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epiretinal membrane peel & vitrectomy
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epiretinal membrane peel & vitrectomy


I'd very much appreciate any advice in deciding whether to have this surgery.  I'm very myopic but, with contact lenses, my eyes are:  L 20/20 and R 20/70.  The epiretinal membrane has been present in both eyes for a few years.  Tests a few months ago showed that it had progressed.  (I've recently developed pingueculae as well.)  The surgery is recommended for my non-dominant R eye.  I haven't been able to read well with this eye for several years because of some corneal warping from HSV and a large floater.  Now, with the membrane, I'm having difficulty reading with both eyes, as well as having to be extra-careful driving, etc.  The surgery will remove the floater and likely improve my R eye to about 20/40.  The major  risks seem to be cataract formation, recurrence of the HSV, retinal detachment and infection.  

What I'm mostly wondering about are more minor risks of the surgery, especially possible side effects that might make it difficult to wear contact lenses (such as drier eyes?) because my vision is poor with glasses.  It would be quite devastating to gain 20/40 vision in my R eye but be unable to wear contact lenses.  I was particularly interested in the comments by JodyJ on this site about "bothersome problems" following this kind of surgery (even with vision improvement to 20/20) and wondered whether Jody would mind elaborating a bit on this - even though everyone likely has a different experience.  If the membrane progresses further, I won't have a choice about the surgery.  But I'm hoping this will not be the case.
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It is unlikely that the proposed surgery would affect your ability to wear contacts but the likelihood of a cataract is almost 100%.  If the membrane is progressing and your vision decreasing and/or a macular hole is forming you may need to accept these risks.

JCH III MD
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Please see my response to your post on the other forum.

Are you aware that having cataract surgery can eliminate your myopia?  (It's true!  And in my case, my Blue Cross paid for everything!)  Since you're highly myopic, you would either need laser vision correction or a clear lens exchange on your other eye.  (My Blue Cross paid for that eye, too!)  But please don't even consider multifocal/accommodating IOLs.  They're just not designed for eyes with a less-then-perfect retina.  If you do have the retinal surgery, get aspheric monofocal IOLs made of acrylic for best results post cataract surgery.    



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Thanks very much for your replies.
Jodie, I'm so glad that things turned out well for you and that you were able to eventually find a solution to the tearing!  I'll think carefully about the information in your responses, especially when I see the retinal surgeon again in January.
Did you ever obtain a copy of the article about the continuing challenges of calculating implant lens strength in cataract surgery?  I thought I saw your name in some questions and answers about this, but I might be mistaken.  I'm in Vancouver, Canada and have an extended health plan that will help out with the costs.  An article I saw recommended cataract surgery be done at the same time as vitrectomy especially for people my age (61) but apparently this is not done in Canada.
When the doctor said my vision was L 20/20 and R 20/70, was this likely based on my reading of the eye chart while wearing contact lenses?  I'm wondering about this because I forgot to tell him that I have monovision and my R eye is undercorrected for near vision.  If my monovision correction was reversed to R eye for distance, would my vision also be reversed: L 20/70 and R 20/20?  Or does the brief pinhole test measure my R eye vision as if it was fully corrected?
Do you know whether the issues for monovision in contact lenses are very different from monovision with cataract surgery?  I think there are some strings on this site regarding monovision, so I'll have a look at them too.
Thanks again.
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In response to your specific questions, I assume that the acuities that your doctor quoted were for your best corrected vision for each eye.  In this case, reversing the eye used for distance would not change your acuities.  I suspect that if you like monovision with contacts, you'd be a good candidate for surgical monovision.  (However, if you still had some residual distortion in your right eye after the ERM post-surgery, you might be better off using both eyes together for distance/near vision in order to eliminate distortion.  You could wear bifocal/multifocal contacts instead of progressive glasses, if that were your preference.)

I wondered about the wisdom of doing cataract surgery at the same time as retinal surgery, too.  The recent medical literature seems to favor it.  Since I didn't have a cataract at that time, my retinal surgeon saw no reason to do it.  As it turned out, I was very glad that I waited on the cataract surgery.  It gave me time to research my options in IOLs and allowed me to choose an experienced cataract/refractive surgeon.  My cataract surgeon did limbal relaxing incisions which eliminated my astigmatism--something that never would have been done at the time of retinal surgery.  I had been so myopic that I couldn't even read comfortably without correction, and I was really delighted not to be nearsighted anymore.  (Actually, the results of my cataract surgery made more of a difference in terms of my quality of life than the retinal surgery did.)

