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Avatar universal

ERM and now CME after scleral buckle - when is ERM peel advised?

Hi,

Thank you to all of the experts and contributors who are so helpful!  Had a PVD and multiple retina tears just shy of 7 months ago.  After 3 rounds of laser over a 6 week period I was passed over to a retina surgeon at the local university teaching hospital who placed an encircling scleral buckle and did lots of cryo.  I was petrified by all of this because I am a scientist who requires crisp sharp vision for delicate work under stereoscopes, and my vision up to the minute I was wheeled into the operating theater was 20/20 with no field or other defects other than haze/glare from a dysfunctional pupil caused by the lasering.

I was instructed to see a university optometrist for a new glasses Rx two months after the scleral buckle - which I did with a great deal of anticipation.  She said my eye was only capable of 20/50 BCVA and sent me out of the door.  I tried asking her questions about the poor vision and she told me I needed to talk with the surgeon.  In addition to this poor distance vision, my near vision is poor, my vision in general is very grainy, and to add insult to injury it looks as though I am looking through a dirty window pain when it is raining.  When driving at night I must close the operated eye because any lights cause a haze/glare/fog that obscures seeing anything through the haze/fog.

Through the health system’s portal I wrote to the surgeon 2x about this terrible vision and asked for his help.  He never replied to any of the messages.  Six weeks after the optometrist appointment I had the scheduled check with the surgeon (4 months after surgery).  My appointment was for 4.10 PM and by 5.30 or 5.45 the surgeon finally walked into the exam room.  I told him I would happily return on his next appointment day so we could have quality time, but he refused and proceeded to examine the eye.  During the appointment I began asking about the poor vision.  After drawing and typing into his computer, the surgeon told me that the eye now has ERM and told me to come back in 4 months.  I asked whether the poor and distorted vision was due to the ERM and he replied, “No, something else.”  Then he left the exam room.

I feel as though this surgeon does not care one whit about my eye, my vision, my science CAREER!  But, maybe I’m just overreacting because all of this is so depressing and devastating?

Just because I felt I needed an expert to talk with about this, 1 week after seeing the surgeon I went to my regular optometrist who I’ve seen annually for 15 years.  She refracted my operated eye and was only able to attain 20/40 BCVA.  After I mentioned the ERM, she asked me about the scans and imaging done by the surgeons clinic at the university.  I said that no scans or imaging had been done.  My optometrist has a new OCR and did a scan which showed inflammation across 50-60% of the retina, CME, and macular pucker.  She started me on Ketorolac drops and said that we’d do another scan in 2 weeks.  I thanked her profusely for caring and for helping.

After 10 days of Ketorolac drops 4x daily I do not notice improvement in vision.  If we do not see and improvement with this follow up scan (will be 14 days of Ketorolac), how urgent is it that I take steps towards a vitrectomy and ERM peel?  By today, it 20 weeks since the surgery.  Crisp vision is my LIFE, and I’m very concerned that already the edema is causing permanent damage that cannot heal/recover.

Should I wait another 4 months for my next appointment with the original surgeon?

Should I find another surgeon and get a second opinion ASAP?

If the Ketorolac has had some beneficial effect in reducing the edema and widespread inflammation, how long should I continue with drops before trying to get an appointment with a retina surgeon?

Anything else I should be researching, thinking about, or doing?

If my vision is ruined so I am unable to work in my very specialized field (university was the best 10 years of my life), what options are there for assistance as I am the sole breadwinner?

Thank you for your help and recommendation!

2 Responses
Avatar universal
Oops - OCT!  Stupid autocorrect.
233488 tn?1310696703
MEDICAL PROFESSIONAL
It's pretty obvious that your retina surgeon doesn't really care to communicate or discuss your problem. If you have access to a different retina surgeon that is highly regarded AND communicative that would be ideal. Not likely your retina surgeon will change his ways and the treatment of ERM/CME is above the expertise of an optometrist.  Generally ketoralac or another non steroidal antiinflammatory is combined with a steroid drop. Those two may helm macula edema but will not helm the ERM.     ERM surgery is very delicate and even if the ERM is stripped your vision may not be 20/20.   So look for a different retina surgeon competent/communicative/compassionate.  
59 Comments
Thank you, Dr Hagan.

