Epiretinal Membranes, CME and Macular Holes

Laura S. Gilmore, MD

Grand Rounds

November 14, 2003

Texas Tech University HSC

Lubbock, TX

History• Chief Complaint: VA OD “fading away” x 6-

8 months

• HPI: 81yo male referred for evaluation of chronic CME OD s/p CE 3 years ago

• PMH: newly diagnosed DM with BS 120s-140s. HTN. Hypothyroidism. Arthritis. Hypercholesterolemia.

• Ocular History: CE OD 99; KNOWN CME x 3 years

• FH: diabetes, sister

• SH: no alcohol. Quit smoking >30 years ago

Physical Exam• VS: BP 115/79, P 74

• VA: OD 20/50 -1+2PH NI, OS 20/50 -1+1PH 20/40-2;; VF FTFC OU x small central scotoma; AMSLER normal

• IOP: OD 10, OS 14

• PCIOL OD, 3+ NSC OS

• Anterior segment clear, without pupil distortion, PSC, synechiae, lens dislocation

• DFE: OD-ERM; macular hole with flap of retinal tissue; multicystic CME; cryo scar supero-nasally; PVD with Weiss ring. OS-appears flat

Additional History

• 1978: blunt trauma OD-champagne cork vs eye

• Resultant RD, per patient

• Treated in San Diego VA Hospital with cryotherapy, pneumatic retinopexy?

• Still awaiting records from San Diego

Note dragging of vessels, tortuosity, color changes

Dragging, tortuosity

Cystic spaces evident in this incidence

Cystic rupture in another incidence

Hypotheses

• Senile macular hole

• Blunt trauma caused retinal tear and/or detachment, and hole directly or indirectly

• CME with ruptured cyst

• Vitreofoveal traction syndrome 1st, then ERM

• ERM 1st, leading to 1) tractional macular hole or 2) CME from ERM traction, then hole

• Typical senile hole- not likely, since usually shows early hyperfluorescence

• Direct result of trauma in 1978? symptoms would have appeared within 6-12 months

• CME with ruptured cyst

• Not likely result of CE, or symptoms would have been evident within 6-8 months post-op. CE was over 3 years ago.

Unlikely Choices

Most Likely Choice

• RD repair/cryo, with resultant ERM 1st, leading to 1) tractional macular hole or 2) CME from ERM traction, then hole

Macular Dysfunction Caused by Epiretinal Membrane Contraction• Distortion

• Intraretinal edema, CME

• Degeneration of underlying retina

Classification by Distortion• Grade 0: Cellophane Maculopathy-translucent with

no distortion of retina; cellophane light reflex

• Grade 1: Crinkled Cellophane Maculopathy-irregular retinal folds and light reflex, radiating retinal folds; no to mild VA c/o, 20/40 at worst, +/-metamorphopsia, insidious onset

• Grade 2: Macular Pucker-grayish membrane; marked retinal crinkling and puckering of macula; PVD in 90%; may see edema, retinal heme, CWS, SRD, leakage by FA; VA 20/200 or less, insidious to sudden onset, usually with metamorphopsia

ERM Following Retinal Tear/Detachment Repair

• Grade 1 or 2 frequently seen s/p RT/RD repair

• usually occurs 8-16 weeks post-op

• VA in 20% of pts improves due to relaxation or partial peeling of ERM and resolution of intraretinal edema

• Traction on macula can lead to hole or CME

Clinical Features of CME• Visual acuity is reduced according to

severity and duration

• Longstanding cases usually result in coalescence of fluid-filled microcysts into large cystic spaces

• Lamellar holes form at fovea, causing irreversible damage to central vision

• SLE shows loss of foveolar depression, thickening of retina, and multiple cysts in sensory retina

Signs of Macular Hole• Watzke-Allen-beam on foveola appears broken

• round, red spot in the center of the macula, 1/3 to 2/3 DD, surrounded by a gray halo

• lose foveolar depression; yellow spot in macula.

• Small, yellow precipitates in hole subretinally

• retinal cysts at the margin of the hole or a small operculum above the hole, anterior to the retina (stage 4) or both

• May be caused by vitreous or epiretinal membrane traction on the macula, trauma, or cystoid macular edema

Fluorescein Angiography• CME-Dye accumulates in outer plexiform

layer; Dye leaks into parafoveal region during the arteriovenous phase, coalesces into flower-petal pattern in late AV phase; hyperfluorescence from dye pooling in microcystic spaces persists through late phase

• Macular/lamellar holes-EARLY hyperfluorescence

• ERM-diffuse leakage of capillaries around FAZ; what we see

Summary

• ERM following RD repair

• tractional macular hole vs. CME from ERM traction, then hole

Proposed Treatment in this Case

• Surgery at 20/50? F/U this week, 20/25 OD

• No metamorphopsia, no Amsler symptoms

• just small central scotoma

• No; will follow. If VA decreases (at least 20/60) or pt has intolerable distortion, proceed with PPVx, membrane peeling

Gass, J. Donald M. Stereoscopic Atlas of Macular Diseases, Diagnosis and Treatment, Volume II, 4th Edition. 903-916, 938-954.

Kanski, Jack J. Clinical Ophthalmology. 4th Edition. 424-425.