Prevalence and associations of epiretinal membranes. The Blue Mountains Eye Study, Australia

Nutrition and age-related eye diseases: the Alienor (Antioxydants, Lipides Essentiels, Nutrition et maladies OculaiRes) Study

BACKGROUND

Worldwide, degenerative eye diseases (age-related maculopathy (ARM), cataract, glaucoma) are the main causes of visual impairment and blindness, which contribute to disability in the elderly. Mainly three types of nutritional factors are investigated for their potential protection against eye ageing: antioxidants; lutein and zeaxanthin (carotenoids which accumulate specifically in the eye); omega 3 polyunsaturated fatty acids. Few epidemiological studies have been conducted in this field, particularly in Europe.

OBJECTIVE

The Alienor (Antioxydants, Lipides Essentiels, Nutrition et maladies OculaiRes) Study aims at assessing the associations of eye diseases with nutritional factors, determined from plasma measurements and estimation of dietary intakes.

DESIGN, SETTING AND PARTICIPANTS

Subjects were recruited in Bordeaux (France) from the ongoing population-based 3C study. In 2006-2008, 963 subjects from the 3C Study, aged 73 years or more, had an eye examination and will have follow-up eye examinations every 2 years.

MEASUREMENTS

Vascular, genetic and nutritional factors were assessed at baseline (1999-2001) and follow-up examinations of the 3C Study. Eye diseases were classified according to international classifications.

RESULTS

Nutritional status and vascular disease and risk factors were similar between participants and non participants, except for a slight difference in plasma triglycerides and HDL-cholesterol. As expected, the prevalence of eye diseases was high: early and late ARM (28.4 % and 5.6 %, respectively), open-angle glaucoma and treated ocular hypertension (4.8 % and 10.0 %, respectively), cataract extraction (45.2 %), retinopathy (8.4 %), retinal vein occlusion (1.1 %), epiretinal membrane (3.9 %), current use of artificial tears (17.3 %).

CONCLUSIONS

This study confirms the high prevalence of eye diseases in the elderly. Its main strength is the combination of nutritional, vascular and genetic information, collected over a 7 year period of time before the first eye examination. It may help design future interventional studies, which might be common with other age-related disorders, because of common nutritional factors.

Long-term temporal changes of macular thickness and visual outcome after vitrectomy for idiopathic epiretinal membrane

PURPOSE

To evaluate the long-term correlation of visual outcome and macular thickness after vitrectomy for idiopathic epiretinal membrane and to identify prognostic factors for good visual outcome.

DESIGN

Retrospective, observational case series.

METHODS

We reviewed the records of 52 patients with idiopathic epiretinal membrane who were treated with vitrectomy and could be followed up for more than 12 months. The main outcome measures were best-corrected visual acuity (BCVA) and central macular thickness at baseline; at 1, 3, 6, and 12 months after surgery; and at the final follow-up visit. The correlation between BCVA and central macular thickness was analyzed and the receiver operating characteristic curve analysis was performed to obtain cutoff values for visual prognosis.

RESULTS

Most of the changes in BCVA and central macular thickness took place during the first 3 months and reached a plateau at 12 months after surgery. Despite the lack of changes in BCVA after 12 months of follow-up, significant reduction in central macular thickness could still be observed over 12 months after surgery. The final BCVA was correlated significantly with preoperative BCVA and central macular thickness and early postoperative central macular thickness. Among them, the postoperative central macular thickness at 1 month showed the largest area under the receiver operating characteristic curve.

CONCLUSIONS

Given the removal of the confounding effect of cataract, postoperative follow-up of 12 months may be sufficient to reach the final BCVA after surgery. However, more time is needed to achieve final central macular thickness. Because of the significant correlation between final BCVA and early postoperative central macular thickness, serial optical coherence tomography images in the early postoperative period were needed to predict visual outcome after epiretinal membrane removal.

Prevalence and risk factors for epiretinal membranes in a multi-ethnic United States population

PURPOSE

To describe the prevalence of and risk factors for epiretinal membrane (ERM) in a multi-ethnic population and to evaluate possible racial or ethnic differences.

DESIGN

Cross-sectional study.

PARTICIPANTS

Participants of the Multi-Ethnic Study of Atherosclerosis (MESA), examined at the second visit of the MESA when retinal photography was performed.

METHODS

Data on 5960 participants aged 45 to 84 years from MESA, including white, black, Hispanic, and Chinese persons from 6 United States communities, were analyzed. Epiretinal membrane was assessed from digital nonstereoscopic fundus photographs and was defined as cellophane macular reflex (CMR) without retinal folds or preretinal macular fibrosis (PMF) with retinal folds. Risk factors were assessed from standardized interviews, clinical examinations, and laboratory investigations.

MAIN OUTCOME MEASURES

Epiretinal membrane prevalence by ethnic or racial group and risk factors associated with ERM.

