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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.