Any guidance about finding a highly regarded retina surgeon?  I’m in the upper midwest and private retina clinics (I.e. not affiliated with the university system) are 2+ hours away. Other than the ProPublica website with Medicare records on the number of times in one year that a doc coded given procedures, I do not know what other resources are helpful and available.  This week, I had reached out to Dr. Charles’ clinic that an earlier poster on this board was so positive about, but I do not know 1) how urgent it is for me to get in and be seen, and 2) how important it is to have the same person do surgery AND also do ongoing care.

Do you have guidance about finding a highly regarded retina surgeon and about urgency?

Again, many thanks!
Steve Charles MD in Memphis is one of the finest retina surgeons in the world but you need access to one you can drive on a regular basis. Where in the upper midwest do you live exactly?  Mayo Clinic is very good, U of Michigan,  U of Chicago, Northwestern U  Univ of Wisconsin all have strong ophthalmology departments.
Thank you.  My less than stellar experience has been with a well regarded retina surgeon at one of the organizations you list.
Might there be someone of high skill at Retina Associates in Milwaukee?
I’m asking about a private practice in part because on multiple fronts  I’ve had only bad experiences with university affiliated clinicians.
Although I did some of my training a long time ago at Milwaukee County General/ Medical College of Wisconsin I don't know any of those  physicians and I don't see their training listed. As a generalization private practitioners are more personable and explain more than Ivory Tower Professionals.
My mistake - Retina & Vitreous Consultants of Wisconsin (Milwaukee)
I think these Docs. at Davis, Duehr, Dean Eye Clinic in Madison, WI (1025 Regent St) also may have retina surgeons.
Really not able to help you.  Want to be sure they have retina fellowship in their training.  The physicians at Northeast Wisconsin Retina Associates look to be well trained:  http://newretinamd.com/our_physicians.php
Thank you and kind regards. I see that my surgeon has been involved with drug trials for diabetic macular edema - although my case is not due to diabetes, still he should have good knowledge about treating edema.  I will call the surgeons staff in the AM and ask what our treatment plan is for the OCT findings the optometrist faxed in 10 days ago.  Maybe the nurses can get his attention.  Will give him a chance to tap into his knowledge and demonstrate his clinical expertise.
Make a list of your questions and see if he would answer each before flying out of the room like a rocket on fire.
Just an update here.  I called the clinic and was told that the surgeon was not available to respond to me for another month.  I then was given the explanation that he’s a busy guy which is why appointments are scheduled so far out.  I even said that I’d like to see/hear from another retina doc then, but was given the same explanation.  Seems that care is not driven by the needs of the case/patient but instead by the calendar of the Doc.
I believe you are correct. No excuse for that behavior.  Actually its pretty outlandish. You might go on Yelp or Facebook and give a public call out.  Seems things will not get better where you are and you need to find a competent/communicative  retina surgeon.
As a retinal detachment patient myself (both eyes), I would highly recommend seeking a second opinion to get your questions answered. That's a step I took, and I found it very worthwhile. I also requested a copy of my medical records. Do you know whether the staff told the surgeon that you called and the reason; i.e., experiencing a change in vision? Did your optometrist call the surgeon or just send a fax? I've had lots of complications but have also found solutions.
Please try to be hopeful. I wish you the very best.
Yes and if you want to post the name of the department that is giving such poor service and not letting you talk to your physician please feel free to do so.
Just wanted to thank you all, and provide another update.  Finally a nurse called me back.  After hearing my frustration she had the Retina doc in the clinic for the day call me.  This was very helpful because I learned that the surgeon has discussed only 50% of the situation.  Apparently he noted some scarring (PVR) developing inferiorly that he is concerned about.  The doc who called me presumes that the surgeon didn’t investigate the ERM because he wants to see more healing before making any decisions about what to do. She urged me to stay with the non-communicative surgeon if I feel I can.  In the meantime, she put in to have me seen by another of the clinic’s retina surgeons on Friday. I’ve asked her whether she could do comprehensive ophthalmology for me - my recollection is that she is a Retina person (Bascom Palmer fellowship) but she told me she’s not a retina surgeon.  If she would take me on, probably I could stick with Dr. Silence who is supposed to be the region’s most skilled? surgeon.  I am waiting to get her reply.

