Surgical management of epiretinal membrane in young patients

Clinical features of idiopathic epiretinal membrane in children and the factors influencing postoperative visual acuity

PURPOSE

To describe the characteristics and surgical outcomes of idiopathic epiretinal membrane (iERM) in children and to determine the factors associated with postoperative visual acuity (VA).

METHODS

We retrospectively reviewed the medical records of 17 patients with iERM (age, < 18 years) who had undergone ERM surgery from 2009 to 2021. Spectral-domain optical coherence tomography features were documented. The eyes with iERMs involving the fovea were assigned to the localized and diffused groups depending on the morphological description of the membrane. Multiple linear regression analysis was used to explore the factors associated with the final VA.

RESULTS

The mean age was 9.2 ± 3.8 years. The mean follow-up period was 38.9 ± 45.4 months. After surgery, the central foveal thickness and the best-corrected VA (BCVA) improved significantly (all, P < 0.05). Fourteen eyes with iERMs showed involvement of the foveal area (localized group, six eyes; diffused group, eight eyes). There were no significant differences in the preoperative BCVA between the two groups (P = 0.064). However, the final BCVA was better in the diffused group than in the localized group (P = 0.043). Multiple regression analysis indicated that the localized membrane (P = 0.042) and lower preoperative BCVA (P = 0.043) were factors associated with a worse final VA in pediatric iERMs.

CONCLUSIONS

Surgical removal of ERM showed a high anatomical and functional success rate in children. In pediatric patients with iERMs involving the fovea, a good VA was more common when the membrane was diffused than when it was localized.

Clinic study on macular epiretinal membrane in patients under the age of 40 years

BACKGROUND

To describe the risk factors and clinical characteristics of macular epiretinal membrane (MEM) disease in patients up to the age of 40 years and to evaluate the therapeutic effect of IVTA on MEM.

METHODS

Clinical records were reviewed and the etiology of each case and the age distribution data were collected in this retrospective, cohort study. The clinical characteristics of MEM and the factors affecting VA were analyzed. Additionally, we contrasted the effects of MEM peeling with and without intravitreal triamcinolone acetonide on visual acuity (VA) and central foveal thickness (CFT).

RESULTS

In young patients, the incidence of partial posterior vitreous detachment (P-PVD) was considerably higher in IMEM than SMEM (P = 0.007). Furthermore, patients with stage 3 MEM had lower BCVA values than patients with stage 4 MEM (P < 0.001). Patients who live in urban had lower BCVA values than patients in rural (P < 0.001). Patients with IS/OS integrity had lower BCVA values than patients without IS/OS integrity (P < 0.001). The BCVA values in patients with IMEM were significantly lower than those of patients with SMEM (P < 0.001). BCVA was associated most commonly with etiology (P = 0.001), followed by region (P = 0.002). All patients had a decrease in logMAR Vas and CFT, but the combination of intraoperative IVTA resulted in a more significant decrease in logMAR Vas (P = 0.007) and CFT (P = 0.046).

CONCLUSION

In young patients, the incidence of P-PVD was significantly higher in IMEM cases than in SMEM cases. The region, MEM stage, IS/OS integrity, and etiology influenced VA. Etiology was associated most commonly with BCVA. In individuals under 40, the combination of intraoperative IVTA resulted in a more significant decrease in logMAR Vas and CFT.

Description and surgical management of epiretinal membrane due to combined hamartoma of the retina and retinal pigment epithelium

Purpose

To outline the characteristics of Combined Hamartoma of the Retina and Retinal Pigmentation Epithelium (CHRRPE) and provide a comprehensive overview of surgical management of epiretinal membrane (ERM) caused by CHRRPE.

Main text

CHRRPE is a rare ocular tumor. It clinically mimics other diseases such as retinoblastoma and choroidal melanoma. The present study reviewed the multimodal imaging of CHRRPE, highlighted the multimodal imaging modalities which are useful for revealing the unique features of CHRRPE and hence allowing physicians to confirm the diagnosis.Although most of CHRRPEs are benign harmatoma, progressive visual loss may occur because of the traction of the tumor and other complications. It is treated through surgical removal of the ERM caused by CHRRPE to free retina from the traction. Currently, there is no consensus on the surgical management of CHRRPE. Therefore, the current review was designed to explore the surgical management of ERM caused by CHRRPE and hence provide updated data on this subject.

Conclusions

Multimodal imaging technologies, especially optical coherence tomography (OCT), significantly contributes to the diagnosis of CHRRPE and visual prognosis. Surgical management of CHRRPE through removal of ERM is beneficial in patients with worsening VA which is secondary to ERM which is associated with CHRRPE. However, the strategy is limited to patients with long-standing poor vision. However, earlier surgical therapy and subsequent postoperative amblyopia therapy can be explored for children of amblyogenic age.

Surgical Outcomes of Epiretinal Membrane Removal Due to Combined Hamartoma of the Retina and RPE

BACKGROUND AND OBJECTIVE

To evaluate the surgical outcomes of epiretinal membrane (ERM) associated with combined hamartoma of the retina and retinal pigment epithelium (CHRRPE) after vitrectomy and membrane peel.

