Retinal adherence and fibrillary surface changes correlate with surgical difficulty of epiretinal membrane removal

Predictive factors for postoperative visual function in eyes with epiretinal membrane

Our current study aimed to investigate the association of preoperative OCT parameters with visual function after vitrectomy surgery in eyes with epiretinal membrane (ERM). This study enrolled 33 eyes with ERM that underwent vitrectomy surgery. In addition to visual acuity (VA), metamorphopsia was measured pre- and postoperatively for each eye. Using the preoperative horizontal and vertical OCT images, SUKIMA (the gap area between the ERM and retinal surface) was measured respectively and the average of horizontal SUKIMA and vertical SUKIMA was used for the analysis. The associations of baseline parameters (age, axial length, preoperative central retinal thickness [CRT], inner nuclear layer [INL] thickness, ectopic inner foveal layer [EIFL] and SUKIMA) with postoperative VA, the change in VA, postoperative metamorphopsia and the improvement in metamorphopsia were investigated using multivariate regression analysis followed by the model selection. The result suggested that age and INL thickness were related to the postoperative VA, whereas age and preoperative CRT were significantly associated with the change in VA. In contrast, only SUKIMA was correlated with the postoperative metamorphopsia, whilst age, EIFL and SUKIMA were associated with the improvement in metamorphopsia. Measuring SUKIMA might be useful for predicting postoperative metamorphopsia and the improvement in metamorphopsia in ERM eyes.

Variability of Visual Recovery with Time in Epiretinal Membrane Surgery: A Predictive Analysis Based on Retinal Layer OCT Thickness Changes

Purpose: To correlate postoperative optical coherence tomography (OCT) thickness changes of each retinal layer with different patterns of visual recovery after idiopathic epiretinal membrane (ERM) surgery in a cohort of patients showing no known risk factors for poor visual recovery at preoperative imaging. Methods: Best corrected visual acuity (BCVA) and OCT images were acquired preoperatively and 1 month, 3 months and 6 months postoperatively. Patients were divided into four groups according to postoperative BCVA improvement: improvement < 15 ETDRS letters (GROUP 1), immediate improvement of BCVA without further improvements at later follow-ups (GROUP 2), immediate improvement of BCVA with further improvements at later follow-ups (GROUP 3) and delayed improvement of BCVA (GROUP 4). Results: Eighty-five patients were included. GROUP1 was the only one characterized by retinal nerve fiber layer (RNFL) thickness increase and ganglion cell layer/central macular thickness (GCL/CMT) ratio decrease at 1 month and outer nuclear layer (ONL) thickness decrease at 3 and 6 months. GROUP 2 was the only one showing a decrease in GCL/inner plexiform layer (GCL/IPL) ratio at 1 month. GROUP 3 and 4 showed higher preoperative RNFL thickness compared to the other, and GROUP 4 manifested a late increase in RNFL thickness at 6 months. Conclusions: Different patterns of VA recovery are associated with specific layer thickness changes. If further confirmed, this would help detect those cases characterized by poor or delayed visual recovery despite the absence of other known imaging risk factors.

NEW ARTIFICIAL INTELLIGENCE ANALYSIS FOR PREDICTION OF LONG-TERM VISUAL IMPROVEMENT AFTER EPIRETINAL MEMBRANE SURGERY

PURPOSE

To predict improvement of best-corrected visual acuity (BCVA) 1 year after pars plana vitrectomy for epiretinal membrane (ERM) using artificial intelligence methods on optical coherence tomography B-scan images.

METHODS

Four hundred and eleven (411) patients with Stage II ERM were divided in a group improvement (IM) (≥15 ETDRS letters of VA recovery) and a group no improvement (N-IM) (<15 letters) according to 1-year VA improvement after 25-G pars plana vitrectomy with internal limiting membrane peeling. Primary outcome was the creation of a deep learning classifier (DLC) based on optical coherence tomography B-scan images for prediction. Secondary outcome was assessment of the influence of various clinical and imaging predictors on BCVA improvement. Inception-ResNet-V2 was trained using standard augmentation techniques. Testing was performed on an external data set. For secondary outcome, B-scan acquisitions were analyzed by graders both before and after fibrillary change processing enhancement.

RESULTS

The overall performance of the DLC showed a sensitivity of 87.3% and a specificity of 86.2%. Regression analysis showed a difference in preoperative images prevalence of ectopic inner foveal layer, foveal detachment, ellipsoid zone interruption, cotton wool sign, unprocessed fibrillary changes (odds ratio = 2.75 [confidence interval: 2.49-2.96]), and processed fibrillary changes (odds ratio = 5.42 [confidence interval: 4.81-6.08]), whereas preoperative BCVA and central macular thickness did not differ between groups.

