epiretinal membrane peel & vitrectomy

[naoye]

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.

[JodieJ]

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.    

[John C Hagan III, MD, FACS, FAAO]

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

[florex78]

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 !

[Mikek1]

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.

[JodieJ]

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.

[Mikek1]

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! .

[naoye]

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.

[hungan]

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.

[hungan]

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.

[John C Hagan III, MD, FACS, FAAO]

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

[JodieJ]

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?)  

[John C Hagan III, MD, FACS, FAAO]

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

[naoye]

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.

[JodieJ]

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.  

[hungan]

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!

[JodieJ]

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.  

[hungan]

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.

[JodieJ]

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

[hungan]

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.

[naoye]

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.

[JodieJ]

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."  

[naoye]

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.

[JodieJ]

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  

[JodieJ]

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.