Retinal traction from epiretinal membrane?

[BUTTERCUP109]

I know that the doctors here are not retina specialists, but I'm grasping at straws now. I'm into my third year of continuous cystoid macular edema since lens replacement surgery. Over three years I've had every treatment known to medical science, Pred Forte, Durezol, IVK, IVA, Acular, Xibrom, Nevanac, Azopt, and oral Neptazane. The only new thing offered to me is the risky EMP/ILM Peel surgery, which has been suggested on the off-chance that the membrane which is only slightly visable on dilated exam and somewhat peripheral to the macula just maybe could be creating traction and keeping the edema from resolving. I am sitting iddly by at this point and watching my vision get progressively worse and basically doing nothing. It has gone from 20/20 to 20/70 over time. As I understand it, CME that behaves in this way hardly ever happens without some underlying reason. Any comments? Suggestions for something overlooked? Should I try alternative medicine such as acupuncture. Western medicine has surely failed me thus far.

[lucianomagoo]

I have a similar situation to yours, with retinal edema that has lasted for over two years, with no improvement following steroid treatment or the passage of time, and vision in that (left) eye of 20-70. The sequence of events was an initial cataract surgery performed three years ago four hours north of Santa Rosa, followed by two retinal detachments. After the second detachment an ERM developed that was pulling on the retina, so it was removed last year. The retinal surgeries were performed by a woman retinal specialist in Santa Rosa whom my wife and I have a very high opinion of. The epi-retinal membrane has returned, doesn't appear to be pulling on the retina, but the surgeon has recommended that I have it removed, since the edema is likely to eventually lead to further problems. I also have an ERM on the other (right) retina, which also had a retinal detachment following cataract surgery, but there is no edema in that eye, and the vision is good. Since I have had a total of four retinal surgeries so far, but have complete faith in this surgeon, my answer is to wait one year and then have the membrane removed. The membrane peel will be an out-patient procedure in Santa Rosa; I don't consider it that risky, based on my experience with this surgeon, and thirty four years working in acute care hospitals.    

[Sandy Feldman, MD, MS]

Dear Buttercup109,

I would recommend that you seek the opinion of another retinal specialist and obtain a second opinion to make you more comfortable with the recommendation. As your vision is worsening, you might need surgery to improve your condition.

Dr. Feldman

Sandy T. Feldman, M.D., M.S.
ClearView Eye and Laser Medical Center
San Diego, California

[BUTTERCUP109]

Thanks Jodie, You may remember corresponding with me about six months ago. At your recommendation, I saw Dr. Stephen Charles. He did not make a connection to the ERP and did not recommend a peel to me, but he also did not have any advice at all except to keep using the Nevanac and give it more time. I could tell he is very smart, but also observed how over-the-top busy he was and perhaps with so many people coming to him, he does not fully study a patient's history. I feel I am up against a wall because my vision is worsening and nothing is helping. My local retina specialist is ultra-conservative and will not even consider a peel unless he sees numerous clinical studies documenting high rates of improvement of chronic CME from a peel. He feels very stronly about this. However, another local retina specialist is less rigid and has indicated it would be a possibility, but carries no guarantee of helping. I wish I knew the name of at least one or two other highly regarded specialists to talk to, before I decided what to do.

[JodieJ]

I have a few non-professional comments related to your post, based mostly on my personal experience. (1) An ERM in the macular periphery absolutely exerts traction on the retina.  I believe that this is demonstrated by my Spectralis OCT images before and after my second ERM surgery to peel pieces of ERM remaining in my macular periphery.  (2) The fact your ERM was difficult for your doctor to visualize on dilated exam doesn't seem terribly significant to me.  I suspect that doctors differ in their ability to identify ERM.  A local retinal specialist told me that he still saw ERM in my eye following two surgeries to peel it.  (I just about had a heart attack when I heard that!)  Fortunately, subsequent OCT confirmed that there was no remaining ERM.  (3) The risk level involved in ERM/ILM surgery is related to the surgeon's skills.  There is less than a 1% risk of retinal detachment if the procedure is performed by a skilled surgeon.  (You don't have to worry about accelerated cataract development, which is the major side effect of this procedure.)  Personally speaking, I would not have this procedure performed by a surgeon who described it as being "risky."  (4) Unfortunately, a successful ERM/ILM peel would not guarantee a reduction in your CME.  In your place, I'd consult 2-3 top retinal surgeons about the potential risks/benefits of an ERM/ILM peel for me.  I'd make a decision based on their opinions.

With all of us aging baby boomers, I think that there will be a lot of new treatments for CME in the near future.  I'd probably take a pass on the acupuncture for now.