CONCLUSION

The DLC showed high performances in predicting 1-year visual outcome in ERM surgery patients. Fibrillary changes should also be considered as relevant predictors.

Visual, Anatomic Outcomes, and Natural History of Retinal Nerve Fiber Layer Schisis in Patients Undergoing Epiretinal Membrane Surgery

PURPOSE

To evaluate the anatomic and visual outcomes of patients with idiopathic epiretinal membranes (ERMs) complicated by schisis of the retinal nerve fiber layer (sRNFL) in routine clinical practice.

DESIGN

Retrospective case-control study.

PARTICIPANTS

Patients undergoing idiopathic ERM surgery at Cole Eye Institute from 2013 to 2021.

METHODS

Patients were grouped by the presence or absence of sRNFL before surgery. Preoperative and postoperative data were collected regarding visual acuity (VA), changes in central subfield thickness (CST) over time, and presence of cystoid macular edema.

MAIN OUTCOME MEASURES

Frequency of sRNFL in patients undergoing idiopathic ERM surgery.

RESULTS

Overall, 48 (53.9%) of 89 patients presented with sRNFL. Schisis of the retinal nerve fiber layer patients presented with significantly decreased VA compared with those without (58.63 ± 12.48 vs. 67.68 ± 7.84 ETDRS letters, P < 0.001, respectively). At the final follow-up after ERM removal, there was no significant difference in final VA in patients with sRNFL compared with those without (71.16 ± 2.93 vs. 74.11 ± 2.76, P = 0.467). At presentation, patients with sRNFL had greater CST than those without (454 ± 10.01 vs. 436 ± 0.23, P = 0.23). This difference persisted at the 90-day follow-up after ERM removal (402 ± 8.08 vs. 375 ± 10.19 μm, P = 0.043). The resolution of sRNFL was reported at postoperative week 1 in 30 (96.7%) of 31 cases.

CONCLUSIONS

Schisis of the retinal nerve fiber layer is a microstructural feature in > 50% of idiopathic ERMs in routine clinical practice and carries visual significance on presentation and anatomic significance postoperatively.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Tight adherent feature on optical coherence tomography predict postoperative visual outcome in epiretinal membrane eyes

Background

To identify the predictive parameter among preoperative measurements that best predicts postoperative visual outcome in the epiretinal membrane (ERM).

Methods

Thirty-three consecutive patients with idiopathic unilateral ERM patients between 2015 and 2018 were enrolled. Nineteen healthy normal eyes were selected as an independent age-matched group. Based on preoperative optical coherence tomography (OCT), we further divided the patients with ERM into two groups: type 1, loosely attached ERM, and type 2, tight adherent ERM. We documented the vision and thickness of various retinal layers: nerve fiber layer, ganglion cell layer, inner plexiform layer (GCL + IPL), inner nuclear layer (INL), outer retinal layer (ORL), and retinal pigment epithelium/Bruch complex layer before and after the surgery. The association between postoperative visual acuity and these variables was analyzed using multiple linear regression analysis.

Results

All retinal layers of ERM eyes were thicker than the normal eyes (P < 0.05). Among ERMs, we identified 11 eyes with type 1 adhesions and 22 eyes with type 2 adhesions. The preoperative GCL + IPL layers were significantly thicker in type 2 patients than in type 1 patients (93.67 ± 33.03 um vs 167.71 ± 13.77 um; P = 0.023). Greater GCL + IPL thickness was correlated with a worse postoperative visual acuity and multiple linear regression analysis showed that GCL + IPL thickness was an independent predictor of postoperative visual acuity (VA) (beta value = 0.689; P = 0.012). A greater thickness of GCL + IPL layers of type 2 patients had worse postoperative best-corrected visual acuity (BCVA) (P = 0.028). Ectopic inner foveal layers with disappearance of fovea pit were persistently presented in OCT profiles of both groups.

Conclusion

Idiopathic ERM demonstrated significantly thicker inner retinal layers (GCL + IPL and INL). However, the ORL thickness was similar between the normal eyes and ERM eyes. The preoperative GCL + IPL layers were significantly thicker in patients with type 2 ERM than that in patients with type 1 ERM. The increase in GCL + IPL thickness was significantly correlated with worse postoperative visual outcomes.

Clinical and morphological characteristics of patients with idiopathic epiretinal membrane with foveal herniation

PURPOSE

To analyse the clinical and morphological characteristics of eyes with idiopathic epiretinal membrane (iERM) and foveal herniation (FH).