RESULTS

The prevalence of any ERM was 28.9%, of which 25.1% were CMR cases and 3.8% were PMF cases. The prevalence of ERM was significantly higher in Chinese persons (39.0%), compared with Hispanic (29.3%), white (27.5%), or black (26.2%; P<0.001) persons. In multivariate models, increasing age (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.06-1.34, per year increase in age), diabetes (OR, 1.92; 95% CI, 1.39-2.65), and hypercholesterolemia (OR, 1.33; 95% CI, 1.04-1.69) were significantly associated with CMR.

CONCLUSIONS

This study showed that ERM was significantly more common in Chinese persons compared with whites, blacks, and Hispanics. Risk factors for ERM were increasing age, presence of diabetes, and hypercholesterolemia.

Periostin, discovered by nano-flow liquid chromatography and mass spectrometry, is a novel marker of diabetic retinopathy

Diabetes can lead to serious microvascular complications including proliferative diabetic retinopathy (PDR), the leading cause of blindness in adults. Recent studies using gene array technology have attempted to apply a hypothesis-generating approach to elucidate the pathogenesis of PDR, but these studies rely on mRNA differences, which may or may not be related to significant biological processes. To better understand the basic mechanisms of PDR and to identify potential new biomarkers, we performed shotgun liquid chromatography (LC)/tandem mass spectrometry (MS/MS) analysis on pooled protein extracts from neovascular membranes obtained from PDR specimens and compared the results with those from non-vascular epiretinal membrane (ERM) specimens. We detected 226 distinct proteins in neovascular membranes and 154 in ERM. Among these proteins, 102 were specific to neovascular membranes and 30 were specific to ERM. We identified a candidate marker, periostin, as well as several known PDR markers such as pigment epithelium-derived factor (PEDF). We then performed RT-PCR using these markers. The expression of periostin was significantly up-regulated in proliferative membrane specimens. Periostin induces cell attachment and spreading and plays a role in cell adhesion. Proteomic analysis by LC/MS/MS, which permits accurate quantitative comparison, was useful in identifying new candidates such as periostin potentially involved in the pathogenesis of PDR.

Outcomes of idiopathic macular epiretinal membrane removal with and without internal limiting membrane peeling: a comparative study

PURPOSE

To compare visual acuity and macular morphology after epiretinal membrane (ERM) removal with and without internal limiting membrane (ILM) peeling.

METHODS

We studied a retrospective interventional case series of 40 eyes in 40 patients with ERM. All patients underwent standard three-port pars plana vitrectomy. In 19 eyes, the ERM alone was removed. In 21 eyes, the ERM was removed and ILM peeling was performed.

RESULTS

Mean best-corrected visual acuity improved significantly in both the non-ILM peeling and the ILM peeling groups (P = 0.001, P = 0.000). Mean central macular thickness (CMT) decreased significantly in both groups (P = 0.001, P = 0.001). However, there was a significant difference in postoperative CMT between the two groups (P = 0.025). The mean postoperative CMT was significantly higher in the ILM peeling group than in the non-ILM peeling group. Sixteen eyes (84.2%) in the non-ILM peeling group had a normal foveal contour with a foveal depression on postoperative optical coherence tomography (OCT), while nine eyes (42.9%) in the ILM peeling group had a foveal depression (P = 0.01).

CONCLUSIONS

Postoperative OCT revealed that thickening of the macula with loss of the normal foveal contour was more frequent in the ILM peeling group. However, these morphological differences did not result in functional differences in terms of visual outcome.

Population-based incidence of macular holes

PURPOSE

To determine the incidence of full-thickness macular holes in Olmsted County, Minnesota.

DESIGN

Population-based retrospective chart review (cross-sectional study).

PARTICIPANTS

Ninety-four eyes of 85 patients who were residents of Olmsted County, Minnesota.

METHODS

A population-based retrospective chart review was performed for all diagnoses of macular hole between 1992 and 2002 among residents of Olmsted County, Minnesota. Yearly incidence rates for each given age and sex group were determined by dividing the number of cases within that group by the estimated total Olmsted County resident population of the group for that given year.

MAIN OUTCOME MEASURES

Documented clinical diagnosis of a macular hole.

RESULTS

Idiopathic macular holes occur at an age- and sex-adjusted incidence in 7.8 persons and 8.69 eyes per 100,000 population per year in Olmsted County, Minnesota. The female-to-male ratio was determined to be 3.3 to 1, and bilateral idiopathic macular holes occurred in 11.7% of patients and accounted for 20.9% of the affected eyes.

CONCLUSIONS

This study uniquely determined the incidence of macular holes in a predominantly Caucasian population.

Subfoveal pigment changes in patients with longstanding epiretinal membranes

PURPOSE

To characterize subfoveal changes in patients with longstanding epiretinal membranes (ERM).

DESIGN

Retrospective study.

METHODS

Analysis of 123 eyes of 123 consecutive patients who underwent surgery for ERM at the Columbia University Medical Center by a single surgeon (S.C.). Eyes were split into 2 groups: those with a preoperative yellow pigmented foveal spot and those without. The latter group was considered the control group. The primary outcome measures were logarithm of the minimum angle of resolution (logMAR) visual acuity at postoperative months 1 and 3 compared with baseline. Fundus photography, optical coherence tomography (OCT), and autofluorescence images were analyzed.