As you can imagine, I've done lots of research about ERM surgery and have consulted several retinal surgeons.  One of the problems in evaluating surgical outcomes (in my opinion, anyway) is that retinal surgeons seem to use the ability to read an eye chart with the affected eye as their measure of surgical outcome, which doesn't take into account problems related to contrast sensitivity or binocular vision.  A recent Japanese study of post-surgery OCT results shows that the macula of the affected eye is never quite normal post-ERM peeling, even when acuity is 20/20+ (although the exact effect of the residual damage has yet to be systematically investigated.)  Retinal surgeons also have their own vocabulary.  They look at me blankly if  I talk about "retinally-induced aniseikonia" but know exactly what I mean when I translate this to a "condensation of photoreceptors."  I don't think that aniseikonia is that rare post retinal surgery, although I suspect that the symptoms are often misdiagnosed.  I'd love to see more research done about this.  (Do ask your retinal surgeon about the possibility of incorporating ILM peeling into your ERM surgery.)  

But all things considered, I still maintain that you have a lot to gain from having retinal surgery in terms of improved acuity (and getting rid of that floater).  The risks of retinal detachment/infection are really very low.  Having a vitrectomy is not painful--I actually walked to the local multiplex that afternoon (wearing an eye patch) and stayed for a double feature.  And having cataract surgery was (for me, anyway) an unexpected bonus.

(No, I haven't gotten a copy of that article about calculating IOL power, although I'd be very interested in reading it.)

  
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It occurred to me that you could possibly improve your current vision without surgery by changing your contact lenses.  Obviously, what worked for me pre-vitrectomy might not work for you, but I'll pass along the info just in case.  Before my retinal surgery I was highly myopic with mild astigmatism, and I had an ERM in my right (dominant) eye that caused significant distortion and reduced my acuity to between 20/40 and 20/50 (depending on the day).  But I was able to have very functional, comfortable vision for both distance and near with bifocal contact lenses.

There are two types of bifocal/multifocal contacts.  The first (more popular) type has different zones for near/intermediate/distance, very much like a multifocal IOL.  With the macular wrinkling from the ERM, this type of contact made everything one big blur for me.  The second type of bifocal contact (with a "translating" design) is made like a bifocal spectacle lens, with distance vision on the top and near vision on the bottom.  This design is available in both gas permeable and various soft lens materials.  Mine were soft lenses--Triton soft bifocal contacts by Gelflex.  I could get my exact prescription with astigmatism correction for distance, and I had my optometrist increase the near-vision add in my bad eye to compensate for the distortion from the ERM.  With both eyes, my vision was close to 20/20, and I wasn't even aware of the blur/distortion from the ERM unless something blocked the view from my left ("good") eye.  Actually, the distortion from the ERM affects only central (macular) vision, leaving peripheral vision intact.  I guess my brain just learned to ignore the blurred (right-eye) central image, and I maintained good binocular vision by fusing the two peripheral images (my own theory, for what it's worth.)