METHODS

Clinical findings and OCT features of patients with iERM and FH were retrospectively analysed. Primary outcome were changes of the best-corrected-visual-acuity (BCVA) and OCT features from baseline to the last visit. FH patients were divided into two groups based on herniated layers: ganglion cell complex (GCC)-group and sub-GCC-group. Surgical outcome was also assessed.

RESULTS

In this study, 3882 patients with iERM were screened, of whom 51 (1.3%) were identified with FH. The GCC-group (n = 16) had a better baseline BCVA and thinner central foveal thickness (CFT) in comparison to the sub-GCC-group (n = 35) but without statistical significance (p = 0.330, p = 0.417, respectively). The postoperative BCVA-improvement was similar between the two groups (p = 0.280). Fibrillary surface changes were detected in 42/51 (82.3%) patients, significantly more often in the sub-GCC group (p = 0.020). The baseline BCVA was a predictive factor for the postoperative vision change.

CONCLUSION

FH presents with a unique macular morphology in eyes with iERM. Affected eyes experience varying visual disturbances based on the involvement of the inner retinal layers in the foveal herniation. Macular surgery is successful in restoring vision, even though foveal morphology does not fully recover.

Structure-function analysis for macular surgery in patients with coexisting glaucoma

PURPOSE

To develop methods to assess the effects of epiretinal membranes (ERM) and macular holes (MH) coexisting with glaucoma on pre-operative retinal structure and function and evaluate post-operative outcomes.

METHODS

Seven eyes of 7 patients with glaucoma, 6 with ERMs and 1 with MH, were enrolled; 4 underwent vitrectomy for ERM and one for MH. Visual fields (VFs) and optical coherence tomography (OCT) scans were obtained pre- and post-operatively. The 10-2VF deviation map was overlayed on ganglion cell and inner plexiform layer (GCL + IPL) and retinal nerve fiber layer (RNFL) deviation maps derived from OCT macula and disc cube scans. Optic nerve circle scans were obtained to assess RNFL thickness, and OCT b-scans associated with VF defects were compared pre- and post-operatively.

RESULTS

Examination of pre-operative VFs and OCT scans showed the importance of determining the extent to which glaucomatous damage contributed to VF loss; verifying automated segmentation of the GCL + IPL and RNFL; and assessing foveal anatomy. Evaluation of post-operative structure-function outcomes required correction of magnification changes in OCT scans and repeated follow-up visits to clarify the origin of VF changes.

CONCLUSIONS

Pre-operative comparisons of VFs and OCT scans may be beneficial in guiding surgical planning, and evaluating outcomes, in eyes with glaucoma undergoing macular surgery.

Preoperative imaging optimized for epiretinal membrane surgery

Background

To compare imaging modalities for visualizing primary epiretinal membrane (ERM) with each other and with intraoperative digital images (IDI) after blue staining.

Methods

The records of consecutive patients operated for primary ERM over a 12-month period were retrospectively reviewed. Preoperative imaging included color fundus photography (CFP), En Face spectral-domain optical coherence tomography (OCT), 45° infrared- (IR) and blue-reflectance (BR) scanning laser ophthalmoscopy. All images were qualitatively analyzed and scored from 0–4 according to the ability to visualize ERM details (0 = no visible ERM or vessel contraction, 1 = vessel contraction, 2 = retinal folds, 3 = ERM limits, 4 = elevated ERM edge). The preoperative ERM morphology was then compared to that seen on the IDI acquired after 1-min blue dye staining when available.

Results

Seventy eyes were included. The highest score for ERM visualization was obtained on BR and En Face OCT. A score of 3 or 4 was obtained in 68.5%, 62.1%, 17.9% and 13.6% of cases on En Face OCT, BR, CFP and IR images, respectively. IDI were available for 20 eyes, and showed a similar ERM morphology compared to preoperative images in most cases: a negative staining pattern corresponded to a plaque on En face OCT in 91% of eyes. However, IDI failed to show the ERM edges in 37.5% of cases.

Conclusion

ERM morphology was better visualized preoperatively by BR and En Face OCT, in a similar way to the IDI after staining. Future intraoperative visualization systems could integrate both imaging modalities overlaid with the IDI for guiding ERM removal instead of staining.

Long-Term Outcome of Epiretinal Membrane Surgery in Patients with Internal Limiting Membrane Dehiscence

PURPOSE

To identify the effect of internal limiting membrane (ILM) dehiscence on surgical outcomes in eyes that have undergone epiretinal membrane (ERM) removal.

METHODS

Consecutive eyes with performed vitrectomy for ERM removal were included. Subjects were divided into two groups: patients with ILM dehiscence (group 1) and without ILM dehiscence (group 2). The best-corrected visual acuity (BCVA) and retinal layer thickness before and after surgery were compared between the two groups.