RESULTS

We identified 9 eyes with a yellow pigmented spot. All of these eyes exhibited OCT evidence of outer retinal disorganization and hypoautofluorescence. The mean duration of symptoms prior to surgery in these patients was 53 months. The mean duration of symptoms in the control group was 10.7 months. Mean Snellen acuities of the control vs yellow pucker groups were 20/59.7 vs 20/83.5 (P = .041) at baseline; 20/43.3 vs 20/64.8 (P = .006) at postoperative month 1; and 20/34.2 vs 20/50.3 (P = .011) at postoperative month 3. The logMAR magnitude of visual improvement for the yellow pucker vs control groups was not statistically different at either months 1 or 3. Central macular thickness on OCT of patients with yellow pucker decreased from a mean 495 to 395 microns (P = .041).

CONCLUSIONS

A characteristic yellow macular spot associated with ERM appears to be a sign of chronicity. OCT demonstrates outer retinal disorganization. This feature may portend a worse postoperative visual prognosis.

Long-term follow-up results of ilm peeling during vitrectomy surgery for premacular fibrosis

PURPOSE

To evaluate the outcomes of surgical removal of premacular fibrosis (PMF) with peeling of the internal limiting membrane (ILM). Determination of factors associated with favorable outcomes (visual acuity between 20/20 and 20/40).

METHODS

Retrospective chart review, evaluating visual outcomes in 38 patients who underwent pars plana vitrectomy (PPV) and triamcinolone-assisted ILM peeling by a single surgeon between December 2003 and December 2004. Data collected included visual acuity before and 3 months after surgery, and at final follow-up, as well as complications (cataract formation, endophthalmitis, retinal detachment, vitreous hemorrhage, retinal or subretinal hemorrhage, macular hole formation, cystoid macular edema [CME], and PMF recurrence).

RESULTS

Pretreatment visual acuity averaged at 20/90. Vision improved or was unchanged in 89.5% of operated eyes with ILM peeling. Average follow-up was 20.2 months. The average improvement in visual acuity was 2.2 lines. The most common complication was cataract formation. There were no other complications until patients underwent cataract extraction. Two patients developed CME within 4 weeks of cataract surgery. Biomicroscopic recurrence of PMF was an asymptomatic and rare event with an incidence of 2.6% (n = 1 of 38 patients). No adverse outcomes were noted in patients with higher levels of visual acuity and these were in fact the patients with best final visual acuity.

CONCLUSION

ILM peeling may not have the harmful consequences previously attributed to it. Stripping of the ILM may reduce reformation rates of PMF. Surgical removal of PMF with ILM peeling was not associated with unfavorable outcomes in our group of patients.

Density of common complex ocular traits in the aging eye: analysis of secondary traits in genome-wide association studies

Genetic association studies are identifying genetic risks for common complex ocular traits such as age-related macular degeneration (AMD). The subjects used for discovery of these loci have been largely from clinic-based, case-control studies. Typically, only the primary phenotype (e.g., AMD) being studied is systematically documented and other complex traits (e.g., affecting the eye) are largely ignored. The purpose of this study was to characterize these other or secondary complex ocular traits present in the cases and controls of clinic-based studies being used for genetic study of AMD. The records of 100 consecutive new patients (of any diagnosis) age 60 or older for which all traits affecting the eye had been recorded systematically were reviewed. The average patient had 3.5 distinct diagnoses. A subset of 10 complex traits was selected for further study because they were common and could be reliably diagnosed. The density of these 10 complex ocular traits increased by 0.017 log-traits/year (P = 0.03), ranging from a predicted 2.74 at age 60 to 4.45 at age 90. Trait-trait association was observed only between AMD and primary vitreomacular traction (P = 0.0009). Only 1% of subjects age 60 or older had no common complex traits affecting the eye. Extrapolations suggested that a study of 2000 similar subjects would have sufficient power to detect genetic association with an odds ratio of 2.0 or less for 4 of these 10 traits. In conclusion, the high prevalence of complex traits affecting the aging eye and the inherent biases in referral patterns leads to the potential for confounding by undocumented secondary traits within case-control studies. In addition to the primary trait, other common ocular phenotypes should be systematically documented in genetic association studies so that adjustments for potential trait-trait associations and other bias can be made and genetic risk variants identified in secondary analyses.

Prevalence and associations of epiretinal membranes in adult Chinese: the Beijing eye study

PURPOSE

To determine the prevalence of epiretinal membranes in the adult Chinese population.

METHODS

The Beijing Eye Study, a population-based, cross-sectional cohort study, included 4439 subjects out of 5324 subjects invited to participate (response rate 83.4%) with an age of 40+ years. The present investigation consisted of 4378 (98.6%) subjects for whom readable fundus photographs (30 degrees nonstereoscopic colour images) were available. Assessing the fundus photographs, we differentiated two membrane types: cellophane maculopathy and premacular fibrosis.