I still wear the same brand of bifocal contacts sometimes (but in a very different Rx) as an alternative to progressive glasses.  By adjusting my distance from the computer, I don't need glasses for intermediate vision.  I don't know whether my solution would work for you, but it might be worth a shot.        
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Jodie, thanks again for the info and especially for your encouragement based on your personal experience.  
What you said about the benefits of having the cataract surgery later has reconciled me to that - even with the necessity of two surgeries and having the process spread out over a year or more for each eye (vitrectomy, waiting for the cataract to form, etc.).  
The retinal surgeon did say he would remove the ILM, which I understand would reduce the likelihood of recurrence of the ERM.  
Would you please let me know how to access the Japanese article you mentioned?  
Do any studies indicate that removing the ILM might also help to prevent the anisekonia you experienced?  With anisekonia, do the eyes see different sized images - thereby affecting your balance?  I might already have some, because I noticed years ago that typed print looks smaller with my right eye.  Could this be because of the difference in the short-sightedness of each eye (L: -12 and R: -8.5)? I don't notice any difference in size of large signs, etc. when walking down the street, but I do have a slightly unbalanced, sort of weird feeling when walking along the street.  However, I think this weird feeling is probably because of the monovision contact lenses.  (Monovision with single vision contacts is the best compromise I've found so far, despite the unbalanced feeling walking on the street.  It's better than the bifocals I tried recently - maybe because of my other eye problems.  The monovision gives me good, steady intermediate vision for talking to people, as well as some distance and reading ability.)
I certainly agree with what you say about vision with eye charts not being equivalent to all the qualities that contribute to  functional vision and therefore quality of life!  I'm so thankful to have found this forum.
Jodie, I just saw your most recent message as I was finishing the draft of this message.  I think in the paragraphs above, I was wanting to ask you about what you just said - without troubling you too much!  I've had several different pairs of contact lenses in the last 3 years - trying to compensate for the floater (which reduced my competence in so many areas of life - everyone in this forum is trying to preserve or improve that right?).  If the retinal surgeon gives me a choice about the surgery in January, I'll find out what kind of bifocals I had and, if they're not the "translating" kind, will definitely try that.  I have astigmatism too and wear Boston gas permeable lenses so it's great that the translating ones can be gas permeable rigid ones too.  If I have all the surgery, I'll look for those lenses afterwards.
From the OCT, it looks my ERM is the pretty much an even thickness and the same in both
eyes.  That's partly what makes me think that the surgery might not help me that much.  My R eye partly has worse vision because of the corneal warping from the HSV infection.  I don't have a central blurred patch like you did - rather an over-all distortion.  When I look at a printed page, some of the letters look "dirty".  Some are blurry and some have fine lines joining them.  But this is all over the page, not just in the centre.  When I look at an Amsler Grid, all the lines are evenly a bit wavy with my R eye, not distorted as if someone was pulling the centre of the grid as I've seen in diagrams that show you what it looks like to have an ERM.  But I sure feel funny when I go into the bathroom at work which has 2" beige tiles on the floor and walls.  It's like a giant Amsler Grid!
Thanks so much, Jodie!  It's really good to know about options.  You've cheered me up immensely!
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It was Dr. Steve Charles, a well-known and well-published retinal surgeon in Memphis, Tennessee, who suggested that I consider having a second retinal procedure involving ILM peeling in order to relieve my post-surgery image size difference, i.e., the retinally-induced aniseikonia.  (This suggestion was made through email correspondence; he never actually examined my eyes.)  I did some research on pubmed (www.pubmed.gov); one of the articles supporting this suggestion is a pilot study by Park,DW et al ("Macular pucker removal with and without internal limiting membrane peeling").  The article is a little technical; basically peeling the ILM seemed to eliminate post-surgery distortion related to ILM contracture (which causes the aniseikonia).  I consulted two local retinal surgeons about having a second retinal procedure; both basically dismissed me as soon as they found out that I could read the 20/20 line with my affected eye.  (This is apparently the gold standard for measuring successful retinal surgery.)

There are two types of bifocal contact lens designs:  simultaneous and translating.  Just about all the new contact designs involve simultaneous vision, so this is probably what you tried.  Before my retinal surgery, I tried a couple of types of simultaneous GP multifocal contacts; they worked fine in my left ("good") eye but made my vision in my right eye a total blur.  But I do think that a translating design bifocal contact might work better for you than monovision, especially if one of your eyes has significantly better acuity than the other.  The distortion I had from the ERM used to be so bad that I had trouble reading with just my right eye; however, when reading with both eyes I was actually unaware of any distortion.  I guess my "good" left eye was carrying the burden.

I started noticing cataract symptoms less than 3 months after retinal surgery.  I was very eager to have cataract surgery sooner rather than later, just to get it over with.  Initially, I knew nothing about it, so the waiting time gave me the opportunity to research different implants and consult more than one cataract surgeon.  I do think that having an experienced cataract/refractive surgeon can make a major difference in outcome.

I don't know much about the Canadian health care system, but I think that you should definitely get a second opinion before having surgery.  I decided to have the surgery because my ERM was making my acuity worse and worse.  It was initially 20/20 when the ERM was first diagnosed, then 20/30, then 20/40 to 20/50.  But with my bifocal "translating" contacts, the progressive deterioration in my vision was not apparent to me.

I did lots of research on Google and pubmed before having the vitrectomy.  One of the OCT studies about surgery outcomes (on pubmed) is by Massin P et al., "Optical coherence tomography of idiopathic epiretinal membranes before and after surgery."  Maybe you can find the Japanese study I mentioned previously; I remember that it involved beta waves.  (In my real life, I'm a psychologist, but I've become more interested in some areas of ophthalmology than in my own field.)      
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Jodie, I did actually get a second opinion about a month ago.  This second retinal surgeon talked with me for quite a while and gave me the option of coming back in January rather than deciding right away on the surgery.  He did say that people usually regain about half of the vision lost to an ERM so it's better not to wait too long.  It's helpful to know that the progression of the ERM was a big factor in your decision - as that's what would make me decide to have the surgery too.

