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ERM - Treatment Options
I have been studying the exchange between Dr. Hagan, Jodie, and others regarding ERM. I am 42 years old and have had visual problems throughout my entire life (beginning from birth with retinopathy of prematurity). I had right cataract removal in 2006 and the left in 2007. I am extremely myopic with bilateral astigmatism (L - 20/40, R - 20/70, both with correction using trifocal lenses). My vision in the left eye has declined from 20/30+ since having the cataract removal, the right has essentially remained unchanged. I am now being referred back to my retinal specialist for a second opinion due to the ERM. My ophthlamologist did little more than tell me that this was a significant change from my appointment a year ago and that there was the option of what he referred to as a "retina peel". In his opinion I should wait on this procedure however he wasn't comfortable making this decision alone and therefore referred me back to my specialist. I too feel my vision is improved with contact lenses. I've only worn one in the left which I lost in August while running so have been wearing trifocal lenses. I was hoping that I would be prescribed a new lens today but the news of the ERM shook me so much that I forgot to mention it. I am an ER nurse who is a semester away from graduating with an FNP degree. I recently finished battling a profound iron deficiency anemia and am scheduled for a hysterectomy on Dec 17. My ophthalmologist emphasized that I should wait until after the surgery to proceed with the EMR intervention. I can't for the life of me understand the correlation, but knowing that I have "good" (if you will) vision in only one eye am hesitant to wait. I am thinking of moving my appointment up as they have an opening next week. I have four children and am in no way prepared to stop working anytime soon. Can anyone offer further insight into the procedure and the general intra- and post-op expectations? I don't have distorted vision, balance problems, etc; it seems sometimes my vision requires a prolonged period of time to adjust to reading and darkness. I have also noted more "glare" and blurred vision which my doctor informed me is due to the "wrinkling". Quite honestly, I just don't know what to think. Any feedback would be appreciated.
Thank you,
Jayce711
Thank you,
Jayce711
There's no easy method for finding the right doctor. My first surgeon continues to be listed as one of the "best doctors in America" in Castle-Connolly's directory. Yet I was unhappy with my outcome as well as with the surgeon's persistent tendency to evade my questions. I would not recommend that you go to Hopkins. The staff at even the most prestigious places has a range of skills and experience. (And you definitely don't want to see a resident or a fellow, who might someday become great doctors but aren't there yet.) If you can travel for surgery, I'd suggest that you go to Memphis to see Dr. Charles. He is very prominent in his field (ask your local retinal specialists) and highly skilled at performing vitreoretinal procedures. He certainly knew a lot more than some of the "best" retinal surgeons in Chicago.
Since you are an ER nurse, you're already familiar with medical vocabulary. There's a wealth of information available online about ERM surgery. The more you know, the better off you are--so learn as much as you can.
Avastin and Xibron might (or might not) be helpful in reducing the macular edema associated with an ERM. However, in many cases an ERM involves macular wrinkling and visual distortion. Unless the ERM is peeled in these cases, it can eventually cause irreversible damage to the underlying macular tissue.
If you can see better with contacts, then definitely try them. You might be a good candidate for a bifocal contact like the Gelflex.
Since you are an ER nurse, you're already familiar with medical vocabulary. There's a wealth of information available online about ERM surgery. The more you know, the better off you are--so learn as much as you can.
Avastin and Xibron might (or might not) be helpful in reducing the macular edema associated with an ERM. However, in many cases an ERM involves macular wrinkling and visual distortion. Unless the ERM is peeled in these cases, it can eventually cause irreversible damage to the underlying macular tissue.
If you can see better with contacts, then definitely try them. You might be a good candidate for a bifocal contact like the Gelflex.
Thank you all so very much for your feedback.
Dr. Oyakawa,
Can you please provide some education on Avastatin injection? Have the above mentioned been around for a time? I saw 3 retinal specialists prior to my cataract surgery and do not recall mention of these (which is quite concerning actually). Another thing that my ophthalmologist stated was, "This is not any different that what you've had." Then why am I just now being referred back to the retina guy? I'm wondering if it would it be of benefit to look in the direction of somewhere like Hopkins? Also, what options are available if there is a leakage and what symptoms would one find associated with this? What treatments are available for this type and how quickly do they progress? I feel better knowing that some puckers do not progress. I truly wish I knew more details regarding my condition.
Berrywoo,
What is a Spectral Domain OCT and how does it differ from the Standard OCT? How do I determine the extent of expertise when choosing a surgeon and do you have any suggestions as to the which teaching hospitals would be best? I'm considering. I'm considering Hopkins as mentioned by Dr. Oyakawa but otherwise don't even know where to start. Thank you for your high hopes regarding my future outcomes. I am feeling quite distraught and overwhelmed since my ophthalmology visit and appreciate your words of kindness.