For the Friday appt - should I try to get them to do an OCT scan?  I saw the scan from the optometrist and the membrane looked to be flat against the retina - however there was no “dip” as the macula area was thick.  Even in light of PVR, does it make sense to try to preserve cell quantity and health in the macula and rest of the retina - i.e. do things to control edema/inflammation?

Your advice on all fronts would be greatly appreciated.
Oh ...and so presumably the reason the surgeon wanted to see me 3 months later instead of the usual 6 months was because of the scarring and possible re-detachment and had nothing (or little) to do with the ERM.  Oddly, the surgeon never mentioned scarring to me and instead said that the scleral buckle was healing nicely and holding well.  He had mentioned the ERM.  Yet, it seems that in his mind he was focused only on the scarring.

As I wondered earlier - shouldn't we be trying to preserve cell quality and quantity + vision in addition to having the surgeon watch the scarring?  This isn't an either or situation ...is it?
Yes get an OCT.  Hopefully the comprehensive ophthalmologist will be more compassionate and communicative. Voice your concerns about  Dr. Stonewall.  If you hit it off with the comprehensive ophthalmologist have both follow you. I'm sure Stonewall talks to her.  Medications may help inflamaation and swelling but won't have much effect on membranes.  
Thank you again.  I am taking to heart the wisdom shared by you, Dr. Hagan, and pinhole.

Would you agree that the complication rate of vitrectomy has been reduced with newer technologies, thus leading to an increase in the risk:benefit for PVR and ERM.  Or, is this just convenient propaganda?  I see some in Britain claiming that there is no longer a reason for anything except vitrectomy for re-attachment, etc.  Are the Brits implementing such an approach, or does all of this remain as little more than pronouncements by academics with only a distant connection with practicing surgeons?

(In light of the info. about scarring in addition to the ERM, I’m quite discouraged, and so feel I must wrap my head around the risks of vitrectomy, and especially for my case. I just don’t know why it wasn’t done initially given all of what the surgeon described as ‘tobacco dust’ in the eye. Is there any positive light to look towards?  The only positive I see is in warning others about what I was thoroughly unaware of at the onset of this life disaster.)
As technology advances complication rates decrease but never reach zero.  I don't know that the "Brits" hold any opinions radically different than the rest of the world's retina surgeons. Problem with "Brits" is timely intervention, the NHS posters on this forum complain bitterly about interminable waits for what would be emergency treatment most places.
Hopefully the surgeon on Friday can answer all your questions and offer a fresh perspective. Waiting is hard, though.
Because I had vit-buckle procedures on each eye (years apart) as initial (urgent) procedures for detachment, I wasn't as apprehensive about getting a second vitrectomy in one of them to remove an ERM (very good outcome).
I think you said you had retinal tears, but did you have an actual detachment?
On my own (not referred) I did get additional opinions at various junctures, even traveling out of state.
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Thank you for your insights.  In the end, I did have a detachment - by the time the non-communicative surgeon rushed me into surgery, I still had 20/20 vision and NO field defects in the affected eye.  Like you, pinhole, the prospects of the original urgent scleral buckle surgery made me shake uncontrollably for 18 hours (literally) - in part as a result of the defunct bedside manner of the docs. and many across the system.  I will give kudos to two clinic nurses who were extremely kind, helpful, and compassionate.  Now, however, the thought of a vitrectomy to clean out all of the ERM, PVR, and risky cells seems much less scary.

Pinhole - how long between your vit-buckle and vit-ERM removal procedures?  Did you have any macular edema with visible cystoid spaces before the vit. for ERM?

Another update ...this morning I went back to my very experienced and helpful optometrist for a check after 2 weeks on the Ketorolac.  There may have been a bit of reduction in the retinal thickness in the periphery (may 5-10 um), depending on the repeatability of the instrument.  But, there certainly was no reduction in the central thickness nor in the size of the 2 edema cysts - although they did appear to change in orientation from being horizontally oval to being a bit more round to slightly oval vertically. I made the point to schedule this appt. at the same relative time of day as the appt. two weeks earlier so we would minimize what I assume to be diurnal changes.