RESULTS

A total of 86 eyes were enrolled. Forty-six eyes (53.5%) showed ILM dehiscence before surgery. The baseline BCVAs were 0.46 ± 0.29 and 0.45 ± 0.25 in groups 1 and 2, respectively (p = 0.801). The BCVAs at 3, 6, and 12 months after surgery differed significantly between the two groups. The subfoveal thickness and inner retinal layer thickness (IRLT) of group 1 vs. 2 were 507.4 ± 80.0 vs. 417.6 ± 63.6 μm, and 270.2 ± 74.3 vs. 182.6 ± 60.4 μm, respectively (both p < 0.001). These differences between the groups remained significant until 12 months after surgery. In multivariate analyses, the location of ILM dehiscence (B = -0.105, p = 0.034) and final IRLT (B = 0.001, p = 0.046) were significant factors affecting the final BCVA.

CONCLUSIONS

ILM dehiscence is a relatively common finding and associated with preoperative and postoperative increased IRLT, which results in worse surgical outcomes compared to the absence of ILM dehiscence in patients with ERM. Additionally, the final BCVA was significantly affected by its location and final IRLT in patients with ILM dehiscence.

Bare retinal nerve fiber layer and internal limiting membrane tear associated with epiretinal membrane: OCT findings and visual outcomes

PURPOSE

This study aims to describe spectral-domain optical coherence tomography (OCT) characteristics and assess surgical outcomes for bare retinal nerve fiber layer (RNFL) and internal limiting membrane (ILM) tear associated with the epiretinal membrane (ERM).

METHODS

This retrospective study comprised 158 consecutive patients with idiopathic ERM with (group A) or without (group B) bare RNFL (19 and 139 patients, respectively) who underwent vitrectomy between March 2016 and May 2019. Surgical videos and pre- and postoperative OCT images were reviewed to characterize bare RNFL and ILM tear and analyze postoperative visual outcomes.

RESULTS

Typically, the torn ILM is seen as a mono- or multi-layered thin scrolled membrane in OCT, correlated frequently with areas of RNFL schisis. On the near-infrared fundus images, a hypo-reflective band corresponding to rolled-up edge of torn ILM and ERM was identified. The bare RNFL area was located adjacent to and peripheral to this band and showed a less-wrinkled retina preoperatively. Mean logMAR BCVA and central foveal thickness (CFT) progressively improved in both groups. However, group A had greater mean CFT change than group B (P = 0.001).

CONCLUSION

Typical appearances of bare RNFL and ILM tear associated with ERM were identified. Thorough evaluation of preoperative OCT is important for vitreoretinal surgeons to recognize bare RNFL and ILM tear to minimize surgical trauma.

Are There Funduscopic and Optical Coherence Tomography Preoperative Characteristics to Predict Surgical Difficulty of Epiretinal Membrane Removal?

PURPOSE

To identify the correlation between preoperative funduscopic and optical coherence tomography characteristics of epiretinal membranes and the difficulty of surgical removal.

METHODS

Fifty eyes of 50 patients with an idiopathic epiretinal membrane (ERM) scheduled for pars plana vitrectomy (PPV) and ERM peeling were included. Surgical videos were analyzed and the difficulty of ERM removal (easy or difficult) determined subjectively by an independent surgeon. Furthermore, the peeling time and amount of grasping were measured on the videos to provide an objective factor of surgery difficulty. Preoperative spectral-domain optical coherence tomography (OCT) images and color fundus photos were analyzed to identify predictive factors for membrane removal difficulty.

RESULTS

The subjective surgical difficulty of ERM removal was strongly associated with fibrillary changes between the ERM and retinal nerve fiber layer (RNFL), severe retinal vascular tortuosity and severe glinting fundus reflex. Higher fundus pigmentation was associated with fewer and cystoid spaces with more attempts of grasping ERM. No other preoperative signs were found to be associated with the duration of the peeling time.

CONCLUSION

The presence of fibrillary changes between the ERM and RNFL, severe retinal vascular tortuosity and severe glinting reflex are preoperative findings that have a strong association with the difficulty in ERM peeling.

Schisis of the Retinal Nerve Fiber Layer in Epiretinal Membranes

PURPOSE

To describe schisis of the retinal nerve fiber layer (sRNFL) associated with epiretinal membranes (ERMs) seen on spectral-domain optical coherence tomography (OCT) prior to vitreoretinal surgery. Areas of sRNFL (size and location) were noted during preoperative planning. Spectral-domain OCT scans were obtained to study the inner retinal morphology postoperatively.

DESIGN

Retrospective observational consecutive case series.