RESULTS

Prevalence rate of epiretinal membranes was 2.2+/-0.2% (mean+/-SE) (95% confidence interval (CI): 1.9,2.5) per eye or 2.2+/-0.2% (95% CI: 1.8,2.7) per subject. In binary logistic regression analysis, the prevalence of epiretinal membranes was significantly associated with age (P<0.001; 95% CI: 1.07,1.12), visual field loss (P<0.001; 95% CI: 1.03,1.07), hyperopia (P=0.02; 95% CI: 1.01,1.18), and higher education (P<0.001; 95% CI: 1.29,1.74). Cellophane maculopathy showed a prevalence rate of 1.11+/-0.1% (95% CI: 0.9,1.3) per eye and 1.8+/-0.2% (95% CI: 1.4,2.2) per subject. Its prevalence was significantly associated with age (P<0.001; 95% CI: 1.08,1.13), higher education (P<0.001; 95% CI: 1.26,1.92), and visual field loss (P=0.009; 95% CI: 1.01,1.07). Premacular fibrosis had a prevalence rate of 1.06+/-0.1% (95% CI: 0.9,1.3) per eye and 1.8+/-0.2% (95% CI: 1.4,2.2) per subject. It was significantly associated with age (P<0.001; 95% CI: 1.06,1.11), higher level of education (P<0.001; 95% CI: 1.15,1.74), and visual field loss (P=0.001; 95% CI: 1.02,1.08).

CONCLUSION

In adult Chinese in Greater Beijing, epiretinal membranes including cellophane maculopathy and premacular fibrosis occur in a relatively low frequency which may be lower than in Western countries. Epiretinal membranes including its subtypes of cellophane maculopathy and epiretinal fibrosis were associated with age and hyperopic refractive error.

Surgical removal of idiopathic epiretinal membrane with or without the assistance of indocyanine green: a randomised controlled clinical trial

PURPOSE

To carry out a prospective investigation of the functional and morphological outcome of idiopathic epiretinal membrane (IEM) surgery with or without the assistance of indocyanine green (ICG) in a randomised controlled clinical trial.

METHODS

Sixty patients who underwent vitrectomy with removal of IEM combined with cataract surgery were randomly allocated to two groups: 27 patients were operated on with ICG 0.1% in glucose 5%, 33 patients without ICG. Functional outcome was assessed 3-4 months postoperatively with improvement of best-corrected visual acuity (BCVA), Amsler grid test, and automated and kinetic perimetry. Postoperative residual or recurrent IEM was assessed with bio-microscopy, and macular oedema with optical coherence tomography (OCT). Improvement in BCVA was the main outcome measure.

RESULTS

BCVA improved in 49 patients, remained unchanged in five and decreased in five. Improvement in BCVA and reduction of macular oedema were statistically significant within both groups (P < 0.01). Improvement in BCVA was not statistically significantly different whether ICG was used or not [0.17 (logarithm of minimum angle of resolution; logMAR) with ICG and 0.24 (logMAR) without ICG] (P = 0.59). There was no statistically significant difference in preoperative or postoperative BCVA, reduction of macular oedema, postoperative Amsler grid test, or incidence of residual or recurrent IEM between the two groups. Visual field defects were detected in two patients operated on with ICG.

CONCLUSIONS

Removal of IEM with or without the assistance of ICG equally improved visual function and macular morphology.

Prevalence of full-thickness macular holes in urban and rural adult Chinese: the Beijing Eye Study

PURPOSE

To determine the prevalence of full-thickness macular holes in the elderly Chinese population.

DESIGN

Population-based, cross-sectional cohort study.

METHODS

The Beijing Eye Study included 4439 subjects out of 5324 subjects invited to participate (response rate 83.4%) aged 40 years or older. The present investigation consisted of 8653 (97.9%) eyes of 4346 subjects for whom readable fundus photographs were available.

RESULTS

Full-thickness macular holes were found in eight (0.092%) eyes of seven (0.16%) patients (six women). Prevalence was 0.09 +/- 3.04% [95% confidence interval (CI): 0.03, 0.16%].

CONCLUSIONS

Full-thickness macular holes may be present in approximately 1.6 out of 1000 elderly Chinese in Northern China. Calculated for the entire population in China, the figure would be approximately 750,000 patients with unilateral full-thickness macular holes [n = 650,000 (95% CI: 217,000 to 1,156,000)] or bilateral full-thickness macular holes [n = 100,000 (95% CI: 33,000 to 178,000)].

EPIRETINAL MEMBRANE REMOVAL IN EYES WITH GOOD VISUAL ACUITIES

PURPOSE

To evaluate the results of vitrectomy for epiretinal membrane in eyes with a preoperative visual acuity of 20/50 or better.

METHODS

The visual results and complications of vitrectomy for epiretinal membranes were analyzed in a retrospective, consecutive case series of 40 eyes of 40 patients treated by a single surgeon.

