Macular Pucker


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eye condition, ERM, Pucker, treatment, ophthalmlogy

Macular Pucker

  1. 1. EPIRETINAL MEMBANE Dr Amit Srivastava
  2. 2. Definition • Acquired formation of semi-transparent cellular sheets on the macular surface, which are formed due to varied etiologies. • 1865, first described by Iwanoff
  3. 3. Introduction • Premacular fibroplasia, Macular pucker, Cellophane maculopathy, and Premacular gliosis • Contractile properties, often leading to mechanical distortion of macula. • Wide spectrum of presentation and clinical findings
  4. 4. Epidemiology • Beaver Dam Eye Study and the Blue Mountains Eye Study • Prevalence of ERM was 7–11.8%, with a 5-year incidence of 5.3%. • Idiopathic ERMs were bilateral in 19.5–31%, with 13.5% 5-year incidence of second eye involvement. • Age distribution shows a peak between the ages of 70 and 79 (11.6%), with ERMs being uncommon before the age of 60(1.9%)
  5. 5. Indian Scenario 7.6%
  6. 6. Classification • Idiopathic ERMs (no associated ocular abnormality) • Secondary ERMs with a pre-existing or coexisting condition has had a significant impact on development • Iatrogenic if they occur following medical or surgical intervention
  7. 7. Pathogenesis • Reactive gliosis in response to retinal injury or disease involving inflammatory and glial cells. • Involves – Cellular & Extracellular component – Growth Factors • Two main components of ERM – Extracellular matrix (consisting of collagen, laminin, tenascin, fibronectin, vitronectin, etc.) – Cells of retinal and extra retinal origin (such as glial cells, neurites, retinal pigment epithelium, immune cells and fibrocytes).
  8. 8. Growth factors (formation, progression and transformation of membranes)
  9. 9. Pathogenesis (PVD +) • Müller cells have proliferated and migrated onto the inner surface of the retina. • PVD exerts traction on the retina and induces – Müller cell gliosis (cellular hypertrophy) – Upregulation of cellular proteins such as vimentin and – Transient cellular proliferation. • Migrate to epiretinal surface via small defects in ILM, either natural (near retinal vessels) or as a result of larger paravascular breaks observed following PVD
  10. 10. Pathogenesis (PVD -) • Vitreomacular traction cause chronic irritation of Müller cells inducing gliosis and vascular leakage. • Glial cells appear to grow through the posterior hyaloid which then in turn becomes incorporated into the membrane
  11. 11. Clinical Features (Symptoms) • Grade 0 Incidental finding • Grade I ERM involving fovea causes – – – – – distorted or blurred vision loss of binocularity, Central photopsia, Macropsia. Monocular diplopia • Grade 2 ERM – blurred vision or – metamorphopsia
  12. 12. Clinical Classification Grade 0 Translucent membrane with no underlying retinal distortion Grade 1 ERM with irregular wrinkling of Inner retina Grade 2 ERM with opaque membrane and vascular tortuosity
  13. 13. Clinical Features • Grade 2 ERM associated with cotton-wool spots, exudates, blot hemorrhages and microaneurysms • Cystoid macular edema (20–40%) • Vascularization of the ERM and underlying RPE rare and indicate more severe disease A posterior vitreous detachment (PVD) is present in approximately 60–90% of patients at the time of diagnosis
  14. 14. Clinical Features • Macular pseudoholes (steepened foveal contour) 20% • Lamellar holes (retinal cysts ERM rupture) • Full-thickness macular holes (Tangential traction).
  15. 15. Clinical Assesment • Distinguish between idiopathic/Secondary/ iatrogenic ERM. • Good ophthalmic and general medical history. • Visual acuity that is lower than expected for the degree of ERM indicate underlying retinal disease • Intraretinal hemorrhages, exudates or cottonwool spots,
  16. 16. • Best corrected Visual Acuity for distance and Near. • Thick ERM cause decreased VA • Amsler grid distortion – Does not allow for the quantification of the severity of metamorphopsia; – Difficult to monitor the visual function over time
  17. 17. M-chart – Developed by Matsumoto – Quantifying metamorphopsia Metamorphopsia score MV 0.4 MH 0.5
  18. 18. OCT • Detects ERM in up to 90% cases • Assess the anatomical relationship between vitreous face and the retinal surface • Diagnosis, monitor the clinical course prior to and following surgery. • IS-OS junction • More recently, intraoperative OCT has also been used
  19. 19. OCT • • • • • Hyper-reflective layer retinal surface. Underlying corrugation of the retinal surface, Blunting of the foveal contour, Increased retinal thickness and Intraretinal cysts
  20. 20. Globally adherent ERM Focally Adherent ERM • Idiopathic ERMs tend to be adherent globally to the underlying retina, • Secondary ERMs are more likely to be characterized by focal retinal adhesion
  21. 21. OCT Patterns
  22. 22. • Inner retinal layer thickness (IRT) distance from the vitreoretinal interface to the inner border of the outer nuclear layer at the foveal center. • The outer retinal layer denoted layers of photoreceptor, encompassing the outer nuclear layer and inner segment/outer segment (IS/OS) junction line in OCT scan images
  23. 23. Fovea attached type ERM • Group 1A included ERM with outer retinal thickening; the inner retina, however, showed a minimal increase in thickness and maintained a nearly normal configuration. • Group 1B included ERM with more exaggerated tenting of the outer retinal layer in the foveal area; the inner retinal layer was slightly thickened and its configuration was distorted by centripetal and anteroposterior tractional forces due to ERM. • Group 1C included ERM with prominent inner retinal thickening, with inward tenting of the outer retinal reflectivity in the foveal area.