METHODS

Pre- and postoperative spectral-domain OCT and en face images of 41 eyes with ERMs that had undergone vitrectomy by a single surgeon were analyzed to record the presence of sRNFL. The extent of sRNFL was classified as focal or diffuse. Other characteristics such as involvement of the papillomacular bundle and areas of fibrillary protrusion of sRNFL above the internal limiting membrane (ILM) were documented. Color fundus photographs were reviewed to correlate with the spectral-domain OCT images.

RESULTS

Mean patient age and length of follow-up were 69.3 years (range 52-82 years) and 6.8 months (range 0.25-21 months), respectively. Mean preoperative and postoperative central thicknesses were 477 μm and 387 μm, respectively (P < .0001). sRNFL was observed in 51.2% (21/41 eyes), and was classified as diffuse (>1 disc diameter) in 90.5% (19/21 eyes). Protrusion of sRNFL through the ILM was present in 76.2% (16/21 eyes) and occurred in areas of dehiscence of the adjacent ILM. sRNFL was best visualized on spectral-domain OCT and en face imaging at the vitreoretinal interface and sometimes correlated with areas of retinal whitening. sRNFL resolved in all cases postoperatively.

CONCLUSIONS

sRNFL was a relatively common occurrence in ERMs, correlated frequently with areas of dehisced ILM intraoperatively, and resolved postoperatively in all cases.

Comparison between support vector machine and deep learning, machine-learning technologies for detecting epiretinal membrane using 3D-OCT

PURPOSE

In this study, we compared deep learning (DL) with support vector machine (SVM), both of which use three-dimensional optical coherence tomography (3D-OCT) images for detecting epiretinal membrane (ERM).

METHODS

In total, 529 3D-OCT images from the Tsukazaki hospital ophthalmology database (184 non-ERM subjects and 205 ERM patients) were assessed; 80% of the images were divided for training, and 20% for test as follows: 423 training (non-ERM 245, ERM 178) and 106 test (non-ERM 59, ERM 47) images. Using the 423 training images, a model was created with deep convolutional neural network and SVM, and the test data were evaluated.

RESULTS

The DL model's sensitivity was 97.6% [95% confidence interval (CI), 87.7-99.9%] and specificity was 98.0% (95% CI, 89.7-99.9%), and the area under the curve (AUC) was 0.993 (95% CI, 0.993-0.994). In contrast, the SVM model's sensitivity was 97.6% (95% CI, 87.7-99.9%), specificity was 94.2% (95% CI, 84.0-98.7%), and AUC was 0.988 (95% CI, 0.987-0.988).

CONCLUSION

DL model is better than SVM model in detecting ERM by using 3D-OCT images.

CHARACTERISTICS OF EPIRETINAL MEMBRANE REMNANT EDGE BY OPTICAL COHERENCE TOMOGRAPHY AFTER PARS PLANA VITRECTOMY

PURPOSE

To evaluate the incidence, characteristics, and the progression of epiretinal membrane (ERM) remnant edge seen by optical coherence tomography after ERM peeling.

METHODS

A retrospective chart review was conducted for 86 eyes of 85 consecutive patients who were diagnosed with ERM and underwent pars plana vitrectomy for epiretinal membrane peeling between 2013 and 2014. Data collected and analyzed included age, gender, preoperative and postoperative visual acuity, use of indocyanine green dye to stain internal limiting membrane, tamponade used after vitrectomy, ERM edge boundaries, presence of cystoid macular edema, and central foveal thickness.

RESULTS

An ERM remnant edge was detected in 33/86 study eyes (38.4%) at the first postoperative optical coherence tomography scan. Compared with those without an ERM remnant, patients with an ERM remnant after surgery were significantly older at baseline and had a higher incidence of ERM recurrence at their last visit. They were not significantly different in terms of gender, preoperative and postoperative visual acuity, reduction of central foveal thickness from baseline, proportion of eyes with preoperative ERM elevation on optical coherence tomography, presence of macular edema before surgery, intraoperative use of indocyanine green staining for ILM peeling, or tamponade used. Based on the edge morphology, we classified the ERM remnant into three types: Type 1 was flat and blended with the retina (14/33 eyes, 42.4%), Type 2 was flat but stepped (17/33 eyes, 51.5%), and Type 3 was elevated (2/33 eyes, 6.0%). A significantly higher risk of ERM recurrence was seen in Type 2 and Type 3 ERM remnants (75% and 100%, respectively) than Type 1 ERM remnants (10%).

CONCLUSION

An ERM remnant edge was detected by optical coherence tomography after ERM peeling in 38.4% of eyes. The presence of a postoperative ERM edge was associated with a higher risk of ERM recurrence, particularly in Type 2 and Type 3 ERM remnants.