RESULTS

The mean preoperative visual acuity was 20/50 + 2 (range 20/30 + 1 to 20/50 -3). The mean visual acuity improved to 20/40 + 2 (P = 0.02) by the final examination at a mean of 2.4 years following surgery. The status of the lens at the final examination was correlated with the visual results of surgery. Twenty-one eyes were phakic preoperatively and 14 of these eyes had cataracts removed by the final examination. The mean preoperative visual acuity in 7 eyes which were still phakic at the final examination was 20/50 and this decreased to 20/50 -2 (P = 0.82). The mean preoperative visual acuity was 20/50 + 2 in 33 eyes which were pseudophakic by the final examination and this improved to 20/32 -2 (P = 0.005). There were no other serious complications such as retinal detachment or infectious endophthalmitis.

CONCLUSIONS

Vitrectomy for epiretinal membranes is safe in eyes with relatively good preoperative visual acuities but cataract surgery is necessary in phakic eyes to achieve long-term visual acuity improvement.

Visual outcomes following vitrectomy and peeling of epiretinal membrane

BACKGROUND

Visual outcomes of patients following vitrectomy and peeling of visually significant epiretinal membranes were assessed to determine the influence of specific perioperative factors and surgical complications on final visual acuity and functional vision.

METHODS

In an unmatched, consecutive surgical series, vitrectomy and membrane peeling were performed on 125 eyes of 123 patients with visually significant macular epiretinal membranes. Patients were followed for 6-36 months. Visual outcome measures included postoperative logMAR visual acuity, change in visual acuity and functional vision tasks evaluated by questionnaire. Perioperative factors including duration of symptoms, preoperative visual acuity, aetiology, membrane type and leakage on fundal fluorescein angiogram were correlated with final visual outcomes.

RESULTS

Visual acuity improved by a mean of 0.31 A+/- 0.21 units (three lines of vision). In 104 cases (83%), visual acuity improved in patients by two lines or more, with 20 cases (16%) having unchanged acuity and one case (1%) having worse acuity. Ninety-three per cent of interviewed cases reported improvement in functional vision, especially reduction of distortion. Cataract was observed in 52 cases (52% of phakic eyes) postoperatively compared with 19 cases (19%) preoperatively. Postoperative visual acuity correlated with preoperative visual acuity. Patients with worse preoperative vision recorded greater visual improvement following surgery. No other perioperative factors were found to have a prognostic value in this study.

CONCLUSION

Epiretinal membrane peeling improves vision in the majority of patients with significant symptoms, even if preoperative visual acuity is not substantially reduced. Surgery improves functional vision including metamorphopsia not measurable by visual acuity, and thus assessment of functional vision should be included in surgical case planning.

Prevalence and associations of epiretinal membranes in the visual impairment project

PURPOSE

To determine the prevalence and factors associated with epiretinal membranes in a random sample of the population aged 40 years and older in Victoria, Australia.

DESIGN

Population-based cross-sectional study.

METHODS

Detailed eye examinations, including retinal photographs, were conducted in 1992 and 1997 in 3271 people (83% of the eligible) in Melbourne and 1473 (92% of the eligible) in rural Victoria. Eyes present with either cellophane macular reflex (CMR) or preretinal macular fibrosis (PMF) were classified as having epiretinal membranes. Eyes with both CMR and PMF present were classified as having PMF. Age-standardized prevalence rates and 95% confidence limits were calculated by the direct methods using Segi's world population.

RESULTS

Epiretinal membranes were observed in 253 of 4313 participants (6.0%; 95% confidence interval [CI] 5.2 to 6.7), bilaterally in 19%. Prevalence increased significantly by age group (0.5% for 40 to 49 years, 2.6% for 50 to 59 years, 9.4% for 60 to 69 years, 15.1% for 70 to 79 years, and 11.3% for 80 years and older). Prevalence was similar in males and females after adjusting for age. The overall age- and gender-standardized prevalence of CMR was 4.8% (95% CI 4.0 to 5.6) and PMF was 1.7% (95% CI 1.2 to 2.3). A decrease in visual acuity (<6/6) was significantly associated with idiopathic PMF (odds ratio [OR] 1.9; 95% CI 1.0 to 3.6) and CMR (OR 1.5; 95% CI 1.1 to 2.0) after adjusting for age.

CONCLUSIONS

The prevalence of epiretinal membranes was similar to that reported in other population-based studies. Population shifts in the age distribution to older ages could lead to an increase in mild visual impairment caused by epiretinal membranes.

Macular function and morphology after peeling of idiopathic epiretinal membrane with and without the assistance of indocyanine green

AIM

To investigate macular function and morphology after surgical removal of idiopathic epiretinal membrane (IEM) with and without assistance of indocyanine green (ICG).