PATIENTS AND METHODS

A retrospective review of 15 patients who underwent pars plana vitrectomy with membrane peeling. No plasmin enzyme was used.

RESULTS

The mean age at surgery was 10 years old, with an average follow-up of 5.7 years. The average preoperative visual acuity (VA) was 20/514. The average postoperative VA was 20/138 (P = .0251) at 1-year follow-up and 20/89 (P = .0025) on the latest exam on final follow-up. VA was improved in 14 patients (93%) and deteriorated in one patient (7%). All 15 patients (100%) had improvement of retinal/macular anatomy postoperatively.

CONCLUSION

In the treatment of patients with ERM due to CHRRPE, vitrectomy with membrane peeling without plasmin injection can result in improved VA and retinal structure. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:546-554.].

Photocoagulation-associated spontaneous release of epiretinal membrane secondary to retinal vascular tumor: case series of 8 cases

To evaluate the secondary epiretinal membrane (ERM) response after photocoagulation in retinal vascular tumor. This retrospective interventional case series included 8 patients (8 eyes) who were diagnosed with retinal vascular tumor and secondary ERM. All eyes were treated with photocoagulation and underwent comprehensive ophthalmologic examinations at baseline and at each follow-up. Of the 8 eyes with retinal vascular tumor and associated ERM, 4 eyes (50%) were von Hippel and 4 eyes (50%) were vasoproliferative tumor of the retina. The mean follow-up time was 12.63 ± 14.64 (range, 4-51) months. The BCVA in the eyes at baseline was 1.16 ± 1.10 logMAR (range, HM to 20/40). ERM located in the macular region in 100% of the eyes and led to CME with a mean central foveal thickness of 497.6 ± 147.7 μm (range, 294-736 μm) at presentation. After photocoagulation, the ERM spontaneously peeled in 7 of 8 eyes (87.5%), among which one case required surgical treatment due to complicating tractional retinal detachment. After ERM peeling without complications, 6 eyes recovered normal macular structure, with an improved BCVA in 5 eyes and a stable BCVA in 1 eye. Laser photocoagulation is necessary and effective treatment for retinal vascular tumor. After laser photocoagulation, retinal vascular tumor-related ERM spontaneously released in 75% of the cases, without complication and surgical intervention.

CLINICAL CHARACTERISTICS, LONG-TERM SURGICAL OUTCOMES, AND PROGNOSTIC FACTORS OF EPIRETINAL MEMBRANE IN YOUNG PATIENTS

PURPOSE

To explore the clinical characteristics, long-term surgical outcomes, and prognostic factors for vision improvement in young patients with epiretinal membrane (ERM).

METHODS

A cohort of in-patients aged <40 years and underwent surgical removal of ERM were selected from medical records between January 2009 and December 2015. Data from pre- and postoperative examinations were analyzed for evaluation of surgical outcome.

RESULTS

A total of 142 eyes of 140 patients were included. Epiretinal membrane was secondary in 64.79% of eyes and inflammation was the most common secondary cause. Epiretinal membrane in young patients was characterized by severe proliferation and a tendency to center off-macula and for optic disk involvement. Ninety-three eyes of 91 patients were included in the surgical outcome analysis. Mean follow-up time was 28.95 months. The average vision improvement was 4.2 lines, with an ERM recurrence rate of 4.3%. Patients with idiopathic ERM attained better visual outcomes, whereas those with secondary ERM showed greater improvement. Preoperative visual acuity, the duration of symptoms, and patient sex were predictive factors for visual outcome.

CONCLUSION

Surgical removal of ERM improves visual acuity, and patients with greater preoperative visual acuity and a shorter duration of symptoms attain the best visual outcomes.

Pars plana vitrectomy with intraoperative optical coherence tomography for sub-internal limiting membrane fibrosis excision in a child with Terson syndrome: Surgical and pathological correlation

Purpose

To report the intraoperative optical coherence tomography (OCT)-guided surgery of a consolidated sub-internal limiting membrane (ILM) hemorrhage that developed into a sub-ILM fibrotic membrane in a child with a history of Terson syndrome.

Observations

A one year-old boy with a history of Terson syndrome due to a motor vehicle accident presented three months after trauma with a white feather-shaped membrane in the left macula. Preoperative OCT showed a preretinal hyperreflective tissue at the foveal center. The patient underwent pars plana vitrectomy. After separation of the posterior hyaloid, intraoperative OCT did not show any change in structural components. After peeling the ILM, the fibrotic membrane persisted. A bent 30-gauged needle was used to create a plane of dissection in the adherent sub-ILM membrane, which was then peeled with ILM forceps without complication. Post-operative OCT confirmed complete excision without evidence of macular edema. Pathology results indicated presence of fibrocellular tissue that contained hemosiderin, consistent with old organized hemorrhage as a component of the membrane.

Conclusion and importance

Sub-ILM hemorrhage may persist as a tautly adherent fibrotic membrane that can mimic the appearance of an epiretinal membrane or a chronic subhyaloidal hemorrhage during examination, especially in young children. Intraoperative OCT may aid in select complex macular surgery cases to better delineate the planes of dissection during sub-ILM fibrosis excision.