IDENTIFICATION OF FACTORS RELATED TO SUBFOVEAL DETACHMENT SECONDARY TO EPIRETINAL MEMBRANE

PURPOSE

To demonstrate factors related to the presence of subfoveal detachment (SD) secondary to epiretinal membrane (ERM) and to characterize the predictors for the resolution of SD after membrane peeling.

METHODS

A retrospective chart review was conducted for the patients who underwent pars plana vitrectomy for the idiopathic ERM peeling. Preoperative spectral domain optical coherence tomography characteristics of the eyes including central foveal thickness, foveal center point thickness, presence of intraretinal cyst, continuity of the membrane, area of the membrane within fovea (1 mm), and entire macula (6 mm) were evaluated to find the best predictors for the presence of SD. These predictors as well as perioperative parameters including use of internal tamponade and volume of SD were considered for time of resolution of SD.

RESULTS

Of 158 included eyes, 20.2% eyes (32 eyes) had SD, and the presence of SD was significantly related to involvement of the membrane within the macula. After surgery, SD completely resolved in 90.6% of eyes (29 eyes) at a median of 2.97 months (range: 0.03-12.0 months). The area of the membrane within fovea was the only significant predictor for time to resolution of SD (hazard ratio = 1.20, 95% confidence interval = 1.100-1.324, P = 0.021). A small percent of eyes showed some further changes including fluctuation (6.2%) or persistence (3.1%) of fluid.

CONCLUSION

A larger extension of ERM over the macula is related to higher likelihood of the presence of SD. Time for resolution of subfoveal detachment does not seem to be affected by the preoperative and perioperative factors except the extent of membrane within 1,000 μm of the fovea.

Morphologic and Postoperative Fixation Characteristics of the Macular Epiretinal Membrane in Young Patients Undergoing Surgery

BACKGROUND AND OBJECTIVE

To describe morphologic characteristics, surgical outcomes, postoperative preferred retinal loci (PRL), and fixation stability of epiretinal membranes (ERMs) in young patients.

PATIENTS AND METHODS

This retrospective study analyzed 43 eyes of 41 young patients (age range: 0.8 years to 28 years) with ERMs, which were divided into two groups: secondary ERMs (SERMs; n = 28) and idiopathic ERMs (IERMs; n = 13). All 43 eyes underwent 25-gauge vitrectomy and membrane peeling. Spectral-domain optical coherence tomography scans and microperimetry were used to analyze morphologic and fixation characteristics, respectively.

RESULTS

Premacular fibrosis was more common in SERMs group (P = .006). SERMs were also associated with less external limiting membrane (ELM) (P = .008) and ellipsoid zone visibility (P = .008) compared with IERMs. Best-corrected visual acuity (BCVA) improved in 20 eyes (69%) with SERMs (P = .005) and in 12 eyes (86%) with IERMs (P = .13). From the analysis of the postoperative fixation characteristics, there was a linear correlation between visual acuity and fixation stability (R² = 0.495).

CONCLUSION

BCVA improved significantly in young patients with ERM, even in cases with a severely disrupted ELM and ellipsoid zone. More attention should be paid to the postoperative fixation location and stability. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:655-662.].

EPIRETINAL MEMBRANE IN NONEXUDATIVE AGE-RELATED MACULAR DEGENERATION: Anatomical Features, Visual Outcomes and Prognostic Factors

PURPOSE

To evaluate clinical characteristics, assess surgical outcomes, and determine prognostic factors after vitrectomy for epiretinal membrane (ERM) associated with nonexudative age-related macular degeneration (AMD).

METHODS

This study comprised 171 consecutive patients with idiopathic ERM (n = 132) or nonexudative AMD-associated ERM (AMD-ERM, n = 39) undergoing vitrectomy. Preoperative morphologic characteristics on spectral-domain optical coherence tomography images and postoperative outcomes of the two groups were compared. Factors influencing postoperative best-corrected visual acuity in the AMD-ERM group were also analyzed.

RESULTS

The AMD-ERM group was more likely to have an ERM with a smooth appearance (P = 0.009), a less severe vessel traction score (P = 0.002), a thinner central foveal thickness (P = 0.016), and more photoreceptor disruption than idiopathic ERM group. Mean central foveal thickness improved from 404.92 ± 82.08 and 369.87 ± 68.17 μm at baseline to 339.77 ± 39.27 and 331.72 ± 45.76 μm 1 year after surgery in eyes with idiopathic ERM and AMD-ERM, respectively (all P < 0.001). Mean logarithm of the minimum angle of resolution best-corrected visual acuity improved from 0.30 (20/40) ± 0.21 and 0.32 (20/42) ± 0.18 at baseline to 0.02 (20/21) ± 0.09 and 0.13 (20/27) ± 0.17 1 year after surgery in the idiopathic ERM and AMD-ERM groups, respectively (all P < 0.001). Baseline integrity of the ellipsoid zone line (P = 0.009) and preoperative best-corrected visual acuity (P = 0.024) were significantly correlated with visual outcome in the AMD-ERM group.