The optometrist joked - but I'm afraid there is truth in it - now my record is red-flagged within and throughout the prestigious institution system of Dr. Silence.  She also recommended a 2nd opinion at Mayo, as Dr. Hagan has recommended.  Maybe someone here has a retina surgeon at Mayo that they can recommend?

Thank you!
My experience with Mayo's is their reputation is well deserved and they are highly orientated towards patient satisfaction and communication with patients, family and docs back home.
DesperateRetina,
In answer to your question: length of time between retina repair and ERM removal was about 9 months. I had a cataract removed and an IOL implanted in the same surgery as the membrane peel (two different surgeons). No CME in that eye. When my other eye got in trouble, CME was part of the picture at some point -- specific onset was never clear to me. It was treated successfully with prednisolone (steroid) and Ketorolac over quite a long time.
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pinhole, your experience gives me some hope.  If you don’t mind, what is your BCVA in the ERM eye?  In the CME eye now that you’ve finally gotten rid of the edema?  Were your detachments mac on or mac off?
Dr. Hagan, thank you. By the way, I did post reviews about my experience with Dr. Silent on websites like Vital and RateMD.  I am thinking about writing a letter to the Chair of the Education committee in my state legislature whose committee oversees the illustrious (in their minds) institution to report on my 3x BAD experiences with the university health system.  One earlier BAD experience was a broken elbow that they did not diagnose and still two weeks later refused to refer me to an ortho. instead telling me I just needed to take more ibuprofen (by a nurse who also told me that aspirin is not an anti-inflammatory!).  I found a sports med. guy outside of their system and in fact there were 3 breaks in my elbow/arm.  In my experience, unfortunately the arrogance is widespread through the system ...although from listening to my optometrist the arrogance within the tertiary level is off the charts.

Do you have experience with any of the 2nd gen. ophthalmic NSAIDs and new gen. steroids?  Is there benefit and are they worth discussing during the retina appt. on Friday after the OCT?
Yes ketorolac was the first and made a huge difference in preventing post cataract surgery swelling of the macula (cystoid macular edema). Most surgeons including our practice use new NSAIDS with all our cataract surgery and for other causes of macular edema such as vein occlusions.  They are more effective but quite a bit more expensive. some examples are Bromday, Ilevro    Macular edema under a ERM is more difficult to treat.  
Does the ERM cause edema or did the edema promote the development of the ERM?  Seems like a chicken-egg scenario.  I’m upset in part because the supposed reason for the detachment was early scarring and rolling over a larger tear even in the face of extensive laser. Despite this known evidence of PVR risk which the surgeon knew about, he did scleral buckle with lots of cryo and no vit. to remove potential seeding cells.  Now PVR continuing in same area (which he chose to not tell me about), ERM, and CME. Surgeon’s comment is, “well, these things can happen, and after all you have a reasonably large tear and tobacco dust.”  So why no measures like vit. and minimizing cryo to try to minimize risk factors for scar tissue formation?  I am able to read the journal articles that are available to Dr. Ivory Tower.  The scientist and statistician in me sees that either 1) Dr. Ivory Tower does not read or believe the literature, or 2) is not a Bayesian so does not use prior information/evidence when making decisions going forward, or 3) believes that his skill outweighs all risks, or 4) believes that hope is a strategy. Sorry for the frustration ...but my philosophy is that prevention always beats attempts to cure ...and now I’m left with to live with a problematic eye and a bestroyed career and Dr. Ivory Tower is making >$600k per year.
Dr. Hagan, Mayo and U of Iowa are similar drive times. Any guidance on which one may do better with a problem case and likely a very delicate surgery all working to help achieve my needs?
Emphasis on my goals and needs ...not the “good enough” goals of Dr. of Industrialized Medicine ....
They both are excellent and you are obviously a good internet researcher so if you find reason's to elevate one over the other or if one is easier to drive or better for you insurance I would choose that department. I have worked with both Iowa and Mayo's over the years on ultra complex problems and found them both excellent. Unfortunately some 'professors' at U of Ivory Tower are arrogant and non-communicative.  Mayo's depends on self referral from patients and physicians so their customer service is extraordinary.  Do you live in the Badger State?  
Thank you - this is very helpful.  And, yes, I do.
In your experience, is it always necessary to remove the ERM in order to have a better than 75% shot at getting rid of the CME? From what I can see from the optometrist’s OCT, the ERM is not adhered to the layer of cells within the fovea (yet) because there appears to be a visible gap.
ERMs are so unique its not possible to generalize. It's a common problem and some people with relatively large ERM have good vision and are happy and some with small ERM have unacceptable vision.  Most ERMs are not removed because its the risk/benefit ratio for small and medicum ERM don't favor peeling.  