METHODS

A retrospective study as a consecutive case series, of 39 patients with IEM. 39 patients, 23 female, 16 male, mean age 67 years, underwent standard three port pars plana vitrectomy with removal of epiretinal membrane. Two groups of patients were consecutively operated: in 20 patients ICG 0.1% in glucose 5% was used to stain the epiretinal membrane. 19 patients underwent the identical procedure but without use of ICG. Postoperative follow up was 1-92 months (mean 15.5 months). Functional outcome was assessed with subjective improvement, best corrected visual acuity (BCVA), Amsler grid test, 10 degrees and 30 degrees automated perimetry (Heidelberg visual field analyser) (HFA), and Goldmann kinetic perimetry. Macular morphology was assessed with stereoscopic biomicroscopy and optical coherence tomography (OCT). The main outcome measures were macular function as determined by BCVA, presence of visual field defects, and metamorphopsia as determined by Amsler grid test, macular morphology as determined by slit lamp biomicroscopy, and OCT.

RESULTS

BCVA improved in 28 patients, remained unchanged in eight patients, and decreased in three patients. Improvement of BCVA was statistically significant in both groups (p = 0.003). Mean BCVA in patients operated with ICG improved from 0.33 preoperatively to 0.53 postoperatively. Mean BCVA in patients operated without ICG improved from 0.32 preoperatively to 0.54 postoperatively. Reduction of macular oedema as measured by OCT was statistically significant in both groups (p<0.01). There was no statistically significant difference in postoperative BCVA, macular oedema as measured by OCT, postoperative Amsler grid test, and subjective improvement between the two groups. The incidence of residual or recurrent epiretinal membrane was greater in the group operated without ICG (p = 0.014). Visual field defects were detected in one patient operated with ICG and in three patients operated without ICG.

CONCLUSIONS

Removal of epiretinal tissue with or without assistance of ICG improved visual function and reduced macular oedema in most patients. Adverse effects clearly attributable to the use of ICG were not observed but further investigation is warranted.

Intérêt de la microscopie confocale in vitro dans l’étude des membranes épirétiniennes et des membranes limitantes internes après chirurgie maculaire

PURPOSE

To study specimens obtained from epiretinal membrane (ERM) and macular hole surgery with confocal microscopy and to evaluate its advantages in understanding their pathophysiology.

MATERIAL AND METHODS

This retrospective study included 50 patients undergoing surgery for epiretinal membrane (40 patients) or idiopathic macular hole (10 patients). Infracyanine green was used in 45 cases. Immunohistological examination of the excised tissues was undertaken using confocal microscopy after labeling with antibodies to glial fibrillary acidic protein (GFAP) and vimentin.

RESULTS

Confocal microscopic analysis of epiretinal membranes identified three types of tissues: 13 ERMs, which appeared thick and rich in cells, 20 internal limiting membranes (ILMs), which appeared thin, wrinkled and poor in cells, and seven composite tissues, where ERM and ILM were removed at the same time. The analysis of ten specimens obtained from macular hole surgery revealed nine ILMs and one composite tissue that were quite similar to those removed in epiretinal membrane surgery. In all, 27 specimens (10 ERMs, 12 ILMs and five composite tissues) contained GFAP-positive glial cells.

CONCLUSION

The confocal microscope provided a fast, three-dimensional analysis of ERMs and ILMs. An immunohistological study identified cells that take part in the genesis of the membranes. Glial cells were found both in ERM and ILM specimens. Our findings suggest that Müller's cells may contribute to the pathogenesis of ERM and macular hole development.

Prevalence and risk factors for epiretinal membranes in a Japanese population: the Hisayama study

PURPOSE

To examine the prevalence and risk factors for epiretinal membranes (ERMs) in a sample Japanese population.

METHODS

In 1998 a cross-sectional community survey was conducted among residents of Hisayama. A total of 688 men and 1087 women living in Hisayama, Japan, aged 40 years or older consented to participate in the study. Each participant underwent a comprehensive physical examination that included an ophthalmic examination. The presence of ERMs was judged from grading based on fundus examination using indirect ophthalmoscopy, slit lamp examination, and color fundus photographs. This study used non-stereoscopic 45 degrees fundus photographs to grade ERMs, whereas the other population-based studies used 30 degrees stereoscopic fundus photographs, which might explain some differences in prevalence of ERMs. Multiple logistic regression analysis was performed on the cross-sectional data to determine the risk factors for ERMs. The following ten possible risk factors were used: age; gender; hypertension; diabetes; serum cholesterol; serum HDL cholesterol; serum triglycerides; smoking habits; alcohol intake; and body mass index.

RESULTS

The prevalence of ERMs was 4.0%, and increased with age. The ERMs were more prevalent in women (4.3%) than in men (3.5%). Multiple logistic regression analysis showed that age and serum cholesterol significantly associated with ERMs.

CONCLUSIONS

This study suggests that ERMs are less common in the Japanese population than in similar populations in Western countries, and that hypercholesterolemia is a relevant risk factor for ERMs.

The effect of indocyanine-green on functional outcome of macular pucker surgery

PURPOSE

To compare functional results after surgery for macular pucker either with or without indocyanine-green staining of the internal limiting membrane (ILM) and to evaluate the ultrastructure of the tissue removed.

DESIGN

Retrospective analysis of two successive, consecutive, interventional case series.