One reason the progression would be significant to me is that, although I've had the ERM for a few years, it's probably been stable until May, 2007 when I experienced a chemical eye burn.  Fumes from rug glue being used in office renovations came up through the heating vent beside my desk.  At the end of the day, I noticed that my eyes were sore and eyelids very swollen. I should have washed my eye with water but didn't think it was that serious.  The next day, my vision had deteriorated.  It was as if there was a slight fog everywhere, and a hazy patchy brightness in some areas, especially after being out in the sunshine.  When I peel onions now, my eyes water instantly although I never had this problem before unless I peeled quite a lot of onions.  My eyes were scratchy and sore for a few weeks, so I went to see my regular ophthamologist and then the first retinal surgeon, whom I had seen a few years before.  The OCT showed that the ERM had progressed and the retinal surgeon recommended surgery within a few months.  I've been told by all the doctors I've seen (GP, regular ophthamologist, optometrist, retinal surgeons), that the chemical could not have affected my eyes, except on the surface, and that the deterioration in vision at that time must have been a coincidence.  But I guess I have an irrational hope that the chemical did have an effect and that things will be stable again. (I have probably adjusted to the slight fog, and the hazy brightness is not bothering me as much these days, maybe because the weather is more cloudy.)

Is a cataract/refractive surgeon different from a cataract surgeon?  It sounds like a good combination of specialties, if so.  

Does your  intermediate vision, with the translating contact lenses, include being able to talk with people comfortably - without wearing glasses or having unbalanced vision?  You mentioned that you could work on the computer without wearing glasses and perhaps conversational distance is similar.  I don't mind putting on reading or distance glasses (or not having great vision for these), but am very uncomfortable talking with people while wearing glasses or having a sense of unbalanced vision.  (Like you, I have trouble reading with just my R eye, because of distortion, but it's better with both eyes.  I think you're right about the images fusing.)  

I'm thinking that I should try these lenses before I see the retinal surgeon again in January.  Whether my vision is satisfactory would certainly be another factor in deciding about the surgery.  (I'm a lawyer but considering early retirement because it's been so difficult to work without good vision.  Jodie, it's very generous of you to share the results of your experience and research with people on this forum.  I think your psychology training shows in the sensitivity of your responses too -  as you know, I've done some browsing on this site in the areas relevant to my condition.)  Thank-you again very much.
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The statistic that people regain about half their vision post ERM peeling is based on data from several years ago.  I think that vitreoretinal techniques and equipment have improved the picture dramatically in the past few years.  I recall a recent article stating that several years ago, it was rare to operate on an ERM patient with better than 20/70 vision because of the risks of surgery.  Today (per that article) some surgeons will operate on a patient with 20/20 vision if distortion from the ERM were a big issue.  (The retinal surgeons I consulted about having a second procedure to eliminate my retinally-induced aniseikonia obviously weren't in the latter group, though.  One of them actually seemed to become quite hostile when he learned that I could read the 20/20 line yet I still wasn't satisfied with my vision.)

To be honest, my intermediate vision was sharper with monovision (with two good eyes) than with bifocal contacts.  But even with no correction, I wouldn't have a problem interacting with people (although I'd have to strain to read my monitor without presbyopia correction).  It seems reasonable to assume that you'd have better vision using both eyes (than with monovision) if one of your eyes was significantly stonger than the other--but ask your doctor about this.

I was told that the course of an ERM is impossible to predict.  In most cases, the deterioration in vision is supposed to be limited.  It seems feasible that your eye could stabilize at this point and remain that way indefinitely.  (Unfortunately, my own vision seemed to deteriorate progressively from the time my ERM was diagnosed until I had surgery almost a year later.)

Not all cataract surgeons do refractive procedures (e.g., laser vision correction, limbal relaxing incisions).  Since I had some astigmatism, I wanted a surgeon who could address that problem at the time of my surgery.  I have no idea whether it's true or not, but since cataract surgery itself has become refractive surgery, I hypothesized that a surgeon who was already experienced doing refractive procedures might give me better results.  (I may have stepped on some toes by saying this.)
  
I think that the Internet is creating a different type of patient--who is better informed and more willing to take an active role as a collaborator in their own medical treatment.  From my perspective, forums like this are an invaluable resource.  I've learned so much from reading about the experiences of others, and I'm happy to be able to contribute what I can.    
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I'm glad that there's a good chance of better recovery of vision now.  But I'm sorry you had those difficult experiences, Jodie.  It's hurtful and bewildering when a doctor is impatient or even hostile even though I know they are always under a lot of pressure and time constraints.  I've experienced that too.  A few years ago, I was panicked by the appearance of a floater that looked to me like a large black spider hanging from my eyebrow and was told curtly that my eye chart vision was still very good, that the floater was just a normal part of aging and that I'd almost certainly get more of them.  It would have been somewhat comforting at least to be told that the floater would look smaller and less black as I learned not to focus on it.