I have been to some lectures from Badger U  and this do have a high opinion of themselves.
This is very disappointing to hear.  Unfortunately my tax dollars support such a culture.

Do you know the author of this article?  Clearly the wider retina community takes a much more conservative view than is represented by this author.  Does the author's position have merit - or is his view too pollyanna?

http://epubs.democratprinting.com/article/RETINA%3A+Advances+in+Epiretinal+Membrane+Treatment/765211/72752/article.html
Well that paper is from 2011.  Second read the complications paragraph carefully:  Complications

The most common complications include intraocular bleeding and retinal breaks. Following surgery, as many as 75% of treated eyes ex Perience accelerated progression of nuclear sclerosis of the lens, and most patients have to undergo cataract removal within 2 years to maximize the benefits of membrane peeling. Postoperative retinal detachment may occur in about 3% to 6% of patients, but this can be treated with a followup surgery. Postoperatively , the patient can expect vision to improve over a 3 to 6 month period. Patients should be monitored for recurrence.

On the horizon, understanding cellular metabolism and pathologic anatomic changes will provide a better idea of when to do surgery and how the eye will respond to the procedure.
DesperateRetina,
In answer to your question, it was a mac-off detachment in the first eye. That eye now has BCVA 20/20 minus a letter. The second eye, the one that had CME, was 20/30 before the detachment, and many complications and procedures later is 20/20-2. It has an ERM but surgery is not indicated at this time and may never be.
Delving into the literature will tell you who's doing the research and where. I've also found youtube informative. I hope things will get clarified for you in a positive direction tomorrow.
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@DesperateRetina I had a vitrectomy/ERM peel 2 1/2 years ago and have some residual CME in that eye, but my best corrected vision has returned to a stellar 20/20 to 20/15. I did not have a scleral buckle.  As @pinhole stated, after having had one vitrectomy performed I wouldn't hesitate to have another if the situation called for it, which is possible since my non-operative eye has also been diagnosed with (so far non-symptomatic) macular pucker.
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Hi.  Back from the retina appt.  What a sorry visit.  I truly wished to get a thoughtful doc. who could think with me about improving my VA, especially near/fine vision - and consider risks to my vision for the macular edema.  I also wanted answers to what is causing the terrible graininess in my vision - visible black lines running through my vision - and the striations in my intermediate and near vision  The black lines that look like spaces between cells obscure vision when looking through a pinhole.  I got no answers and no thoughtful dialogue.

It appears that I got a retina surgeon who had predetermined that his only purpose was to recite the "camera" analogy and to say, oops, too bad for you but ERMs happen with RD surgery.  This was after a tech did the passive-aggressive thing of telling me about an 80 year old patient with 20/200 corrected vision who had been in the clinic yesterday.  Yup - my record is red-flagged.

Anyway, so the retina guy didn't do an OCT, but agreed that he could see what was going on from the scan (poor printed copy) done by my optometrist.  He was going to prescribe pred. + ketorolac when I asked him about the new generation versions.  He was unaware of these and had no experience using them.  Oh my.

In the end, he did write the scrips for the new gen. drops.  I certainly don't feel *good* about this because I didn't go in there just to get eye drops.  I went in there to discuss and prioritize the factors that are causing the disappointing vision and to talk about ways to address these.  If the edema is detrimental near and long term, then might it make sense to address it?  If there are other factors we can address, then I'd like to discuss those as well.

Guess I will try the bromfelac drops ..but because he didn't do an OCT, how will we know if the drops are making progress?