METHODS

Functional outcome (visual acuity, Goldmann perimetry) of 48 eyes of 48 consecutive patients with (group 1, n = 20) or without (group 2, n = 28) intraoperative use of indocyanine-green (ICG) was retrospectively analyzed. For statistical analysis, best-corrected visual acuity measured at the last presentation was considered. Only patients with an idiopathic macular pucker were included. Surgery consisted of three-port pars plana vitrectomy, and removal of epiretinal tissue and the ILM in a second step. Commercially available ICG with a concentration of.05% and an osmolarity of 275 mOsm was used to stain the ILM. The surgical technique used for both groups was identical, except the use of ICG. Epiretinal tissue of all eyes was harvested and prepared for ultrastructural analysis using light and electron microscopy.

RESULTS

Follow-up time was 8.5 months in group 1 and 5.4 months in group 2. Whereas patients operated on without ICG experienced a significant improvement of median best-corrected visual acuity from 20/63 (range, 20/400 to 20/32) preoperatively to 20/40 (range, 20/200 to 20/25) postoperatively (P < .001), median best-corrected visual acuity remained 20/63 before (range, 20/200 to 20/63) and after (range, 20/400 to 20/20) (P > .9) ICG-assisted peeling. There was a statistically significant difference (P = .013) in best-corrected postoperative visual acuity of patients with and without the use of ICG. An improvement of vision was noted in 86% of patients without and 55% of patients with ICG-assisted surgery. Thirty-five percent of patients after ICG application presented with a deterioration of visual acuity. Furthermore, we observed large visual field defects in 7 of 20 patients after ILM staining. No visual field defects were noted after conventional peeling. Histologic analysis revealed clear differences between the two groups concerning the amount of cellular elements adjacent to the retinal surface of the ILM: There was more cellular debris visible in specimens after ICG application during surgery. Additionally, in contrast to surgery without ILM staining, epiretinal cells had ruptured and lost their cellular integrity after ICG-assisted vitrectomy.

CONCLUSIONS

Indocyanine green-assisted surgery for macular pucker might have an adverse effect on functional outcome. Although there were obvious differences in the ultrastructure of tissue removed during surgery, our observations cannot be explained by histologic analysis alone. Other, so far unknown mechanisms of action must be considered.

Five-year cumulative incidence and progression of epiretinal membranes: the Blue Mountains Eye Study

PURPOSE

To describe the 5-year cumulative incidence and change in epiretinal membranes in a defined older Australian population.

DESIGN

Population-based cohort study.

PARTICIPANTS

Three thousand six hundred fifty-four persons 49 years of age or older, living in the Blue Mountains area, west of Sydney, Australia, participated in the baseline survey during 1992 to 1994. The cohort was reexamined after 5 years in 1997 to 1999. Excluding persons (543) who died since the baseline, 75% of survivors (n = 2335) attended the follow-up examination.

METHODS

All participants underwent a detailed eye examination, including stereo retinal photography. Epiretinal membranes were diagnosed from grading of baseline and 5-year retinal photographs.

MAIN OUTCOME MEASURES

Epiretinal membranes were classified as either preretinal macular fibrosis (PMF), with retinal folds, or as a less severe form, termed cellophane macular reflex (CMR), without retinal folds. The incidence of epiretinal membranes was determined if either lesion was found in eyes with no preexisting epiretinal membrane at baseline. Progression was defined if the area of involvement increased by more than 25%, regression if it decreased by more than 25%, and stable if it changed by less than 25%.

RESULTS

Epiretinal membranes developed in the first eye of 108 of 2030 participants who had no sign of this condition in either eye at baseline, 5.3%, 95% confidence interval (CI) 4.4 to 6.4. Five-year cumulative incidence rates for PMF and CMR were 1.5% and 3.8%, respectively. Of those participants with epiretinal membranes in one eye at baseline, 18 of 133 (13.5%) developed this sign in their second eye after 5 years. New epiretinal membranes (mostly CMR) occurred in 15 of 165 subjects (9.1%; CI, 5.2-14.6) who had undergone cataract surgery since the Blue Mountains Eye Study I. This rate was significantly higher than in the nonsurgical group, 92 of 1861 (4.9%; CI, 4.0-6.0) of whom developed epiretinal membranes. Progression from CMR to PMF was observed in 17 of 183 eyes (9.3%). Existing epiretinal membranes progressed, regressed, or remained stable in 28.6%, 25.7%, and 38.8% of eyes, respectively.

CONCLUSIONS

This study has documented the 5-year cumulative incidence and the natural history of epiretinal membranes in an older population.

Macular holes: classification, epidemiology, natural history and treatment

BACKGROUND

Macular hole is a retinal disease primarily affecting elderly women. Its overall prevalence in the Danish population is estimated to be 0.14%. The majority of cases are unilateral. The fully developed macular hole evolves through a series of stages starting with an impending hole. About half of impending macular holes regress spontaneously. The remaining half progress to full thickness macular holes. In a patient with a macular hole in one eye, the risk of development of a macular hole in the fellow eye is less than 2% if posterior vitreous detachment is present. If the posterior vitreous is attached, the risk is approximately 15%. If an impending hole is found in the other eye, the risk rises to 50%.

