NOTE TO JODIE J

[John C Hagan III, MD, FACS, FAAO]

I have sent you the vitrectomy article text from the Am J of Ophthalmology. Please confirm you recieved it. Thanks
JCH MD

[JodieJ]

Thanks, caren123, I've learned a lot about ERM surgery, which I'm happy to share with others.  Re your macular edema:  It will most likely diminish slowly after your ERM is peeled, although some (minor) edema will probably always be present.  There is good evidence that peeling both the ERM and the ILM (a very thin membrane underneath the ERM) helps to to eliminate visual distortion post-surgery.  However, some surgeons use ICG dye during surgery to help them visualize the ILM.  This dye can have toxic effects on the retina--be sure that it won't be used during your procedure.    

[caren123]

Your experience is a great source of help for me at this time. You have been through so much and you give so much to me and others.  Thank you.

[JodieJ]

I've learned more about ERM surgery since last May.  I think it would be helpful for others if I briefly summarized my (ongoing) personal experience.

I had a vitrectomy with ERM peeling in January 2006, performed by a very highly respected local (Chicago) retinal surgeon.  The surgery restored my acuity to 20/20+, but left me with an image that was about 15+% larger in my affected eye than the image in my other eye.  (This image size difference was not present before surgery.)  It caused many problems, including continuous tearing and impending double vision.  I was given no explanation or referral for my symptoms.  I subsequently saw three additional respected retinal surgeons here in Chicago, all of whom strongly recommended against having further surgery.  I have a copy of one of their reports, which states that there was no ERM remaining in my eye, and my surgical outcome was "very good."  I got relief from my bothersome symptoms from an optical correction prescribed by Dr. Gerard de Wit of the Netherlands following online testing.

Last March at the suggestion of my general ophthalmologist, I traveled to Memphis to see Dr. Steve Charles.  I was shocked to learn from Dr. Charles that my original surgeon had successfully peeled the center of my ERM, but had left the two tails of the membrane in the macular periphery.  This apparently was the source of my image size difference.  Dr. Charles stated that many retinal surgeons were not skilled at removing smaller pieces of ERM, but he was confident that he could peel them safely.  I had a second ERM peeling the following day, and the thin ILM was also peeled.  No dyes were used.  I could read the 20/20 line with my affected eye the morning after surgery, but there was no immediate change in my image size disparity.

When there was no improvement in my image size difference after three months, I began writing to researchers worldwide.  What I learned was discouraging.  Early ERM surgery is associated with better outcomes, both for acuity and for reduction in distortion.  In fact, there is evidence that delayed surgery can cause irreversible damage to the macula.  With a 3+ year delay between my surgeries, I was in the "poor prognosis" group.  However, I did begin to get improvement during my 4th month postop.  At the present time (7 months postop), the image size in my affected eye has been reduced by about 50% according to testing results.  Good, but not quite good enough.  I'm hopeful about getting more improvement.

Based on my experience, I have a couple of suggestions for others with an ERM.

(1) Your choice of surgeon is SO important.  If it is possible, go see Dr. Charles in Memphis.

(2) If the ERM adversely affects your vision to a significant extent, don't delay your surgery.

      

[John C Hagan III, MD, FACS, FAAO]

-

[caren123]

Thank you for everything!  I am about to schedule the epi-retinal peeling because I thought it was the only answer for the distortion which bothers me - color, size, slanting, objects jump around from eye to eye - and I also thought it would help with the edema which has not solved itself with drops over a long period of time. Guess that is not necessarily so.  My surgeon said it is elective if I want it, I do if it will help with the distortion.  Any comments would be appreciated.

[JodieJ]

Yes, I received the article--and thank you SO much!  This is an area of great interest to me.  I'll share my own reactions, and hopefully others will, too.

The article measured "vision related quality of life" along 12 sub-scales (e.g., general health, near activities, social functioning) before surgery to peel an ERM and again 3-months after surgery.  The responses of 28 Japanese ERM patients were compared to those of 28 normal controls.  The authors found that the quality of life scores for the ERM patients improved after surgery, but were still lower than those of the normal controls.  Furthermore, improvement in the quality of life scores correlated with improvement in metamorphopsia (distortion), but not with other measures, such as visual acuity.  The authors concluded that retinal surgeons should pay more attention to changes in the distortion following ERM surgery.

Wow!  I'd certainly agree that many retinal surgeons still measure the success of surgery by a patient's ability to read lines on an eye chart with one eye only, ignoring such factors as binocular vision difficulties, contrast sensitivity, etc.  This practice may present a false picture of the surgical outcome from the patient's perspective.

I've read that completely peeling the ERM and ILM eliminates most of the distortion (metamorphopsia) caused by an ERM.  I'll have to consult an expert in the field to verify that this is really true.  If it is, then it seems to me that the outcome of many ERM peels is less than what I'd consider successful (since distortion persists.)  (Was ERM left in the eye?)  On the other hand, gains in visual acuity may be limited by the persistence of macular edema (which may be beyond the surgeon's ability to control.)

I had to wonder why the authors measured quality of life scores at 3-months post-op, when healing isn't complete until 6-12 months (or longer) post-op.  (The authors did acknowledge this limitation.)