer_Thickness_in_Various.11.aspx
Case Study #2: Optic Nerve Head OCT
Images from Cirrus OCT
Case Study #2: Optic Nerve and RNFL
Images from Cirrus OCT
Case Study #2: Optic Nerve Head OCTCompare OD to OS
Images from Cirrus OCT
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Case Study #2: Optic Nerve OCT
Images from Cirrus OCT
Case Study #2: Retinal Nerve Fiber Layer OCT
Images from Cirrus OCT
Case Study #2: Nerve Fiber Layer Analysis
Images from Cirrus OCT
Case Study #2: Optic Nerve OCT Summary
Images from Cirrus OCT
Case Study #2: Matrix N-30-5 Screener is Unremarkable
• Why did we run a frequency-doubling visual field screening?• There are two reasons:
both related to cranial nerves• Which two nerves were we
checking with his screening field?
Images from Humphrey Matrix
Case Study #2: 24-2 SITA Standard Visual Fields
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Case Study #2: Pachymetry with Ant Seg OCT
Images from Cirrus OCT
Case Study #2: Assessment & Initial Plan
http://opticaldiagnostics.com/info/aniseikonia.htmlhttp://cdn.iofferphoto.com/img3/item/568/007/701/o_xalatan-
eye-drops-latanoprost-0-005-anti-glaucoma-3932.jpg
Case Study #2, Second Visit: Contact Lens Telescope and New discovery
https://www.flonase.com/allergies/is-flonase-a-nasal-steroid-spray/
http://gogadgetplus.blogspot.com/2014/02/terminator-telescopic-contact-lens.html
Case Study #2: Macular OCT OD and OS
Images from Cirrus OCT
Case Study #2, Visit 1: Macular OCT OU
Images from Cirrus OCT
Case Study #2, Second Visit: Macular OCT OD
Images from Cirrus OCT
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Case Study #2, Visit 2: Macular OCT OS
Images from Cirrus OCT
Case Study #2: Macular OCT OD and OS
Images from Cirrus OCT
Case Study #2: What’s Your Diagnosis OS?
Images from Cirrus OCT
Case Study #2: Macular OCT 5-Line Raster
Images from Cirrus OCT
Case Study #2 Dx: Central Serous Retinopathy (CSR) OS
Images from Cirrus OCT
Case Study #2: Macular OCT OD and OS
Images from Cirrus OCT
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Summary: Epiretinal Membrane
• Epiretinal membrane can be concurrent and confused with:• Eye disease, like Coats’ and Eales• Cystoid and Microcystic Macular Edema• Central Serous Retinopathy
• Systemic hypertension leads to some of these conditions, but not necessarily ERM
• Aniseikonia is a presenting and residual symptom, uniquely treated by optometry
• ERM causes macropsia, magnify the fellow eyehttp://iovs.arvojournals.org/a
rticle.aspx?articleid=2458795
Questions? Thank You!
James Kundart OD MEd FAAO FCOVD-A
Professor, Pacific University College of
Optometry3D Performance Clinic,
Beaverton, [email protected]
Additional References
1. Xiao W, Chen X, Yan W, Zhu Z, He M Prevalence and risk factors of epiretinal membranes: a systematic review and meta-analysis of population-based studies. BMJ Open. 2017 Sep 25;7(9):e014644. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5623383/
2. Shen Z, Duan X, Wang F, Wang N, Peng Y, Liu DT, Peng X, Li S, Liang Y. Prevalence and risk factors of posterior vitreous detachment in a Chinese adult population: the Handan eye study. BMC Ophthalmol. 2013 Jul 16;13(1):33. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3726418/
3. Daruich A, Matet A, Dirani A, Bousquet E, Zhao M, Farman N, Jaisser F, Behar-Cohen F. Central serous chorioretinopathy: Recent findings and new physiopathology hypothesis. Prog Retin Eye Res. 2015 Sep;48:82-118. https://www.sciencedirect.com/science/article/pii/S1350946215000336?via%3Dihub