TREATMENT AND OUTCOMES

Macular hole surgery is able to close full thickness macular holes in approximately 90% of cases. Visual acuity of 20/50 or better can be obtained in approximately half of patients with recent onset of symptoms. Complications include retinal detachment, endophthalmitis, late reopening of an initially successfully closed hole and retinal pigment epithelial abnormalities. Retinal detachment should be expected in less than 5% of cases.

Epiretinal membranes after extracapsular cataract surgery

PURPOSE

To determine whether uneventful extracapsular cataract extraction (ECCE) with posterior chamber intraocular lens (PC IOL) implantation induces epiretinal membranes (ERMs).

SETTING

Private practice, with statistical evaluation at a university department in Germany.

METHODS

This prospective study comprised 296 consecutive patients (332 eyes) who had uneventful ECCE with PC IOL implantation for senile cataract. Eyes were examined within 2 weeks preoperatively and 2 weeks and 6, 9, and 12 months postoperatively. The macula was examined with a 78.0 diopter Volk lens. The main outcome measure was the presence of ERM. The membranes were classified as present when cellophane macular reflex (CMR) or macular pucker (MP) was observed.

RESULTS

The median age of the patients was 78 years (range 50 to 97 years). At baseline, ERM was present in 49 of 332 eyes (14.8%), 40 (12.1%) with CMR and 9 (2.7%) with MP. Six months postoperatively, ERM was present in 84 of 332 eyes (25.3%), 72 (21.7%) with CMR and 12 (3.6%) with MP. The difference between the baseline and 6 month incidence was significant (P <.001). All new cases of ERM were of the CMR type. One year after surgery, ERM was present in 54 of 198 eyes (27.3%), 47 (23.7%) with CMR and 7 (3.5%) with MP. The ERMs rarely influenced visual acuity; however, 6 of 12 eyes (50.0%) with MP and 13 of 72 (18.1%) with CMR had metamorphopsia.

CONCLUSIONS

The prevalence of ERM increased by 71.4% during the first 6 months after uneventful ECCE with PC IOL implantation. Thereafter, the prevalence remained about the same. Newly formed ERMs were probably induced by the uneventful surgery. Although new-onset membranes usually do not preclude good visual acuity, they can cause metamorphopsia postoperatively.

Perifoveal microcirculation in eyes with epiretinal membranes

BACKGROUND/AIMS

Eyes with epiretinal membranes (ERMs) often have alterations of retinal vessels. The authors studied perifoveal microcirculation in eyes with epiretinal membranes (ERMs) using scanning laser ophthalmoscope (SLO) fluorescein angiography.

METHODS

Mean capillary blood flow velocity (CFV) was measured as an index of perifoveal microcirculation by SLO fluorescein angiography in 26 eyes with ERMs (19 eyes with idiopathic epiretinal membranes, seven eyes with epiretinal membranes after retinal detachment surgery) before and 6 months after vitreous surgery, and in 23 healthy control subjects.

RESULTS

The mean CFV was significantly reduced in eyes with ERMs compared with healthy controls (p=0.012), and the postoperative mean CFV was significantly increased compared with the preoperative mean CFV (p=0.041).

CONCLUSION

Significant changes of capillary blood flow velocity in the perifoveal areas were observed between normal subjects and eyes with epiretinal membranes. This indicates that eyes with ERMs show abnormal haemodynamics in the perifoveal capillaries.

Ocular complications of pediatric bone marrow transplantation

OBJECTIVE

To investigate the ocular complications in pediatric bone marrow transplantation (BMT) patients.

DESIGN

Cross-sectional study.

PARTICIPANTS

A total of 29 pediatric BMT patients were studied.

TESTING

Comprehensive ophthalmic check-up, including best-corrected visual acuity, intraocular pressure (IOP), Schirmer's test, tear breakup time, and slit-lamp and fundus examinations, was performed.

MAIN OUTCOME MEASURES

Tear film instability and its related complications, IOP, cataract, and fundus lesions were measured.

RESULTS

The mean age of patients was 9.1 years (range, 1.5-15 years). The mean post-BMT duration was 20.2 months (range, 3-54 months). Fifteen patients (51.7%) had tear abnormalities. Subconjunctival fibrosis was detected in two patients (6.9%). Dry and scaly skin of the eyelids was seen in one patient (3.4%). Lens opacities were found in 2 (33.3%) of 6 irradiated patients and 2 (8.7%) of 23 nonirradiated patients. Two patients (6.9%) had fundus changes, one with unilateral epiretinal membrane and the other with bilateral multiple discrete chorioretinal hypopigmented lesions in the middle to peripheral part of the retina. The overall complication rates for the anterior and posterior segments were 75.8% and 6.9%, respectively.

CONCLUSION

Ocular manifestations of BMT in children are not uncommon. The most common anterior segment problem is tear dysfunction. Posterior segment complications are less common but do exist. High rate of cataract formation is reported, and this probably is the most important long-term "amblyogenic" problem in these immature eyes. Awareness and management of these problems with routine eye examination and early intervention are recommended.