  24. 24. • Group 2A included ERM with the formation of a macular pseudohole, • Group 2B included ERM with macular pseudohole accompanied by marked intraretinal splitting
  25. 25. Cone outer Segment tips Attributed to scattering from the tips of the cone OS, in the region of interdigitation between the photoreceptor OS and the RPE cell processes that extend into the OS layer
  26. 26. Fibrillary Changes • Alternating linear hyperreflective and hyporeflective signal between ERM and Retinal Surface • Extent of ERM retinal adherence and presence of fibrillary changes gives reliable method of intraoperative difficulty of membrane peeling
  27. 27. Fluorescein Angiography • Recently decreased diagnostic utility • Underlying vascular event or CNVM is suspected • Highlight the extent of retinal wrinkling, degree of retinal vascular tortuosity and presence of macular edema
  28. 28. • Extensive leakage from retinal capillaries or veins was associated with more rapidly progressing lesions* • Displacement or distortion of the foveal capillary network may indicate foveal ectopia * Wise G. Clinical features of idiopathic preretinal macular fibrosis. Am J Ophthalmol 1975;79:349–57.
  29. 29. Course • Appiah et al 324 idiopathic ERMs with a mean follow-up of 33.6 months, – 49.5% maintained a visual acuity within 1 line of the initial acuity; – 37.4% showed a reduction in vision, and – 13.1% stayed the same. • Blue Mountains Study, the area of retina occupied by the ERM remained over 5 year – Stable 39%, – Regressed 25.7% and – Progressed 28.6% (where change was defined as a change in area of >25%). Course is one of stability or slow progression over years
  30. 30. Surgery Indication • Patient-reported symptoms of reduced visual acuity with or without metamorphopsia. • Reduction in acuity to ≤20/60, • Better than 20/60 if – Annoying metamorphopsia – Diplopia – Occupational reasons.
  31. 31. Prognostic factors • • • • • Visual acuity, Central foveal thickness, Presence of a macular pseudohole, Cystoid macular edema, and Location, thickness and degree of opacification of the membrane. • IS-OS junction (photoreceptor inner and outer segments), intact, it is strongly suggestive of viable photoreceptors • SLO based association between structural abnormalities of photoreceptors (microfolds) and symptoms of metamorphopsia. • Cone outer Segment tips (COST)
  32. 32. AO-SLO • Structural abnormalities in individual photoreceptor cells in patients with idiopathic ERM • IS/OS disruption is not specific to eyes with ERM
  33. 33. Focal macular ERG (FmERG) • Oscillatory potentials, “b” wave and “a” wave are all reduced in patients with ERM. • Reduced b : a wave ratio appears to be a sign of early disease with a reduction in the a-wave amplitude being correlated with poor postoperative visual acuity.
  34. 34. Cone Outer Segment Tips (COST) (Verhoeff membrane) • 3 groups – Group A, with a continuous IS/OS and COST line – Group B, with a continuous IS/OS but disrupted COST line – Group C, with a disrupted IS/OS and COST line • At 6 months, Group A showed a significantly better BCVA than Group B ( P < .005), and poorer BCVA was noted in Group C • Status of the COST line, in conjunction with the IS/OS junction, is a useful prognostic factor after ERM surgery
  35. 35. • Hierarchy of vulnerability among the 3 lines; – COST line, (ERM) – IS/OS junction (Macular Hole) – ELM (Retinal Detachment) • Can be disrupted when mild, moderate, and severe photoreceptor damage respectively is caused
  36. 36. Differential Diagnosis
  37. 37. Surgery Machemer developed the concept of membrane peeling in 1972
  38. 38. ERM Peeling • Vital dyes to assist visualization and removal, particularly over the macular area • Indocyanine Green (ICG) • Infracyanine Green(IFCG), • Trypan Blue4 (TB) and • Triamcinolone accetonide (TA) • Brilliant Blue G (BBG) • Chicago Blue • Bromophenol blue, • Patent blue (PB).