What you said about monovision with eyes of quite different strengths makes a lot of sense to me.  I've been trying to accept that I can't expect not to feel somewhat unbalanced or weird at times, but it's worth looking into the translating kind of bifocals if there's a chance they could eliminate that.

It's also good to know about refractive procedures vs cataract surgery.  I'll have to learn more about these if I have the ERM surgery - especially about issues that arise when cataract surgery is done on only one eye.  (They are not recommending any surgery for the L eye at this time.)   As you mentioned, it's good that I would have time after the ERM surgery to consider this.

The first retinal surgeon's report in August said:  "Progressive ERM OU with an early lamellar hole OD (appearance consistent with parafoveal traction as well).  Given the increased distortion and the worse OCT configuration, vitrectomy is recommended.  Surgery may also be require OS in the future."  

I should receive a copy of the second retinal surgeon's report soon.  He didn't do another OCT but probably he will in January when I see him again.
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I'm not sure what's causing your unbalanced feeling.  (Maybe distortion from the ERM?)  You do have a fairly large difference in refraction between your eyes, but it seems to me that monovision would help eliminate problems related to that.  All I can suggest is that you try a different type of correction with contacts and see if it helps.  If not, go back to monovision.

I'm not very knowledgeable about interpreting OCT reports, but it sounds like you have a lot of distortion (wrinkling) in your central vision (right eye), and you may be developing a macular hole.  With 20/20 vision in your left eye and no increase in ERM density, it makes sense that no left-eye surgery is recommended at this time.  If all goes well for you (and there's no reason why it won't), you could end up with very good (corrected) vision at all distances using both eyes.  And you would benefit so much from cataract surgery, which could reduce/eliminate your myopia.  So maybe you should hold off on your plans for early retirement.  I really think that you can look forward to having significantly better vision in the near future.      

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I have another idea for improving your vision without surgery which you may not have tried; then I promise to stop overwhelming you with unsolicited advice.  It would involve fully correcting the distance vision in both eyes with contact lenses, which would minimize the problems you've had with glasses due to the difference in prescription between your eyes.  Then you could wear trifocal (preferred) or progressive glasses with a plano top over the contacts.  This type of correction would involve using both your eyes together at all distances, thus allowing your stronger left eye to compensate for the blur/distortion in your right eye.  And you could avoid the intermediate vision issues associated with bifocal translating contacts.  The glasses would have thin lenses, and they would hopefully give your vision the boost you need to function comfortably at work.

I'm out of ideas--best of luck!

Jodie  
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Jodie, I appreciate your ideas more than I can say and your advice is by no means unsolicited.  It's been a tremendous relief to be in contact with someone who has personally come through similar situations with success and also done a lot of research into them.  
Although the retinal surgeon's report didn't say this, it looked from the OCT as if the ERM thickness increased about the same in both eyes, not just the R eye.  He did say that I wasn't developing a macular hole (that's what I thought he meant too), which he said was a more serious condition, but he didn't explain what a lamellar hole is. If the second retinal surgeon's report is similar, I'll ask him more about this in January.
In the meantime, I'll definitely look into the translating type of bifocal contacts.  Then, maybe the distance vision with glasses too.  
Maybe my unbalanced feeling is because the contact lens in my L eye overcorrects it a little too much for distance.  Because of this, there might be too much difference between the L and R eye which is undercorrected for near vision.  Would you happen to know whether there's a certain amount of difference that people can generally tolerate or whether it's different for everyone?
Thanks so much again, Jodie.  Very best wishes to you.
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I imagine that there is some variation in the amount of refractive power difference between the eyes that people can tolerate.  The problems actually arise when you attempt to correct vision with glasses.  (Correcting vision with contact lenses in this situation is a great way to avoid such difficulties.)  I'm guessing that a 3D difference in spectacle lenses would cause problems for most people.  This is probably the reason why you are not able to comfortably correct your vision with glasses alone.

I'm a total amateur when it comes to optics, so I'd really welcome feedback from anyone more knowledgeable.  In your present situation, naoye, I think it's very important for you to maximize the vision that you have, so that you can function as comfortably as possible at your job.  Wearing monovision contacts is a great way for you to avoid the problems associated with correcting your myopia with glasses, given the 3.5D difference in refractive power between your eyes.  Unfortunately, monovision involves some compromise in vision at all distances (distance, intermediate, and near), and you don't want to compromise--period.  In addition, monovision does not allow your stronger left eye to compensate for your weaker right eye for intermediate and near vision.  Your best bet, I'm guessing, would be to fully correct your distance vision with contacts, and then wear glasses on top to correct presbyopia.  Trifocals might give you more of a boost than progressives.  Bifocal "translating" contacts would also work, although your intermediate vision would be compromised.  (Of course, amateur theories may not live up to real world conditions, but I think it would be worth discussing a possible change in correction with your eye care provider.)

