epiretinal membrane

[gentlejim]

I have been diagnosed with epiretinal membrane which developed after catarct  surgery. it is affecting both my near and far vison but my eye doctor says since my vision is still 20/20 he will not do anything. what is the prognosis for this ?

[Zakuski]

I've been poring over a number of peer-reviewed articles from a variety of sources including NIH, Archives of Opthamology, etc.  I think Jodi is right- the surgeon selection is a big factor in victrectomy, maybe bigger than in many other kinds of surgery.  The research literature says that there's been a decisive increase in the number of vitrectomies being done for macular pucker and of course that statistic coincides with the boomer generation move into their 60's.  However, the number of post-vitrectomy adverse events is disproportionate to the increase in the current number of operations for this diagnostic and age demographic.  I couldn't find any currently completed studies on this though it seems NIH is working on that. I am reminded however of what can happen when significant advancements in technology make specific surgeries safer and easier to perform successfully - some times for a long period of time it's as though in the OR ,to pick a metaphor, everyone who is a licensed Airbus pilot is equipped to fly the space shuttle.  Z

[Ray T Oyakawa, MD]

Thanks for the info.  I will let you know what I will do.  

Dr. O.

[JodieJ]

I've communicated with others who first became aware of their image size disparity after "successful" ERM surgery.  Cases where an image size difference became apparent after ERM surgery are also noted in the medical literature ("Diplopia secondary to aniseikonia associated with macular disease", Benegas et al., 1999).  I don't think that such cases are all that uncommon.  (I suspect that such cases seem to be rare because no one asks the patient about this.)  It's my personal theory that (at least in some cases) these image size differences are related to traction from ERM remaining in the macular periphery.  (I'm a clinical psychologist with no background in any area of medicine, but I've spent lots of time researching this topic over the past 3+ years.)

I've corresponded with Marta Ugarte ("Aniseikonia associated with epiretinal membranes", 2005) in the UK, who has been studying the effect of surgical intervention on micropsia/macropsia.  She reports that no definitive pattern of variables has yet been associated with a good surgical outcome, although early ERM surgery appears to have a positive influence.  (The presence of ERM post-surgery would be evident in Spectralis OCT images, but I suspect that these are not used in her research.)

    

[Ray T Oyakawa, MD]

This is amazing.  I have a similar problem.  All my colleagues can not explain it.  I have done over 500 to 600 puckers and never had this complaint.  My pucker went from 20/20 to 20/200 in about a month.  After the ERM peel the image size was the same but my refraction changed from -2.25 to about -7.00.  The minus contact lens was probably minifying my retinal image and probably masking the magnification of the image.  After the cataract surgery my refraction was about -.75 and the image is about 15% larger.    My photo show a small tag of residual membrane above the optic nerve.   My cataract surgeon has seen this before, but could not explain it.   My other eye is about plano but pre-PRK it was -3.50.

Dr. O.

[JodieJ]

Dr. Oyakawa, reading about your fantastic results with both your retinal surgeries and the Crystalens was really elating.  My experience was different.  I had also anticipated that my ERM peel would be relatively simple.  It was performed by one of the top vitreo-retinal surgeons in my area.  The surgery restored my acuity to 20/20+ but left me with an image in my affected eye which was 15+% larger than the image in my other eye.  This caused many problems, including continuous tearing and double vision.  My surgeon never gave me a satisfactory explanation about what was causing my problems.  My own research suggested that an ILM peel might help my situation, and I consulted three other very respected retinal specialists about this possibility.  All of them strongly advised me against having further surgery, predicting that it would only make my symptoms worse.  More than 3 years later, I was stunned when Dr. Charles informed me that my surgeon had peeled the center of the ERM from my fovea but had left the two tails in the macular periphery.  Dr. Charles also suggested that the retinal specialists I'd seen had lacked the skills to peel smaller pieces of ERM.  It's been about 9 months since my second ERM peel, and I've experienced about a 50% reduction in my image size disparity.  But the long delay between surgeries has probably caused some permanent macular damage.  (If I had only been aware of what was causing my problem I would have consulted Dr. Charles much sooner, and my outcome might have been different.)  So I want others to know how very important their choice of retinal surgeon can be.  

[Ray T Oyakawa, MD]

I agree with Jodie except that I personally consider ERM peel a relatively simple procedure for any well trained vitreo-retinal surgeon.   Howard Gilbert, a former Wilmer (Johns Hopkins)  Resident was the first to do the procedure and introduced it to to Ron Michels at the Wilmer Institute.  He spread the word among the ophthalmic community.  In fact he and other doctors from Wilmer went to the Soviet Union to remove Gorbachev's ERM.

Dr. O.

[JodieJ]

Not all ERMs require surgery.  In most cases visual acuity with an ERM does not get much worse after about a month or two.  However, distortion (aka metamorphopsia) may worsen somewhat over time.  Recent evidence suggests that delayed surgery (more than 10 months after ERM development) may be associated with permanent macular damage and poorer outcomes (poorer acuity and more distortion.)

I've posted information about my ERM surgeries (two surgeries on the same eye to remove the same ERM) on this forum within the past week.  (Check recent threads.)  My experience illustrates the importance of choosing the right surgeon.  It's my belief that there are only a few truly skilled doctors worldwide performing this type of surgery.  If your ERM really bothers you and you're able to travel for surgery, I'd recommend Dr. Steve Charles in Memphis, Tennessee (www charles-retina com).  Do not have surgery performed by a doctor who advises against it.