CONCLUSION

Morphologic differences between AMD-ERM and idiopathic ERM were identified. Vitrectomy resulted in significant anatomical and visual improvements in eyes with AMD-ERM, but final visual outcome was worse in these eyes than in those with idiopathic ERM.

The role of membrane-inner retina adherence in predicting simultaneous internal limiting membrane peeling during idiopathic epiretinal membrane surgery

PurposeTo correlate the frequency and extent of simultaneous inadvertent internal limiting membrane (ILM) peeling during idiopathic epiretinal membrane (ERM) removal with characteristics of ERM adherence demonstrated on pre-operative spectral domain optical coherence tomography (SD-OCT).Patients and methodsThis is a prospective, observational, case series of patients undergoing pars plana vitrectomy for idiopathic ERM. Inner retina-ERM adhesion was categorized as focal, broad or complete in five anatomic locations at macular area based on preoperative SD-OCT findings. The extent of spontaneous ILM peeling was quantified on a scale 0-100% in each of the aforementioned anatomic locations by the operating surgeons who were masked to the OCT characteristics. All operations were recorded with a high definition recording system and the area of simultaneous ILM peel was quantified by a second masked observer. The final extent of spontaneous ILM peel was calculated as the average of the two scores.ResultsThirty consecutive subjects who underwent surgery for idiopathic ERM were included in the study. Evidence of simultaneous ILM peeling was identified in 80.3% of individuals. With regards to the type of ERM-macula adhesion, inadvertent ILM peel was observed in 70% of the patients who pre-operatively showed complete adhesion, in 43% with broad adhesion and in only 21% with focal adhesion (P<0.001). The extent of the spontaneous ILM peel during removal of ERM was also significantly dependent on the type of ERM-inner retina adhesion. Total simultaneous ILM peel was observed in 59% of locations with complete ERM-macula adhesion but only in 22% and 7% of locations with broad and focal adhesion respectively (P<0.001).ConclusionsSimultaneous ILM peel is a frequent occurrence during ERM surgery, especially when there is complete or broad ERM adherence to the macula. The type of ERM-inner retina adhesion represents a valid predictor of the extent of simultaneous ILM peel during removal of ERM. Thorough evaluation of preoperative OCT may be a useful tool in determining a safer, more simplistic strategy in ERM surgery.

[Idiopathic epiretinal membranes: visual function impairment, morphological and functional features of retinal involvement]

By affecting different retinal layers, an idiopathic epiretinal membrane (iERM) produces changes in macular architectonics and functioning. Morphological and functional assessment of these patients using modern visualization methods and electroretinography contributes to a better understanding of pathogenetic mechanisms of iERM.

Determination of a New Parameter, Elevated Epiretinal Membrane, by En Face OCT as a Prognostic Factor for Pars Plana Vitrectomy and Safer Epiretinal Membrane Peeling

Purpose. To evaluate the significance of the area of epiretinal membrane (EM) that is not in contact with the retinal structure as a preoperative parameter for safer grasping of the EM and a prognostic factor for visual improvement/outcome. Methods. This prospective observational study included 73 consecutive patients (80 eyes) who underwent pars plana vitrectomy (PPV) and EM peeling. Corrected distance visual acuity (CDVA) and central foveal thickness (CFT) were evaluated preoperatively and at 12 months postoperatively. The number of initial peeling grasps was recorded in the operation protocol. The elevated EM portion was identified by en face optical coherence tomography (OCT) and processed digitally to calculate its area. Results. Surgery was found to significantly improve CDVA and decrease CFT. CDVA improvement correlated with elevated EM, preoperative CFT, and the number of grasping attempts. Conclusion. The detection of elevated EM via en face OCT could assist safer grasping of the EM and indicate the potential for visual outcome improvement after PPV and EM peeling.

Spectral domain optical coherence tomography characterization of pediatric epiretinal membranes

PURPOSE

To compare the macular morphology of pediatric versus adult eyes with epiretinal membrane (ERM) using spectral domain optical coherence tomography and identify characteristics associated with postoperative visual acuity.

METHODS

This retrospective study analyzed spectral domain optical coherence tomography from pediatric subjects and a randomly selected cohort of adult subjects with ERM. Morphologic retinal and ERM features were graded by two masked spectral domain optical coherence tomography readers and compared with a postoperative change in visual acuity.