An ERM is a layer of scar tissue on the macula which can cause terrible blur and distortion.  The wrinkling that results can alter the distribution of photoreceptors, causing weird changes in image size and shape.  (Fortunately, surgery will usually eliminate most of this.)  This may be what is responsible for your feeling of "imbalance."  
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Thank-you again, Jodie, for taking the time to give me your ideas, which are truly very helpful.   Thank-you also for your patience with my questions.  It will take awhile to try out some of these ideas, but the paths to try are a lot clearer to me now.
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Hi,

I am 54 now. I've had trouble with clarity of vision as far back as 2006, but my 24/7 lower back pain took precedence culminating in a successful spinal fusion surgery.

Now, the vision on both eyes has gotten worse. My optometrist could never get me to 20/20 vision even with corrections. On the eye chart test with L eye, I can only see the lower 2/3 of the first letter, the second I can see fully however blurry, and the last two are jittery & blurry. I can see all four letters with the R eye, but they are all so blurry. This is with corrective lenses, and I can only go down the third set of letters on the eye chart.

My optometrist referred me to a retinal specialist. I have been having what I thought were migraines. In my line of work, I do computer work and assembly in tight quarters with tools, and soldering where closeup vision & mid-range vision is critical. I just recently started seeing a huge long semi arcing floater that looked like a  worm in my R eye.  Last Friday, I experienced my first light streaks or flickers. I called my Retinal Specialist' office today and was seen immediately just to make sure I am not getting a detached retina. The conclusion was the R eye has a large ERM that is pulling apart.

I had been diagnose with ERM in both eyes. My doctor could only get me to 20/30  and 20/25 with correction, and this if you do not count the blurred vision. He said that eventually, surgery may be required in both eyes as they are progressively getting worse.

Driving is not a problem yet, as back issues always make one real careful about speeding and merging. I am extremely worried about my eyes affecting my job performance.

My question is, will it be better to have ERM vitrectomy sooner than later knowing that things are progressively getting worse? I may be losing mu job soon, so insurance coverage is a big consideration.

My doctor teaches at the local medical school and has done hundreds and hundreds of this type of surgery. However, I am still worried about the risks. I have decided to go on with vitrectomy on the R eye this Friday. I hope that I am making the right decision.

Any inputs will be greatly appreciated.
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Recent reports in the medical literature all state that visual outcomes are better when surgery is done sooner.  So I believe that you are wise not to delay the surgery.  I think that you'll be pleasantly surprised by how easy the surgery has become with the use of 25-gauge "sutureless" instruments.  When performed by an experienced surgeon, it is not a very risky procedure.  Most people regain significant vision, although recovery takes several months.  (My post-vitrectomy acuity is 20/20+.)  Feel free to contact me by PM if you have additional questions about your surgery and recovery.  Best wishes for an excellent outcome.  Jodie
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Thanks for the assuring reply.  Tomorrow, I'll find out if I still have a job. The surgery Friday will proceed as planned. However, depending on when the second surgery can be done I may not be able to have it covered under insurance.

I have gotten very good feed backs about my surgeon and the clinic. All the surgeons are affiliated with the University in a professorial or consultative role.

Two surgeons that I have spoken with both agreed that vitrectomy is highly recommended in both eyes. The epi-retinal membrane in both eyes are starting to significantly affect my central vision. It is scary to notice finally how far my vision has deteriorated in 2 1/2 years! I am not waiting until I get to 20/70 vision.

All in all, there is the risk of retinal detachment or cataracts. At this point, it is a risk worth taking to be able to maintain current or future employment.
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Research shows that people with good pre-surgery vision (like you) have the best post-surgery vision, so your prognosis is excellent.  Chances of retinal detachment are low (1% to 5%)--and even in the worst case scenario, an RD can be repaired.  On the other hand, you will undoubtedly need cataract surgery within a year or two post-vitrectomy.  (For me, this turned out to be an unexpected gift.  I went from high myopia to plano.)  So it would be worth the expense to continue your insurance payments yourself.  Try to find a cataract surgeon who would be willing to operate soon after your cataract begins to develop if insurance is an issue.

