Epiretinal Membranes, CME and Macular Holes

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Epiretinal Membranes, CME and Macular Holes

• Laura S. Gilmore, MD
• Grand Rounds
• November 14, 2003
• Texas Tech University HSC
• Lubbock, TX

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History

• Chief Complaint VA OD fading away x 6-8
  months
• HPI 81yo male referred for evaluation of chronic
  CME OD s/p CE 3 years ago
• PMH newly diagnosed DM with BS 120s-140s. HTN.
  Hypothyroidism. Arthritis. Hypercholesterolemia.
  
• Ocular History CE OD 99 KNOWN CME x 3 years
• FH diabetes, sister
• SH no alcohol. Quit smoking gt30 years ago

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Physical Exam

• VS BP 115/79, P 74
• VA OD 20/50 -12PH NI, OS 20/50 -11PH
  20/40-2 VF FTFC OU x small central scotoma
  AMSLER normal
• IOP OD 10, OS 14
• PCIOL OD, 3 NSC OS
• Anterior segment clear, without pupil distortion,
  PSC, synechiae, lens dislocation
• DFE OD-ERM macular hole with flap of retinal
  tissue multicystic CME cryo scar
  supero-nasally PVD with Weiss ring. OS-appears
  flat

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Additional History

• 1978 blunt trauma OD-champagne cork vs eye
• Resultant RD, per patient
• Treated in San Diego VA Hospital with
  cryotherapy, pneumatic retinopexy?
• Still awaiting records from San Diego

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Note dragging of vessels, tortuosity, color
changes
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Dragging, tortuosity
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Cystic spaces evident in this incidence
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Cystic rupture in another incidence
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Hypotheses

• Senile macular hole
• Blunt trauma caused retinal tear and/or
  detachment, and hole directly or indirectly
• CME with ruptured cyst
• Vitreofoveal traction syndrome 1st, then ERM
• ERM 1st, leading to 1) tractional macular hole or
  2) CME from ERM traction, then hole

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Unlikely Choices

• Typical senile hole- not likely, since usually
  shows early hyperfluorescence
• Direct result of trauma in 1978? symptoms would
  have appeared within 6-12 months
• CME with ruptured cyst
• Not likely result of CE, or symptoms would have
  been evident within 6-8 months post-op. CE was
  over 3 years ago.

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Most Likely Choice

• RD repair/cryo, with resultant ERM 1st, leading
  to 1) tractional macular hole or 2) CME from ERM
  traction, then hole

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Macular Dysfunction Caused by Epiretinal Membrane
Contraction

• Distortion
• Intraretinal edema, CME
• Degeneration of underlying retina

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Classification by Distortion

• Grade 0 Cellophane Maculopathy-translucent with
  no distortion of retina cellophane light reflex
• Grade 1 Crinkled Cellophane Maculopathy-irregular
  retinal folds and light reflex, radiating
  retinal folds no to mild VA c/o, 20/40 at worst,
  /-metamorphopsia, insidious onset
• Grade 2 Macular Pucker-grayish membrane marked
  retinal crinkling and puckering of macula PVD in
  90 may see edema, retinal heme, CWS, SRD,
  leakage by FA VA 20/200 or less, insidious to
  sudden onset, usually with metamorphopsia

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ERM Following Retinal Tear/Detachment Repair

• Grade 1 or 2 frequently seen s/p RT/RD repair
• usually occurs 8-16 weeks post-op
• VA in 20 of pts improves due to relaxation or
  partial peeling of ERM and resolution of
  intraretinal edema
• Traction on macula can lead to hole or CME

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Clinical Features of CME

• Visual acuity is reduced according to severity
  and duration
• Longstanding cases usually result in coalescence
  of fluid-filled microcysts into large cystic
  spaces
• Lamellar holes form at fovea, causing
  irreversible damage to central vision
• SLE shows loss of foveolar depression, thickening
  of retina, and multiple cysts in sensory retina

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Signs of Macular Hole

• Watzke-Allen-beam on foveola appears broken
• round, red spot in the center of the macula, 1/3
  to 2/3 DD, surrounded by a gray halo
• lose foveolar depression yellow spot in macula.
• Small, yellow precipitates in hole subretinally
• retinal cysts at the margin of the hole or a
  small operculum above the hole, anterior to the
  retina (stage 4) or both
• May be caused by vitreous or epiretinal membrane
  traction on the macula, trauma, or cystoid
  macular edema

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Fluorescein Angiography

• CME-Dye accumulates in outer plexiform layer Dye
  leaks into parafoveal region during the
  arteriovenous phase, coalesces into flower-petal
  pattern in late AV phase hyperfluorescence from
  dye pooling in microcystic spaces persists
  through late phase
• Macular/lamellar holes-EARLY hyperfluorescence
• ERM-diffuse leakage of capillaries around FAZ
  what we see

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Summary

• ERM following RD repair
• tractional macular hole vs. CME from ERM
  traction, then hole

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Proposed Treatment in this Case

• Surgery at 20/50? F/U this week, 20/25 OD
• No metamorphopsia, no Amsler symptoms
• just small central scotoma
• No will follow. If VA decreases (at least 20/60)
  or pt has intolerable distortion, proceed with
  PPVx, membrane peeling

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Gass, J. Donald M. Stereoscopic Atlas of Macular
Diseases, Diagnosis and Treatment, Volume II, 4th
Edition. 903-916, 938-954. Kanski, Jack J.
Clinical Ophthalmology. 4th Edition. 424-425.