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Epiretinal Membrane
Nawat Watanachai
Ramathibodi Hospital
Mahidol University
Epiretinal membrane (ERM)
 An avascular

fibrocellular membrane
that proliferates on the
inner surface of the retina
to produce various
degrees of macular
dysfunction
Common synonyms
 Cellophane maculopathy
 Macular pucker
 Premacular fibrosis/ gliosis
 Surface wrinkle retinopathy
 Epimacular membrane
Epidemiology and pathogenesis
 Idiopathic ERM
 Secondary ERM
Epidemiology and pathogenesis
Idiopathic ERM

6% in > 50 yrs old
F>M
Bilat 20-30%
Epidemiology and pathogenesis
Idiopathic ERM

PVD 90%
Retinal glial cells migrate through defects in the ILM
probably create at the time of vitreous separation
Epidemiology and pathogenesis
Secondary

After 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
Epidemiology and pathogenesis
Secondary

After prophylactic treatment of
peripheral break : 1-2%
Trauma, vit inflam condition, retinal
vascular dis, long-standing VH
Ocular manifestations
 Depend on its

thickness and the extent

(occlusion) to which it has undergone
shrinkage or contraction (traction)
Ocular manifestations:
thin ERM, Cellophane maculopathy
 thin and transparent
 Abnormal glistening light reflex from the inner

retinal surface
 Mostly asymptomatic
Ocular manifestation:
thick ERM, pucker
 Inner retinal striae radaite from edge of ERM
 White-gray/ white translucent membrane, may

obscure visualization of the retinal vessels
Ocular manifestation: thick ERM
 More severe degree of macular dysfunction

Macular distortion, folding, puckering
Macular edema, pre-retinal/ intraretinal
hemorrhage
Foveal ectopia, macular pseudohole
TRD, RB, RRD
ERM with Foveal ectopia
Ocular manifestation: thick ERM
 Vision loss
 Metamorphopsia
 central photopsia
 binocular diplopia
 macropsia
Ocular manifestation :
pseudo or true macular hole
 Pseudohole
Wrinkle of inner retinal surface
Retinal tissue at the base of pseudohole
Absence of characteristics of true hole: yellow
pigment deposits in the base, halo of neural
detachment. Overlying operculum/ pseudooperculum
 Equivocal cases : OCT, FFA
Pseudohole
Diagnosis 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
Diagnosis and ancillary testing
Diagnosis and ancillary testing
DDX
 VMT syndrome
 Combined RPE and retinal hamartoma
 Prominent macular light reflex in the young
 CME
 Optic disc swelling (juxtapapillary ERM)
 Idiopathic MH
Pathology
 ERM consists of avascular

fibrocellular sheet

Native vitreous
Newly synthetic collagen
Fragment of ILM

Myofibroblastic Cells : RPE cells, fibrous
astrocytes, macrophages
Treatment
 ERM with minimal symtoms : no treatment but

observation
Treat in cases of

Significant visual loss
Metamorphopsia
Intolerable binocular diplopia
Goal 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
Surgical procedures
 Pars plana vitrectomy
 +/- staining
 Engage the edge of

ERM with a retinal
pick/ forceps/ sharp
bent-tip needle
 Peel the membrane
with forceps
staining
peeling
Course 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
Course and outcomes
 After Sx, resolute within days/ wks

 VA 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
Cases with minimal benefit
 Patients who have symptoms that has

lasted longer than 1 yr
 Findings that suggest long-standing cases
Atrophic/ hypertrophic RPE alterations
Intraretinal lipid/ hard exudates
Microvascular changes such as
microaneurysms
Complications
 Progressive sclerotic cataract (MC)

60-70% in 2 yrs
 Peripheral retinal breaks
 RRD
 Posterior retinal breaks
 Photic maculopathy
 Endophthalmitis
 Recurrence 5%
Thank you

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NW2010 Epiretinal membrane

  • 2. Epiretinal membrane (ERM)  An avascular fibrocellular membrane that proliferates on the inner surface of the retina to produce various degrees of macular dysfunction
  • 3. Common synonyms  Cellophane maculopathy  Macular pucker  Premacular fibrosis/ gliosis  Surface wrinkle retinopathy  Epimacular membrane
  • 4. Epidemiology and pathogenesis  Idiopathic ERM  Secondary ERM
  • 5. Epidemiology and pathogenesis Idiopathic ERM 6% in > 50 yrs old F>M Bilat 20-30%
  • 6. Epidemiology and pathogenesis Idiopathic ERM PVD 90% Retinal glial cells migrate through defects in the ILM probably create at the time of vitreous separation
  • 7. Epidemiology and pathogenesis Secondary After 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
  • 8. Epidemiology and pathogenesis Secondary After prophylactic treatment of peripheral break : 1-2% Trauma, vit inflam condition, retinal vascular dis, long-standing VH
  • 9. Ocular manifestations  Depend on its thickness and the extent (occlusion) to which it has undergone shrinkage or contraction (traction)
  • 10. Ocular manifestations: thin ERM, Cellophane maculopathy  thin and transparent  Abnormal glistening light reflex from the inner retinal surface  Mostly asymptomatic
  • 11. Ocular manifestation: thick ERM, pucker  Inner retinal striae radaite from edge of ERM  White-gray/ white translucent membrane, may obscure visualization of the retinal vessels
  • 12. Ocular manifestation: thick ERM  More severe degree of macular dysfunction Macular distortion, folding, puckering Macular edema, pre-retinal/ intraretinal hemorrhage Foveal ectopia, macular pseudohole TRD, RB, RRD
  • 13. ERM with Foveal ectopia
  • 14. Ocular manifestation: thick ERM  Vision loss  Metamorphopsia  central photopsia  binocular diplopia  macropsia
  • 15. Ocular manifestation : pseudo or true macular hole  Pseudohole Wrinkle of inner retinal surface Retinal tissue at the base of pseudohole Absence of characteristics of true hole: yellow pigment deposits in the base, halo of neural detachment. Overlying operculum/ pseudooperculum  Equivocal cases : OCT, FFA
  • 17. Diagnosis 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
  • 20. DDX  VMT syndrome  Combined RPE and retinal hamartoma  Prominent macular light reflex in the young  CME  Optic disc swelling (juxtapapillary ERM)  Idiopathic MH
  • 21. Pathology  ERM consists of avascular fibrocellular sheet Native vitreous Newly synthetic collagen Fragment of ILM Myofibroblastic Cells : RPE cells, fibrous astrocytes, macrophages
  • 22. Treatment  ERM with minimal symtoms : no treatment but observation Treat in cases of Significant visual loss Metamorphopsia Intolerable binocular diplopia
  • 23. Goal 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
  • 24. Surgical procedures  Pars plana vitrectomy  +/- staining  Engage the edge of ERM with a retinal pick/ forceps/ sharp bent-tip needle  Peel the membrane with forceps
  • 27.
  • 28. Course 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
  • 29. Course and outcomes  After Sx, resolute within days/ wks  VA 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
  • 30. Cases with minimal benefit  Patients who have symptoms that has lasted longer than 1 yr  Findings that suggest long-standing cases Atrophic/ hypertrophic RPE alterations Intraretinal lipid/ hard exudates Microvascular changes such as microaneurysms
  • 31. Complications  Progressive sclerotic cataract (MC) 60-70% in 2 yrs  Peripheral retinal breaks  RRD  Posterior retinal breaks  Photic maculopathy  Endophthalmitis  Recurrence 5%