There are differing beliefs about visual impairment related to an ERM.  Some think that impairment occurs only during the initial month or two.  In any case, most people with ERMs don't continue to experience impairment over time.

Visual recovery takes about 3-4 months and can continue for a year or longer.  There's lots of info available online about ERMs.  Good luck on Friday.  
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My actual L eye ERM peel took less than an hour on Friday May 15. I could actually see the whole procedure unfold via the reflection on the microscope!  The membrane looked wrinkle & gray like embryonic skin. The surgeon did not use gas at all.

What I don't care about is the itchy gritty feeling in my eye. In my follow-up visit yesterday, my vision was blurry as to be expected. I did noticed that the letters on the eye chart appeared smaller for my L eye (RI aniseikonia?). However, today it seem like the size difference gap has narrowed a little albeit I still have blurred vision. I am happy that I can drive myself and is cleared to return to work on Monday.

I did the Amsler Grid Eye Chart Test. The L eye vision still has similar distortions post ERM peel. Will this improve in addition to visual clarity over time?

If I do have RI Aniseikonia, can this be reversed? What will happen when I get the R eye done? I am glad I went ahead and had my vitrectomy. One interesting observation, all sixteen people that had their ERM peel on Friday morning are in their fifties or sixties. So, I am in the right crowd, LOL!



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The smaller image size in your left eye is probably due to inflammation, and it should diminish over time.  Ask your surgeon.

Time for visual recovery varies.  Most sources say that it takes about 3-4 months for recovery of acuity, although you might continue to experience improvements for a year.  It usually takes longer for distortion to resolve--maybe 6 months or longer.  (I've read that the retina is nerve tissue and just takes a long time to heal.)

I started to experience the first symptoms of cataract development (a slight yellowing and blurring of vision) about 3 months post-vitrectomy.

Yes, ERMs are more common in people over 50.  I was just over 50 when mine happened, and I was shocked to find that ERM patients were described as "elderly" in some of the articles in the medical literature.  (I had thought that "elderly" referred to people over 80, not to ME!)

It sounds like you're headed for a good recovery.  Keep us posted.  

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Hungan, I'm really glad that your retinal surgery went so well.  I wanted to let you know that I also had a good recovery from my retinal surgery last January, much easier than I expected.  The blurriness from the surgery was mostly gone in a few weeks.  I had some scratchiness like you and was told to use lubricating eye drops (without preservatives) several times a day.  I don't know whether this would be indicated in your case as well.

Now the progress is slow but my surgeon says he expects it to continue until I see him again next January.  Mainly, the whitish, erased lines I had after the surgery seem to be fading so I can see things a little more clearly.  

Like you, my eye with the unoperated ERM (left eye) sees a larger image than the operated one.  It has good acuity after cataract surgery (+25) and the ERM does not seem to be progressing but my retinal surgeon said he might nevertheless consider peeling the ERM if the distortions (waviness of straight lines, seeing a larger, wider image than the right eye) really bothers me.  

It sounds as if you will definitely have the surgery for the other eye, so you don't have to make a decision.  In a way, I wish my case was as clear, now that I know the surgery is not that big a deal.  I'm having trouble adjusting to progressive glasses, including difficulty fusing images, so I might consider the ERM peel.  (However, I also have other refractive issues due to other pre-existing problems and may do a separate post about this another day.)

Best of luck with your recovery.
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Study: Clinicians should pay more attention to metamorphopsia in patients with epiretinal membrane
Using the National Eye Institute Visual Function Questionnaire (NEI VFQ-25), researchers prospectively evaluated the vision-related quality of life in 28 patients both before and three months after undergoing vitrectomy for epiretinal membrane. Surgery significantly improved the mean NEI VFQ-25 composite score from 66.2 to 77.9 postoperatively. But even after successful surgery, quality of life remained at a lower level compared with normal controls. American Journal of Ophthalmology, May 2009

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Thanks for the citation, Dr. Hagan.  A few of the very best vitreoretinal surgeons will operate today on patients with 20/20 acuity but significant metamorphopsia.  I wish I had access to entire article; I'd love to know the authors' definition of "successful" ERM surgery.  (How successful could it be if it failed to augment quality of life in a meaningful way?)  
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You may be able to get a full text copy by calling "your" hospital medical library and telling them you have been a patient of their's and would they obtain a copy for you. Some hospitals will do that.

Or you can call my office tomorrow. the phone number is listed under my profile in "the Doctors" section and leave either a fax # or an e mail address and I'll send you the full article.