  39. 39. ICG IfcG TB TA PB BrB FMA BBG Mol wt 774 774 961 434 582 670 418 854 Chemical gr Tricar Tricar Diazo bo bocy cyanin anine e Steroid Triyl methane Triylmetha Steroid ne Triylmeth ane 1st publication 2000 2002 2003 2003 2006 2006 2007 2006 ILM affinit High High Low Low Low Mod Unkno wn High ERM affinity Low Low High Low Mod Mod Unkno wn unknown Vit affinity Low Low Low High Mod Unknown Low Unknow n Retina toxicity Mod Low Mod Mod Low Unknown Low Nil RPE toxicity Mod Low Mod Mod Low Unknown Unkno wn Unknow n
  40. 40. Double Staining Stalmans and colleagues both TB (for ERM) and IfCG (for ILM) in the treatment of macular pucker. • • Overlying ERM, which does not stain, but is visible against a surrounding blue-stained ILM. Non-stained ERM is first peeled off, and then BBG dye is injected a second time to stain the unstained ILM.
  41. 41. • Standard pars plana vitrectomy, • Degree of vitreous clearance is surgeon dependent – should avoid any risk of lens trauma or retinal breaks. • Most cases a PVD will be present at the start of surgery. • If posterior hyaloid is attached, PVD attempted carefully due to the presence of ILM attachments through the vitreous.
  42. 42. PVD • Deactivate cutting mode reach optic nerve head (Preferably nasal edge) and perform suction to grasp posterior hyaloid membrane and swing vitrectome horizontally. • Once posterior hyaloid detached complete halfway down
  43. 43. • Observe the macula – Whether to use dye – Whether to use macular lenses • Dyes – Loaded in 2CC syrringe connected with silicone tipped cannula – Pinch infusion line to decrease turbulence when valved cannulas are not used
  44. 44. • Magnifying contact lens – Microscope head should be moved to lower setting – Drastic reduction in field
  45. 45. Engaging and Peeling ERMs • Edge of the ERM – Clearly visible engaged directly with end-grasping forceps – Cannot be clearly identified, created prior to peeling using a • • • • 23 G Needle Machemer surgical pick (rounded tip instrument) O Malley Diamond dusted scraper Tano End grasping forceps Charles
  46. 46. Technique of ERM peeling • Outside in membrane peeling – Machemer • Inside out membrane peeling - Charles
  47. 47. • Try to look for area of membrane which is thicker (contraction center) or near or over macular vessel • Pinch the membrane and peel it back until it gives a flap • Peel tangentially over the retina centripetally • Observe both the point of membrane being peeled and head of forceps
  48. 48. • Cystic fovea (prevent Deroofing) – Strict centripetal peeling – Membrane dissected from perifoveal retina and at the end cut at fovea with vitrectome
  49. 49. Very Adherent ERM • No clearly defined tissue planes • Membrane peeling leaving areas of retinal whitening underneath. • Finding an alternative edge and peeling this toward the adherent area. • Repeated until only the adherent area remains, • Gently peeled without exerting traction on surrounding areas of retina.
  50. 50. Internal limiting Membrane • Potential benefit of completing an ILM peel following the removal of ERM. • Removes the scaffold for myofibroblast proliferation and any residual microscopic ERM, thus reducing the risk of recurrence as well as improving visual outcomes** **Bovey EH, Uffer S, Achache F. Surgery for epimacular membrane: impact of retinal internal limiting membrane removal on functional outcome. Retina 2004;24:728–35. Park DW, Dugel PU, Garda J, et al. Macular pucker removal with and without internal limiting membrane peeling: pilot study. Ophthalmology 2003;110: 62–4.
  51. 51. Result • Following surgery there is often a period of several weeks without any noticeable visual improvement. • Patients can expect a visual improvement of two or more lines in 60–85% of cases 6–12 months after surgery, • 44–55% achieving a visual acuity of 20/50 or better. • Patients with a higher preoperative visual acuity tend to have a higher final acuity even though the percentage improvement may be less. • Both idiopathic and secondary ERMs appear to benefit to an equal extent from surgery,
  52. 52. Result • Following successful ERM surgery – Macular thickness and foveal contour tend to improve on OCT, – Although neither returns to normal • IVB injection therapy provided no beneficial effects on CMT or visual acuity improvement for eyes with persistent macular edema after idiopathic macular ERM removal*. *J Ocul Pharmacol Ther. 2011 Jun;27(3):287-92. doi: 10.1089/jop.2010.0166. Epub 2011 Mar 23. Intravitreal bevacizumab injection therapy for persistent macular edema after idiopathic macular epiretinal membrane surgery. Chen CH, Wu PC, Liu YC.
  53. 53. Intraoperative Complication • Small petechial hemorrhages 19% • Preretinal hemorrhages selflimiting • Peripheral retinal breaks – 4–9% following 20 G vitrectomy – 1% with 23 G vitrectomy – EL or Cryo with air gas tamponade • Lens touch
  54. 54. Postoperative complication • Cataract – incidence of cataract within the first year ranges from 30% to 65% – alterations in oxygen tension and glucose concentrations, – Disruption of the anterior vitreous in the retrolental area and – Orientation of the infusion cannula at the time of surgery.
  55. 55. Postoperative Complication • Retinal detachment – 2–14% of eyes. – Unidentified entry site breaks at the time of surgery – careful search for retinal tears using scleral indentation at the end of surgeryRecurrence • Recurrence of ERM less than 20% of patients higher in younger patients (25%). • Retinal toxicity vital dyes • Phototoxicity