RESULTS

Pediatric ERMs (age, 0.3-16.5 years) were more confluently attached to the retina than adult ERMs (age, 40-88 years; P = 0.009) and had less fibrillary appearance of the inner retina when separation was present (P = 0.044). Pediatric ERMs were associated with more vessel dragging (P = 0.019) and less external limiting membrane (P = 0.001) and inner segment band visibility (P = 0.010), with a trend toward foveal sparing by ERM (P = 0.051) and "taco" retinal folds (P = 0.052) compared with adult eyes. Visual acuity improvement was associated with intact (P = 0.048) and smooth (P = 0.055, trend) inner segment band in children and with smooth inner segment band (P = 0.083, trend) and visible external limiting membrane (P = 0.098, trend) in adults.

CONCLUSION

We identified morphologic differences between pediatric and adult ERM on spectral domain optical coherence tomography. Similar to adults, photoreceptor integrity with pediatric ERM seems to predict better visual acuity changes after surgical ERM removal.

Optical coherence tomography in the preoperative and postoperative management of macular hole and epiretinal membrane

Optical coherence tomography (OCT) imaging plays an essential role in the diagnosis and treatment of macular diseases, including those of the vitreomacular interface. OCT enables accurate diagnosis and differentiation of full thickness macular hole, lamellar macular hole and epiretinal membrane, with or without the presence of vitreomacular adhesion. This information enables earlier diagnosis and treatment when necessary, and can guide the choice of therapy. OCT is useful to facilitate discussions with patients and manage the visual expectations. Postoperatively, OCT can be helpful to optimise patient comfort and visual outcomes. As the technology continues to improve, OCT will become increasingly critical for all aspects of care for patients with macular hole and epiretinal membrane.

Spectral-domain optical coherence tomography evaluation of vitreoretinal adhesions in idiopathic epiretinal membranes

BACKGROUND

Vitreoretinal adhesions play a key role in the vector forces exerted on the vitreoretinal interface, leading to tractional retina deformation and macular hole formation. The aim of this study was to identify the presence of vitreopapillary and vitreofoveal adhesions in idiopathic epiretinal membranes (ERMs) with spectral-domain optical coherence tomography (SD-OCT) and to evaluate their influence on the vitreoretinal interface.

METHODS

Sixty-five eyes (65 patients) with idiopathic ERM and 64 healthy eyes (64 patients) underwent SD-OCT analysis. We studied vitreopapillary and vitreofoveal adhesion prevalence in eyes with idiopathic ERM using different SD-OCT patterns ("adherent" or "tractional"). We analyzed their influence on central foveal thickness (CFT), on retinal nerve fiber layer (RNFL) thickness, and on morphological modifications (foveal depression profile and inner/outer photoreceptor junction).

RESULTS

Vitreopapillary adhesion was present in 51.6 % of normal eyes and in 24.6 % of eyes with idiopathic ERM, while vitreofoveal adhesion was found in 14.1 % of normal eyes and in 15.4 % of eyes with ERM. Vitreopapillary adhesion prevalence was significantly higher in the tractional ERM subgroup (p = 0.01), than in the adherent ERM subgroup. Both adhesions had no influence on CFT, RNFL thickness, or inner segment/outer segment junction status.

CONCLUSIONS

Our study suggests that vitreoretinal adhesions may influence the pathogenesis and course of idiopathic ERM. The absence of vitreopapillary adhesion in the adherent type, and its presence in the tractional type, seems to play a key role in ERM characterization.

Association of preoperative optical coherence tomography markers with residual inner limiting membrane in epiretinal membrane peeling

Purpose

To identify preoperative markers on spectral domain optical coherence tomography (SD-OCT) for residual inner limiting membrane (ILM) in epiretinal membrane (ERM) peeling.

Methods

In this retrospective case series the preoperative SD-OCTs from 119 eyes of 119 consecutive patients who underwent surgery for idiopathic ERM by a single surgeon were evaluated for markers predisposing for ILM persistence after ERM removal. ILM persistence was determined via intraoperative indocyanine green staining. The main outcome measures were correlation of central foveal thickness (CFT), ERM thickness, extent of elevated ERM and retinal folding, intraretinal cysts, and discontinuation of the ERM, with ILM persistence after ERM peeling.

Results

The persistence of the ILM was found in 50.4% (n = 60). After Bonferroni correction for multiple testing, a greater extent of elevated ERM and thicker ERMs were associated with persistence of the ILM (p<0.005). The other parameters showed no statistically significant correlations with the persistence of the ILM (p≥0.005).

Conclusion

Residual ILM can be found in nearly half of the eyes after ERM peeling. A loose connection between the ERM and the retinal surface predisposes for ILM persistence. Preoperative SD-OCT is helpful in identifying risk markers for the persistence of the ILM in ERM surgery.