Problems as a result of ERM and Cataract Surgeries

[Mikek1]

I had a tiny ERM develop in my right eye in the year 2000. Ironically, I also had back problems develop at the same time. Luckily, the ERM never became a problem and the back problem also got better..  In November 2005 an ERM that was fast growing developed in my left eye. I also had my next back problems. I happen to live in the Baltimore MD area which is known for JHU and great eye doctors. My eye doctor in Towson, MD did not want to operate. Instead I was given experimental shots in the eye and other drops to dislodge the ERM. He kept telling me it was slowly getting better. In 2008 I had  developed a full grown cataract that needed to be removed but also had a backout from a shot in my eye. The cataract surgery I had done was undercorrected so that I only see 20/100 instead of the 20/20 we were going for (April).  In June I went to both the Wilmer Eye Institute and another top doctor for a second opinion on my ERM. In July 2008 I had ERM surgery done by another highly regarded doctor. I see 20/40 with contact correction on the eye chart but I cannot read across any line - I see the first two letters and have to move my head to the right to read any more from my left eye. If I twist my head far enough to the right I can then see the whole line. When I try to read a sentence on the computer or in a book with my left eye, the last few letters of each word look twisted. If I am driving my left eye looks like a 4 x6 picture and my right eye looks like a 3 x5 picture which is hard on my eyes.  Last week my cataract (in my right eye) which was fully grown had to be removed in the middle of our big snowstorm.  (In July 2009 I developed a tiny hole in my right eye and surgery was done around the hole to seal it). Six hours after the surgery I was seeing 20/30 out of my right eye but I may need a surgical correction for my astigmatism.  I am now 61 years old and still working. I would appreciate any thoughts/advice that you have.  Thank you! .

[Mikek1]

I could not agree with you more!

[JodieJ]

If you're up for a challenge, try downloading "Retinally Induced Aniseikonia" from Dr. de Witt's opticaldiagnostics.com website.  The paper is written for eye care professionals, and it is technical but not incomprehensible.  (There's additional information on the website.)  It certainly IS possible to at least partially correct image magnification/minification after an ERM peel.  In my own case, a -3 glasses lens worn over a +3 contact lens reduces the image size in my affected eye by about 5% without impairing my acuity, and it certainly makes my binocular vision more comfortable.  This solution was suggested to me per online consultation with Dr. de Witt, after several local ophthalmologists and optometrists told me that my condition was "untreatable."  (I had already tried the magic tape techniques, but they didn't work for me.  I refused to accept that nothing could be done, and you shouldn't accept this either.)

If you're not comfortable with an online consultation (which may be your best bet), schedule an appointment at Wilmer and bring the De Wit article to the appointment.  (Maybe you can interest an enthusiastic resident.)  It is certainly in your best interest to become as knowledgeable as you can about your condition and its treatment.  You may end up directing your own treatment.  



  



  

[Mikek1]

Response from Dr. Gupton:   Unfortunately there is no way to treat the distortion/magnification/holes in your vision once the ERM has been peeled.  The distortion that it causes does not always subside, and if it does not, there is no known way to fix it.  It can only be blocked out from your vision, if necessary, that is if it is interfering with the vision in your other eye.   If you wear glasses, or can wear light-colored sunglasses, a strip of Scotch Satin (gift-wrap) tape (purple plaid) on the rear surface of the lens before your left eye effectively blocks the central vision in that eye . This is especially helpful when there is actual dragging of the center of the retina in your left eye so that you have actual double vision.  If you do not have double vision, then you will probably have no use for the tape.  I’ll attach a copy of the  paper we wrote on the subject, especially so you can see the different ways the tape can be applied.

I’ll be happy to see you as a patient, for which you can call  for an appointment, but there is a 3- to 4-month wait for an appointment, and you can probably just as effectively experiment with the Scotch Satin tape yourself.

[Mikek1]

I agree with Jodie - Don't put off having the peel. My doctor did  not want to do it -thought it would not work and so gave me shots/drops for 2 1/2 years.  Please read my next response to Jodie

[JodieJ]

Re: that blurry letter at the end of line--I think that the cause might be spherical aberration (a benign condition).  Some IOLs, contacts, and glasses can correct it.  It's unrelated to having a lazy eye.

[eyesonyou]

Caren,
Please do let us know what happens with your epiretinal membrane.

Tomorrow is IT -- I go back to see my retina specialist.  It has been 5 weeks since my cataract surgery, and he will take a look at my epiretinal membrane again.  I'm prepared to go forward with his advice, even if it means doing the peel.

I will do a follow-up post sometime after I consult with him.

Take care.

[JodieJ]

Caren123, please don't postpone your ERM surgery.  I have communicated with several people in situations similar to yours who waited a year (or much longer) before having surgery, and none had a good outcome in terms of eliminating their image size difference.  Your CME will probably improve when the ERM is eliminated; however, the CME is not what's causing the image size difference. (It's the traction and wrinkling from the ERM.)  Please let me know how things work out.

An image size difference resulting from an ERM (aka "retinally induced aniseikonia") creates difficulties with binocular vision (i.e., using both eyes together).  It's not the same as having strabismus or a lazy eye, and the strabismus specialists I've approached do not want to treat patients with retinally-induced problems.  Dr. Guyton at Wilmer might be a rare exception.  I've read that he has a special interest in optics and has been using contacts/glasses to correct retinally-induced distortion for many years.  He has also co-authored papers in this area.  Finding an eye care provider who is knowledgeable about treating retinally-induced distortion is EXTREMELY difficult.  (Here in Chicago I'm stuck orchestrating my own treatment via online advice.)  So I'm really interested in knowing what Dr. Guyton can do for you, Mike.  

