Victrectromy outcome for long duration ERM?

[PlasV]

Hi. I would like both some opinions and patient experiences with a vitrectomy for a log standing >5 yrs ERM.

Long story short - I realize that the outcome is far better and more successful for an ERM of short duration. However, due to some questions of safety regarding possible complications because of glaucoma at the time the ERM was originally diagnosed, the surgery was not done, and I've lived with distorted vision. However, now there has been no further visual field lose from glaucoma, it's been well controlled, and retinal surgical techniques have been improved, I am again considering the procedure. Both my retinal surgeon and my new glaucoma specialist are confident the IOP can be managed successfully. The only thing now to consider is the risk/reward ratio for this long standing ERM.

Now that I've had cataract surgery, the ERM distortion is much more noticeable and worrisome.

So, I'm seeking information from anyone who has the same experience, either from a patient or MD point of view. Realistically, I expect there would not be a great acuity improvement (the eye is BCVA about 20/50, but fuzzy at that), but the main problem I hope to correct is the double, twisted and different sized images that come from both eyes seeing things at different sizes and places. Unfortunately, the bad ERM is in my dominant eye, so there is a constant fight between the two. The other eye has a mild ERM with minor distortion, but decent acuity.

Any opinions or experiences would be greatly appreciated.

THANKS!

[PlasV]

JodieJ, I'm thinking about opening a new discussion thread on this topic, but I'm starting it here as part of this one, since it relates.

One thing that's quite obvious to me now (I suspected it for a long time) is that progressive lenses are a really bad idea if you have an ERM. Since having cataract surgery, I have been using simple fixed focal point readers for close and medium distance work. Before, I had progressive lenses, and had really strange problems with them. As an ERM can cause many things - blurriness, distortion, size differentials, and my personal favorite, blurred and scratchy mixed sizes at various places because of the distortion, the "progression" in each lens behaves very differently in the affected and the non-affected eye. Moving through the "zones" of progression apparently causes the size variation to change very differently in the ERM eye than the intended effect. This results in a much more pronounced variant of the original problem. I always puzzled over the fact that what I saw was far more troublesome in real life than what was apparent from an Amsler grid evaluation.

In my case, images in one eye are shifted slightly up and to the left for portions of what are in the center of fixation. So, I see 2 stoplights, one offset up and to the left of the other. Also, the size varies from the other eye. As I would tilt my head, or change gaze from side to side, the position of the offset would also change - sometimes quite dramatically, as well as the size of the second image. Imagine how confusing that is. The eye can never learn to compensate for that mess. Add to that equation the fact that my optometrist added in some prism to try to pull the images together for me. With a fixed mono-focal lens, that probably would work somewhat, but the prism with progressives probably was worse than not having it. Also, I was incredibly myopic. My best focal point was 5 inches from my face, so I had a very strong prescription, and a wide variation in the progression from far to near.

Now, with a fixed focal length IOL, I still see a distorted image in one eye shifted up and to the left, but at least the size and position doesn't shift every time I move my eyes around! The ERM is almost bearable, but due to the continued traction I will probably go ahead with surgery anyway. (we're talking distance now, not close with the readers - they introduce a bit more problems, as they are very cheap lenses)

Once my eyes settle down from the cataract surgery, and prior to the vitrectomy, I'm at a loss to know what would be best for lenses. Progressives for me were great before because of the convenience factor, and carrying around 2 pair of readers - one for the computer, and one for reading, is a pain. If I did anything, it might be a trifocal of some nature, but that might be almost as bad as progressives, and I hate the thought of those 3 distinct zones, all hopping around when I move my eyes.

So, any experience or recommendations in this area from anyone?  

[JodieJ]

My second ERM surgery was done by Dr. Steve Charles in Memphis.  He is very skilled at performing ERM surgery.  He successfully removed the ERM remaining in my eye and also did an ILM peel.

What helps people with our type of retinal problem seems to vary a lot.  The transparent tape seemed to make things worse for me, although it reportedly really works well in some cases.  Wearing a +3.5 contact in my affected eye under a -3.5 glasses' lens immediately and dramatically eliminated my double vision.  For others I've communicated with, obtaining comfortable vision using both eyes together has involved a trial-and-error process.

I'll send you some papers.

[PlasV]

I just google'd G.C. de Wit and read one of his articles. Interestingly, one of the suggestions offered is one I've kinda tried - partially occluding the visual field in the problem eye. While on a trip several years ago, it was murder trying to drive a long distance with the confusing summed images from both eyes. I tried using some semitransparent tape on sunglasses lens to cover only the center of fixation. This worked remarkably well considering the simplicity. I retained side vision and a sense of my stereoscopic space.

Unfortunately, as I shifted my eyes, the center of fixation would drift in and out of the occlusion, so unless I kept perfectly fixated straight ahead, I would jump in and out of double/distorted vision, which proved to be almost more distracting than the original problem.

The fact that I now have cataracts removed from that eye, as well as it's fellow, means I'm "seeing" the problem more clearly now.

[PlasV]

Thanks Jodie. if you don't mind, I will do that. I've read a number of your posts here while doing my research.

I agree that it should be done regardless. I'm afraid that continued traction from the ERM is bound to keep damaging the retina. On the OCT, the scar tissue shows up very clearly extending partway across the foveal notch, as well as the portion on the rest of the surface.

Did you have an ILM peel as well?

[JodieJ]

I speak from personal experience.  A botched ERM procedure (pieces of membrane were left in my eye, although my surgeon never told me this) left me with a larger, distorted image size in my affected eye and double vision.  I had a second successful ERM procedure three years later.  Although my affected eye never quite returned to normal, there was significant improvement in the distortion and the degree of image size difference between my eyes.  So I'd strongly advise you to have the surgery.  There's been some research done at Moorfields Eye Hospital in London that suggests that late surgery is better than no surgery.

Your goal post-surgery will be to make your vision with both eyes as comfortable as possible.  Dr. Gerard de Wit's paper ("Retinally Induced Aniseikonia") describes some methods you might try, including the use of a contact lens/glasses combination that could reduce the image size difference between your eyes.  It would probably be very helpful if you could find an eye care provider (probably a low vision specialist) to work with you.

If you send me your email address in a personal message, I'll send you some professional papers on the topic.