JodieJ,
I suppose I should be better educated on the subject of the eye being my vision has been so poor. I was made aware of the risks of retinal detachment with surgery but since everything went well had started to relax a bit over time. The physicians I have seen have all been reluctant to touch me in the past and I'm not too optimistic that my appointment in January will be any different. What is the best way to determine the competence and expertise of a qualified surgeon? Where do I find one that is qualified and who would be willing to take a case such as my own? AND why in the world would such a procedure be considered elective? I don't understand that in the least. I'm just looking for a way to remain functional and certainly wouldn't consider doing this electively. I'm wondering if I'd be a candidate for the transitional contact lenses that you spoke of. I have noticed that I see better with contacts than with my glasses.Thank you for sharing your story...I believe I read that you worked in the field of psychology and am therefore amazed at the extent of your knowledge on this subject.
Again, thank you all...I'm appreciate your feedback and feel better knowing that there are options. I just need to find someone whom I can trust is qualified and will help me at the very least to maintain my vision if possible. As I mentioned before, I have four children to raise and am a semester away from graduating with my FNP. I'm just not willing to stop there.
Jayce711
Dr. Oyakawa,
Can you please provide some education on Avastatin injection? Have the above mentioned been around for a time? I saw 3 retinal specialists prior to my cataract surgery and do not recall mention of these (which is quite concerning actually). Another thing that my ophthalmologist stated was, "This is not any different that what you've had." Then why am I just now being referred back to the retina guy? I'm wondering if it would it be of benefit to look in the direction of somewhere like Hopkins? Also, what options are available if there is a leakage and what symptoms would one find associated with this? What treatments are available for this type and how quickly do they progress? I feel better knowing that some puckers do not progress. I truly wish I knew more details regarding my condition.
Berrywoo,
What is a Spectral Domain OCT and how does it differ from the Standard OCT? How do I determine the extent of expertise when choosing a surgeon and do you have any suggestions as to the which teaching hospitals would be best? I'm considering. I'm considering Hopkins as mentioned by Dr. Oyakawa but otherwise don't even know where to start. Thank you for your high hopes regarding my future outcomes. I am feeling quite distraught and overwhelmed since my ophthalmology visit and appreciate your words of kindness.
JodieJ,
I suppose I should be better educated on the subject of the eye being my vision has been so poor. I was made aware of the risks of retinal detachment with surgery but since everything went well had started to relax a bit over time. The physicians I have seen have all been reluctant to touch me in the past and I'm not too optimistic that my appointment in January will be any different. What is the best way to determine the competence and expertise of a qualified surgeon? Where do I find one that is qualified and who would be willing to take a case such as my own? AND why in the world would such a procedure be considered elective? I don't understand that in the least. I'm just looking for a way to remain functional and certainly wouldn't consider doing this electively. I'm wondering if I'd be a candidate for the transitional contact lenses that you spoke of. I have noticed that I see better with contacts than with my glasses.Thank you for sharing your story...I believe I read that you worked in the field of psychology and am therefore amazed at the extent of your knowledge on this subject.
Again, thank you all...I'm appreciate your feedback and feel better knowing that there are options. I just need to find someone whom I can trust is qualified and will help me at the very least to maintain my vision if possible. As I mentioned before, I have four children to raise and am a semester away from graduating with my FNP. I'm just not willing to stop there.
Jayce711
An ERM peel is an elective procedure, not an emergency. If you're scheduled for a hysterectomy a couple of weeks from now, I'm sure that you can leave elective retinal surgery on the back burner until you have fully recovered.
If you do decide to proceed with ERM surgery at some point in the future, your choice of surgeon is extremely important. You want a doctor who has successfully performed this procedure many times in the past. My first vitrectomy with ERM peeling (in 2006) was performed by a very respected local retinal surgeon, but I can only guess that ERM surgery was not his forte. The procedure left me with a larger image size in my affected eye and many associated problems. I consulted several other local retinal specialists, all of whom strongly advised me against having further surgery.
On the advice of my general ophthalmologist, I consulted Dr. Steve Charles in Memphis last March. I was shocked to learn that my first surgeon had left pieces of ERM in my eye, and this was the source of my problems. (Apparently, many surgeons lack the skills to peel smaller pieces of ERM.) I had surgery the next day with the new "sutureless" vitrectomy equipment. The surgery took less than half an hour and was totally painless. I was awake the whole time. Less than 2 hours after leaving the OR, I was having dinner in an Italian restaurant (wearing an eye patch) and feeling fine. I could read the 20/20 line on the eye chart the next morning. (My acuity was excellent before my second ERM surgery.) I was back at work after a couple of days.
