Vitrectomy/ERM

I am a 74 year old, one-eyed patient and have a thick, puckered membrane and 20/60 vision currently. I had a rapid drop in vision from 20/25 to 20/40 to 20/60 within 2 months. I had laser surgery to correct cataract and glaucoma about 3 years ago. I then developed pvd about a year ago. I have been told I am a candidate for a membrane peel and am naturally concerned about the after effects on patients. I need help assessing the risk/reward to the vision of my one eye.  I would be having surgery at John Hopkins. I would appreciate any EyeMDs out there commenting as well as any patients who have actually undergone this surgery with post operative pluses or minuses comments on this complex, and scary surgery to me, . Please answer asap because I have to nake a decision soon. I am a writer and have much left to do and must not lose my vision. I am otherwise healthy and active.

[JodieJ]

I had surgery to peel an ERM two years ago.  My results were mostly positive.  The surgery improved my acuity in my affected eye from about 20/50 to 20/20+, although my retina will never be perfect.

You say that your surgery will be done at Johns Hopkins, but you did not say WHO would be doing it.  I would very strongly advise you against letting a resident or fellow perform this procedure.  My surgery was done at the University of Chicago, which is also a teaching hospital.  My surgeon promised me that he would perform the surgery himself, and he kept his promise.  (And I knew this because I had chosen to skip the sedation and was able to actually watch the surgery being performed.  But don't worry, local anesthesia and IV sedation are the norm--you'll undoubtedly sleep through it.)  In my case, older vitrectomy equipment which requires suturing was used, and my surgeon left this task to his fellow and resident, who obviously needed more experience.  I suffered from weeks of inflammation and steroid treatment as a result of incorrectly placed sutures.  My best advise:  Do not allow a resident or fellow to participate in ANY aspect of your procedure.  This is delicate surgery, although it is neither painful nor terribly dangerous if performed by someone skilled and experienced.  If you are scheduled to see a resident or fellow at Johns Hopkins, I would get another opinion from an experienced retinal specialist in private practice.  

[stefano26]

JodieJ:  I saw this comment.  Could you please tell us what type of doctor TO ask for and define resident or "fellow."  I understand that a resident would still be learning the craft but I don't get the 'fellow" reference.

What should this person and someone else (for instance, myself, if needed) request.

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

After medical school a physician becomes a intern for one year. Then as they specilize they take a residency and are "residents" for ophthalmology this is 3 years. After they finish residency most Eye MDs go into practice. Some seek more training or what is called a "Fellowship" and they are called "Fellows (even the girls)". A Fellowship is generally one or two more years.

You would need to clarify that the main part of the surgery the stripping of the membrane would be done by the "Attending Physician" who is either a full time faculty or a retinal specialist that teaches part time. In most instances this will not be a problem and your preference will be marked on the operating permit.

JCH III MD

[JodieJ]

I admit that I'm prejudiced, but based on my experience I'd want my eye surgeon to be over 40 years old with 10+ years of experience.  Under no circumstances would I want a student (i.e., resident or fellow) doing my surgery, including suturing.  I guess there'd be an upper age limit, but that might vary with the person.

[Sat123]

Hi Jodie,

(Other doctors may also reply, please.)

What is the post operative care needed? My mother in law who is aged over 70 years needs to undergo this surgery. We are in India. We are told that after the operation, the patient is advised to spend most of his/her time (for about two weeks) with head bent down. Is it right? Were you advised in the same way?

Sat123

[JodieJ]

The surgeon told you this?  Does your mother-in-law have a macular hole as well as an epiretinal membrane?  If not, I can't imagine why she would need to stay in a face down position for 2 weeks!  I had no restrictions post-vitrectomy.  I did use antibiotic eyedrops for a few days and steroid drops for a longer time.

One of the best vitreoretinal surgeons in the USA is Dr. Steve Charles of Memphis.  You can read more about epiretinal membrane surgery at his website at www charles-retina com.

[Sat123]

Hi,

Yeah, that's what he said. They put something similar to an air bubble, he said, and it takes about 2 weeks for it to settle. And during that period the patient is advised to spend most of his time with his head bent down.

Anyway, I will also try to go through other info on the net about this.

Thanks Jodie.

Sat

[JodieJ]

An air bubble is used in cases involving retinal detachment or macular hole, but not for peeling an epiretinal membrane.  Why don't you get another opinion from a different retinal surgeon.

[OLDCOT]

If the patient has a macular hole to be repaired and the surgeon intends to do an ILM peel at the same time, this may explain the confusion.  If the patient has a hole and the surgeon intends to do an ILM peel during sx, the patient's macular hole still requires face down recovery.

Most retinal surgeons discuss the possibility of face down recovery when pre-operatively counseling their patients for ERM peels as well.  If the retina tears during the procedure - and this happens in the best of surgical hands on occassion, then the patient will have tx of the tear while still under and then face down recovery for a time determined by the surgeon and by the patient's healing.  It is a significant enough risk that ethical retinal surgeons discuss said risk during pre-operative patient education/informed consent.

[JodieJ]

Thank you for your clarification.  I guess a retinal tear is a possibility with ERM surgery, although the retinal surgeons I consulted never mentioned this to me.  However, according to posts I recently discovered on another forum, there are American surgeons who routinely use a gas bubble with ERM surgery, allegedly to "smooth out" the retina.  (To the best of my knowledge, the retina slowly smoothes out on its own post-op, and there's some evidence that peeling the ILM helps in this regard.)  I've not found any evidence that the routine use of a gas bubble is beneficial, and it requires days of face down posturing by the patient.  (Most patients are able to resume normal activities the day after a 25-gauge "suturesless" vitrectomy with ERM peeling.)  I'd urge anyone who consults a surgeon who intends to use a gas bubble following a routine ERM peeling to get a second opinion before proceeding.