[Mikek1]

I believe my left eye was a little lazy for a while.   Dr. Guyton is a Strabismus specialist.

[Mikek1]

Thank you for sharing your experience. I would appreciate hearing back from you after you have the peel. Hopefully that will make a difference.

[caren123]

I would like to add to the discussion regarding “distortion” in image size and shape. I have not had ERM peeling as yet, but immediately after cataract surgery to R eye, with pre-existing small ERM, image size was much larger (I joked that he had implanted a magnifying glass).  Objects larger and closer, shapes elongated and slanting down towards left, saw objects straight-on with one eye and w operated eye saw them  from above and side.  Also have melting letters and white spots.  Diagnosis is retina complications after surgery (I am told this could have happened no matter which implant I chose).  ERM causing CME, edema, all resistant to drops and injection so next step is peel.  Since ERM was not causing problems before surgery the serious distortion is considered to be relatively recent (8 months since the surgery) and could hopefully improve with peel.  Vision has improved to about 20/50 but is not good enough to drive with the blur, and the other eye is only 20/30.  I am glad to know glasses can help with size image.

[eyesonyou]

I am really sorry that you are having the problem with the distorted letters at the end of a line or the end of a word.
For myself, I have noticed for a few years that the last letter on the right of the eye chart is always a little blurrier and more difficult to read than the rest of the letters.  It's not a terrible difference, but it's there.
I asked my O.D. about this, and she really didn't have an answer.  But she did say, "Were you ever told as a child that you had a lazy eye?"  Well, nobody ever told me that.
I'm in complete ignorance on the subject, actually.  But I thought I'd post this.

[Mikek1]

Again, I want to thank both of you for all of your help. I wrote to Dr. Guyton and will update you once I hear back.

[JodieJ]

Dr. O, I think that an image size difference related to an ERM is more common than you think.  I've corresponded online with more than a dozen people who are coping with this problem.  Often the size disparity is not noticed until after cataract surgery, when acuity is improved.  Improved acuity makes ERM-related distortion a much bigger problem.

Mike, if you do have ERM remaining in your eye, a second peel might help.  I had a second peel last year to remove ERM left in my eye for 3+ years.  My image size difference decreased from about 16% to about 8% (as measured by Dr. de Wit's Aniseikonia Inspector.)  I suspect that my remaining size difference will be permanent.  

[Ray T Oyakawa, MD]

Of interest,  David Guyton was my chief resident and helped me with my first cataract surgery.

I downloaded the article you mentioned and I will read it.


I got an Ozurdex implant yesterday.  I will see if it helps.


Dr. O.

[JodieJ]

The distortion of image shapes and changes in image size are related to the wrinkling of the macula due to the ERM.  There seems to be little current interest in this area among American researchers.  Some recent work by British researchers (R. Asaria, "A Prospective Study of Binocular Visual Function Before and After Successful Surgery to Remove a Unilateral Epiretinal Membrane", 2008) suggests that irreversible macular damage producing progressive distortion and changes in image size may be associated with the presence of an ERM after several months.

The best papers about using glasses/contacts to improve these types of vision problems are written by Dr. Gerard de Wit of the Netherlands.  You can download "Retinally-induced Aniseikonia" free (and in English!) from his website at www opticaldiagnostics com.  From a personal perspective, the glasses worn over a contact which Dr. de Wit suggested for me reduced the image size difference between my eyes and made my binocular vision more comfortable.  (I did not have the type of reading distortion that you described.)

As I mentioned in another thread, Dr. David Guyton, a binocular vision specialist at Wilmer, is one of the few American ophthalmologists who has published papers about improving vision for people with retinal damage.  Since he practices in your home town, I'd strongly suggest that you try to see him, and I'd be very interested in hearing about the results of your consulation.  Here in Chicago, I couldn't find any eye care providers who were knowledgeable about this area.

      

[Ray T Oyakawa, MD]

My last post got lost in cyberspace.

I know both doctors.  I was a resident and chief resident with Dr. Glaser.  Dr. Thompson was a resident when I was chief resident.  Both are excellent doctors.

I believe you problem has to do with a residual membrane or edema.  The Avastin injection did not cause the elevated pressure.  A steroid was probably injected at the same time.

Regarding the larger image:  This is quite rare however, both Jodie (on this chat line) and I have had an enlarge image after an ERM peel.  Jodie saw Dr. Steve Charles who repeated the peel and the image size difference resolved.  Use the search function.  One of the retinal doctors I am seeing has only seen this in me and one other patients.  Both of use have done hundreds to a thousand ERM peels and not seen this except as mentioned.

I would try the Ozurdex.  It is less likely to cause a pressure elevation.



Dr. O.

[Mikek1]

Dr. John Thompson at GBMC. Before switching to Dr. Thompson, I had gone to Dr. Glaser (former director at JHU). Dr. Glaser gave me Avastin and other steroids for 2 1/2 years. He did not feel surgery was the correct route to go with my problem. The Avastin (given by a shot) sent my eye pressure (normally around 12) to 50. The Qzurdex implant may help since I had leakage from the retinal blood vessels before my ERM surgery in the left eye.

My big question is really about the bigger picture in my left eye (compared to my right) and the difficulty I have reading with my left eye - one or two letters from each word followed by twisted (distorted) letters. I have not seen anyone write about this reading problem I have or the fact that on an eye chart I see a couple of letters looking straight and not the rest of the line. I very much appreciate your thoughts/suggestions. Thank you!

[Ray T Oyakawa, MD]

What is your question?  

Regarding the ERM,  you probably has some residual or there is permanent damage.
Options include, injection of Avastin, steroid, or an Ozurdex implant.


Who did the peel?

Dr. O.