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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.
39 Responses
233488 tn?1310696703
MEDICAL PROFESSIONAL
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
Avatar universal
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.    



233488 tn?1310696703
MEDICAL PROFESSIONAL
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Avatar universal
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.
Avatar universal
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.)

  
Avatar universal
MEDICAL PROFESSIONAL
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Avatar universal
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.        
233488 tn?1310696703
MEDICAL PROFESSIONAL
-=------------------
Avatar universal
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!
Avatar universal
MEDICAL PROFESSIONAL
-----------------------------------
Avatar universal
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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