The major side effect of ERM surgery is accelerated cataract development, but since you've already had cataract surgery this would not be a problem for you. The risk of retinal detachment is about 1% (with an experienced surgeon). Visual acuity usually improves by 2+ lines on the eye chart during the months after surgery. Distortion is is also slowly eliminated during the post-op year (when surgery is not delayed.) I'm currently 9-months post-op, and my image size disparity has been reduced by about 50%. I'm hoping for more improvement, but my 3+ year delay between surgeries may limit my recovery. (So don't postpone surgery this long.)
If you do decide to proceed with ERM surgery at some point in the future, your choice of surgeon is extremely important. You want a doctor who has successfully performed this procedure many times in the past. My first vitrectomy with ERM peeling (in 2006) was performed by a very respected local retinal surgeon, but I can only guess that ERM surgery was not his forte. The procedure left me with a larger image size in my affected eye and many associated problems. I consulted several other local retinal specialists, all of whom strongly advised me against having further surgery.
On the advice of my general ophthalmologist, I consulted Dr. Steve Charles in Memphis last March. I was shocked to learn that my first surgeon had left pieces of ERM in my eye, and this was the source of my problems. (Apparently, many surgeons lack the skills to peel smaller pieces of ERM.) I had surgery the next day with the new "sutureless" vitrectomy equipment. The surgery took less than half an hour and was totally painless. I was awake the whole time. Less than 2 hours after leaving the OR, I was having dinner in an Italian restaurant (wearing an eye patch) and feeling fine. I could read the 20/20 line on the eye chart the next morning. (My acuity was excellent before my second ERM surgery.) I was back at work after a couple of days.
The major side effect of ERM surgery is accelerated cataract development, but since you've already had cataract surgery this would not be a problem for you. The risk of retinal detachment is about 1% (with an experienced surgeon). Visual acuity usually improves by 2+ lines on the eye chart during the months after surgery. Distortion is is also slowly eliminated during the post-op year (when surgery is not delayed.) I'm currently 9-months post-op, and my image size disparity has been reduced by about 50%. I'm hoping for more improvement, but my 3+ year delay between surgeries may limit my recovery. (So don't postpone surgery this long.)
I would definitely seek a third opinion, preferably at a well respected teaching hospital.
I also agree with Dr. O. I think in your case a FA and OCT would be important. I would recommend a Spectral Domain OCT over a standard Time Domain OCT in your case as that may provide better imaging.
Given the history of ROP, you face a greater risk of problems when undergoing any sort of eye surgery. I don't mean that to scare you, but it's the reality. Again, I stress the importance of getting another opinion from a retinal specialists who excels at ERM detection and removal.
Forty-two years of being complication free due to ROP is awesome! I hope that your vision does not deteriorate further and that things turn out well regardless of whether or not you have an ERM peel.
I also agree with Dr. O. I think in your case a FA and OCT would be important. I would recommend a Spectral Domain OCT over a standard Time Domain OCT in your case as that may provide better imaging.
Given the history of ROP, you face a greater risk of problems when undergoing any sort of eye surgery. I don't mean that to scare you, but it's the reality. Again, I stress the importance of getting another opinion from a retinal specialists who excels at ERM detection and removal.
Forty-two years of being complication free due to ROP is awesome! I hope that your vision does not deteriorate further and that things turn out well regardless of whether or not you have an ERM peel.
MEDICAL PROFESSIONAL
I have done this procedure since 1981 and trained at Hopkins where it was developed.
It is not a simple question to answer. An f/a and OCT are important tests. The OCT can follow change in the thickness. The f/a can determine if there is leakage (macular edema). The ones that leak tend to get worse. Most puckers do not progress.
From your post your vision has only dropped from 20/30+ to 20/40. I would follow and consider treatment with Xibrom, bid. If the vision decreases, I would first consider an Avastin injection before a ERM peel.
Dr. O.
It is not a simple question to answer. An f/a and OCT are important tests. The OCT can follow change in the thickness. The f/a can determine if there is leakage (macular edema). The ones that leak tend to get worse. Most puckers do not progress.
From your post your vision has only dropped from 20/30+ to 20/40. I would follow and consider treatment with Xibrom, bid. If the vision decreases, I would first consider an Avastin injection before a ERM peel.
Dr. O.
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