Does anyone know what is causing the graininess (black lines)?  These lines seem to be more visible/prominent in near and intermediate vision when there are multiple focal planes, but I am focusing on an object in the far distance.  Also, they are very visible/prominent when I blink.

Doc., pinhole - any other things I should look into?  Thank you in advance!
Seems you have gone as far as you can or as far as you would like in that clinic.  He is assuming the OCT has not changed since you had it last. No I don't know what is causing the problems for sure but ERM -/+  macular edema can cause strange symptoms like that.
Since you described your optometrist as being very experienced and helpful, does she have a recommended retinal specialist to refer you to? That's how I was introduced to my own retinal specialist and later cataract surgeon, I asked my  optometrist who he would go to if it were him needing treatment.
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Thank you, MrPresley, for your positive reports and your suggestion to ask the optometrist for a recommendation.  As you say, you've experienced stellar results from your vitrectomy/peel.  Do you have any sense for the 1st and 2nd most vital factors or decisions which you feel enabled achieving such a good outcome?

To pinhole: it seems that you also have had very good and possibly atypical vision results from the vitrectomy/peel in spite of complications.  I'd ask the same question of you:  Do you have any sense for the 1st and 2nd most vital factors or decisions which you feel enabled achieving such a good outcome?

Thank you again, All!
Dr. Hagan - On behalf of so many who come to this board, I just wish to thank you for your tireless dedication to providing people with down to earth sound, experience-based advice.  Hopefully all realize and appreciate your selfless generosity.  Please accept my most sincere gratitude!
Thank you for saying thank you.  I'm happy to help.  MedHelp supplied some figures the other day that looks like almost a half million people visit this website many of them returning many times.
This is just amazing.  People truly are searching, in part because there is so much conflicting information out there.  Also, I believe that the medical system in the U.S. today is being driven by the profit motives of people/organizations other than the patient and family (real customers).  It seems to reason that this is a significant driving force in creating what I call "revolving door" medicine (I've seen others call this "assembly line" medicine).  This model does not allow time for the informed, reasoned dialogue that I have been seeking.  Heck - I spend more time deciding what to order for dinner at my favorite restaurant than the time and respectful discussion afforded to me in making a decision about RD surgery.

I believe I'm not the only one yearning for respectful dialogue from medical care professionals.  Frequently, I wonder how much of the motivation behind things like anti-vaccine results because people are not afforded respectful dialogue and so no longer trust traditional sources?

The work you are doing is important to individuals, as well as to credible medical and science fields in general!
I'm not going to stand by while you bash the US medical system.  I see a patient with a problem I can get an MRI same day. People come here from nationalized health systems and they wait many long months. I can schedule a cataract/IOL within two weeks some people and countries wait half a year or more.  There is a recent post from a person with a government health system that had a retinal detachment-macula on that was put on the government surgical schedule in 3 months. The person borrowed all the money he could and went to a private retina surgeon and had surgery the next day.  When you have to see more and more people every year and insurance pays less and less and the medical records have to be more and more complex and documented the only way the math works is see more patients in less time.  There is a wholesale departure of physicians from medicine which makes the problem worse and worse.   There is also "concierge" medicine where you spend extra out of the  pocket and sit down for a hour face to face.

If you want to generalize the entire medical system in the US to your bad experience with one professor at Ivory Tower University then I am done with this conversation.  
I am not bashing what you describe. I am expressing my frustration in finding docs. who are patient and respectful of the patient and their needs.  I am also expressing frustration with the health insurance system.  I call health insurance and ask whether pre-authorization is needed - they tell me one story (which later they say wasn't correct because of some bizarre way that the clinic bills) but ultimately I figure out that I am not responsible for getting the pre-auth.  The Med. Clinic does not call in for pre-authorization, despite my comments to them about calling.  I later get the bills and there is a penalty charged to ME pre-authorization was not obtained (the clinic did not make the call).  I call the clinic billing about the penalty and they tell me that they will not refile or reconsider or contest with health insurance because the penalty $$ is too small to justify THEIR time.  So in the end, I am stuck with the penalty - not because it was my fault, not because I didn't fulfill my responsibilities.  Having and using health insurance, the health insurance I pay an arm and leg for (self-employed individual plan), is a full time job.  Sorry if you felt that my frustrations were misdirected.