Thanks again for all the time and expertise you lend this forum

JCH MD
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For my post operative care after ERM peel, I am or have taken the following:

I am just finishing the last eye drops of Maxitrol eye drops which is a combination of antibiotics & corticosteroid. I have to take this until the last eye drop is gone.

For the first week, I applied one eye drop of Atropine Sulfate Ophthalmic Suspension in the L eye at bedtime.  

Soon after I finished off the Maxitrol, I will start the prescribed dosages of Prednisone Acetate Ophthalmic suspension - 4X daily the 1st wk, 3X daily the 2nd, 2X daily the 3rd, and finally 1X daily on the 4th week.

My question is about the Maxitrol & Prednisone containing corticosteroids. Should I be concerned about the risk of  glaucoma, damage to the optic nerve, and cataract formation? I know there is a rhyme & reason for prescribing these medicine after eye surgery, and the dosage are prescribed as such  to minimize risks.

BTW, I am beginning to see better through my L eye without corrective lenses, albeit the visual distortions are grossly evident. With the corrective lenses, it is much worst. This is viewing the computer screen about twelve to eighteen inches away. One the Amsler Grid (white lines, black background - http://www.opt.indiana.edu/riley/HomePage/Amsler_Grid/4TEXTamsler_grid.html) test, the vertical lines are grossly distorted although better than last week. The problem I have is that when I cover the R eye, the horizontal line become very faded/blurry almost disappearing.

Is this normal in the course of healing? Sharing your experiences/comments will be greatly appreciated.
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Thank you JodieJ & Naoye for sharing your experiences and knowledge. I find them very helpful.

My L eye ERM peel was originally set for May 8, but due to a backup system malfunction they re-scheduled it the following May 15.

Towards the end of that day I started seeing a large long arcing floater that looked like a worm with a large head in my R eye on the upper part of my vision. Then, momentarily I saw light flashes in the lower part of my vision. It never repeated after that. The floater remained to this day, but know it is more translucent and less annoying.

When I called my clinic the next morning to report what has transpired, they dispatched me to see another surgeon right away. He explained to me that they want to rule out anything serious. That is when I overheard him telling the nurse I have a PVD of 0.3 in both eyes. Does anyone know what this means?

Does anyone know if there is a correlation between deviated septums and ERM? It so happens that I have a left nostril deviated septum. When I blow my nose, most of the force is imparted in the left nostril. The L eye happens to be the one with the worst ERM.

Thanks again for your replies.

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PVD stands for posterior vitreous detachment which I understand occurs quite commonly as we get older.   (When I had cataract surgery, I was told that I have it in both eyes.  There is another  post about PVD, more recent than yours, with a reply from Dr. Hagen.)  I don't know what the number would mean though.

I hope one of the forum doctors or Jodie will respond more fully to your questions.  Perhaps you could try repeating them in a separate post (this string is pretty long now!) or repeat them on the Expert Eye Care Forum on this site.

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Also Dr. Hagan

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 which was fully grown had to be removed in the middle of our big snowstorm. 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 and still working. I would appreciate any thoughts/advice that you and the doctor have.  Thank you! .
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I have a few thoughts.  I definitely think you should fire your eye doctor in Towson, MD, if you haven't already.  I think he gave you terrible advice by telling you that your ERM was slowly getting better (because of his "experimental" treatment?)  ERMs do not slowly get better without surgery.  Delaying surgery only leads to poorer outcomes (on average) in terms of acuity and distortion.  Permanent macular damage with metamorphopsia and loss of stereoacuity are real possibilities.

You're saying that you currently have pretty good acuity, but distortion and an image size difference are creating problems.  I have an excellent referral source for you--Dr. David Guyton, a binocular vision specialist at Wilmer.  He is probably the top doctor in America for treating these problems.  (You definitely live in the right city!)

I'm also coping with some permanant macular damage due to delayed ERM surgery.  Please let me know if Dr. Guyton was helpful to you.

If you would like feedback from one of the forum ophthalmologists, you'll probably need to re-post your questions as a new thread.

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Thank you Jodie for your response. I will check out Dr. Guyton. I did fire (sort of) my doctor in Towson. I switched to a doctor who immediately scheduled the surgery. Unfortunately, I waited 2 1.2 years before doing so. My doctor was a former director at Wilmer Eye (JHU) and was often consulted in TV pieces so I assumed I had the best. I appreciate all of the help you are giving everyone. You are performing a real service. I will also re-post for Dr. Hagan. Thank you again.
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Hei Mikek1 did you proceed with surgical intervention ? What is your condition for now ? I was diagnosticated with ERM too and i can't decide what to do . Thanks from Romania !
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