By the way, the Ophthalmologist that I spoke to on the phone has responded to my request and said she would work with me.  She asked how she could help me now.  Her Fellowship was in Medical Retina at Bascom Palmer.  Is it reasonable to ask for her help in beating down the retinal inflammation and macular edema from the ERM?
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Dr. Hagan,

The Ophthalmologist that I spoke to on the phone has responded to my request and said she would work with me.  She asked how she could help me now.  Her Fellowship was in Medical Retina at Bascom Palmer.  Is it reasonable to ask for her help in beating down the retinal inflammation and macular edema from the ERM?

In re-reading your post - it seems we are frustrated about many of the same things.  "When you have to see more and more people every year and insurance pays less and less and the medical records have to be more and more complex and documented the only way the math works is see more patients in less time.  There is a wholesale departure of physicians from medicine which makes the problem worse and worse." I do not blame the MD's as I feel that even Dr. Silent has a heart for his patients.  How do we fix this??
I don't want this to devolve into the world of politics. The 'winners' in the US health system are hospitals, insurance companies, malpractice and product liability lawyers and pharmaceutical companies.  The losers are patients and physicians.   You can't get through dinner with the television on without a dozen ads from lawyers wanting to sue doctors, hospitals, drug companies.  If I'm called to the ER to see a person with no insurance the hospital receives a payment from the government but not the physician. The average medical student enters practice with about $250,000 worth of debt.   I think you are headed in the right direction with you eye problem. you have a well trained physician you are communicating with.  I don't like the way this discussion is headed.  I'm signing off this discussion. Best of luck.
Again, I say thank you for all that you do here!
@DesperateRetina the two biggest factors in my outcome, in my layman’s opinion, was the skill of the surgeons and the fact that I had the vitrectomy/ERM peel performed promptly (within 3 weeks) of being diagnosed with macular pucker. I was fortunate to have an optometrist with an OCT scanner in his office which resulted in my quick referral to the retinal specialist the same morning. Very busy office too.
Thank you, @MrPresley.  This is helpful.  Sounds as though your surgeon was fully supportive of doing the vitrectomy/ERM peel procedure.  Or, did you have to press the surgeon to do the procedure?

My local "retina experts" are of the philosophy that they recommend AGAINST the vitrectomy/ERM peel unless the patient has vision that is worse than 20/50 in the affected eye.

From my discussions with them, it is clear that they do not comprehend what 20/50 vision with macular pucker really means.  They told me to use a higher power microscope objective (equivalent to higher powered glasses correction) when doing lab work.  Clearly they do not understand, as this comment implies that they think it all is correctable with better optics (glasses/contacts/microscope objective).  No matter how much better the light rays are "focused", my eye is 100% unable to make out the detail or see anything clearly (near or distance).

I have the raindrop thing that you've described.  I have "dim"/grayish areas. I have striations which someone else described as a looking like everything has been scraped by a fine toothed comb.  I have grainy vision which is as though you are looking though a twisted piece of superfine black mesh.  And, there is no detail to anything viewed close-up - so if I wished to remove a sliver from my finger, my surgery eye would not even be able to see the sliver.  I also cannot drive with the surgery eye (i.e. if something happened to my un-operated eye) because I must be at the sign before I can read it - despite testing at 20/50 and at times, 20/40 BCVA.

What shocks me is that despite my repeated concerns about poor vision quality, they never even offered an explanation or an OCT scan to assess the situation and decide whether action of any type was warranted.  I went to my optometrist out of desperation - luckily she had the sense to do an OCT scan and to put me on Ketorolac.  Also, my optometrist came back and simply offered consulting Mayo, but she had no experience with patients who had gone there for ERM and macular edema.
My retinal specialist stated that the vitrectomy/ERM peel procedure was necessary and to perform it as soon as possible, not longer than a month into the future. I did not have to press him in any manner on performing the procedure. We scheduled it for the first available date he had on the very first day I saw him. As I posted previously this was/is an extremely busy office but his thoroughness and mannerisms on that first visit were and remain today very much appreciated. I still see him every six months to monitor my retinal health.
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