A white membrane beneath the inner limiting membrane of the retina in a 4-year-old child with ultrastructural evidence: a case report

Background

Epiretinal membranes (ERMs), secondary to retinal cell proliferation on the retinal surface, usually affect patients over 50 years of age but occur rarely in children. Here we report the case of a 4-year-old patient with a unilateral sub-inner limiting membrane (sub-ILM) membrane mimicking epiretinal membrane with notable ultrastructural features indicating its possible origin from old sub-ILM hemorrhage.

Case presentation

A 4-year-old boy was admitted with the complaint of poor vision in his right eye, which had been detected at school vision screening performed 6 months earlier. Fundal examination showed a feather-shaped white membrane in the macula of the right eye, and optical coherence tomography (OCT) revealed a thickened retina with a hyper-reflective band on the retinal nerve fiber layer. We suspected epiretinal membrane in the right eye, and pars plana vitrectomy with membrane peeling was performed to improve the patient’s vision. Surprisingly, the membrane was found intraoperatively to be located beneath the intact ILM; it was lifted carefully from the underlying retina as it was strongly adhered to a retinal artery of the superotemporal arcade. Postoperative scanning electron microscopy showed that the membrane consisted of hemosiderin, collagenous fibre and fibrinoid deposits. At follow-up visits, fundal examination and OCT revealed improvement in the retinal structure with disappearance of the hyper-reflective band and reduced retinal thickness. The patient’s visual acuity in the right eye was stable at 20/100 at 1 year post operation.

Conclusions

The white membrane presented here was found to lie between the intact ILM and the rest of the retina, adhering firmly to the superotemporal vessel arch. Given the ultrastructural findings of the membrane and the medical history, we speculate that the sub-ILM membrane probably developed secondary to a sub-ILM hemorrhage.

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.].

Successful surgical management of bilateral epiretinal membrane in a child with only café-au-lait spots

A 6-year-old boy diagnosed as anisometropic amblyopia, with only café-au-lait spots and a family history of neurofibromatosis, presented with decrease in vision in the both eyes. Dilated fundus examination showed epiretinal membrane in both eyes over the macula. He underwent successful surgical management of the epiretinal membrane.

Plasmin Enzyme-Assisted Vitrectomy in Pediatric Patients with Vitreoretinal Diseases

PURPOSE

To evaluate the efficacy and safety of using plasmin-assisted vitrectomy in pediatric patients with vitreoretinal diseases.

METHODS

We prospectively recruited children aged 16 years or younger who presented with vitreoretinopathies and underwent plasmin-assisted vitrectomy between 2012 and 2013. The main outcome measure was the induction of posterior vitreous detachment (PVD) using a suction power of 200 mm Hg or less during surgery.

RESULTS

Eleven eyes of 11 patients (mean age: 3.7 years; average follow-up duration: 14.1 months) were included. Of these 11 patients, there were 3 (27%) cases of stage 5 retinopathy of prematurity, 2 (18%) cases of persistent fetal vasculature, 2 (18%) cases of rhegmatogenous retinal detachment, 2 (18%) cases of idiopathic epiretinal membrane, 1 (9%) case of traumatic macular pucker, and 1 (9%) case of traumatic vitreous hemorrhage (9%). PVD was achieved in all cases (100%) during surgery using low suction after plasmin treatment (mean: 150 ± 39 mm Hg; range: 100-200). Overall, anatomical success was achieved in 8 eyes (73%). Visual acuity improved in all 5 (100%) patients for whom vision could be measured at 6 months after the operation. Cataracts were found in 4 eyes (36%), and a rise in transient intraocular pressure was observed in 1 eye (9%).

CONCLUSIONS

Plasmin-assisted vitrectomy offers an effective and less traumatic intervention for a variety of pediatric vitreoretinal diseases.

[Spontaneous separation of epiretinal membrane: Reports of 3 cases]

PURPOSE

Idiopathic epiretinal membranes most commonly develop in patients over 50 years of age. Posterior vitreous detachment seems to play a role in their formation. Epiretinal membranes are uncommon in young subjects. Surgical intervention is indicated in eyes with true functional symptoms and loss of visual acuity.

METHOD

We report 3 cases with spontaneous separation of epiretinal membranes imaged by Optical Coherence Tomography.

RESULTS

All patients reported improvement in functional symptoms after spontaneous separation of the epiretinal membrane. Anatomic recovery with reappearance of the foveolar depression was observed on Optical Coherence Tomography.

CONCLUSION

A longer period of observation may be indicated in young patients with epiretinal membrane, due to the higher rate of spontaneous separation.

[Juvenile idiopathic epiretinal membrane]

Idiopathic epiretinal membrane (iERM) is very rare in adolescent patients. The pathogenesis remains unclear although the role of hyalocytes is of major importance. The clinical features in young patients are different from those in older patients. We describe a case of iERM in a 15-year-old girl who presented with metamorphopsia of the right eye. This case report presents the basis for the decision for surgical treatment as well as the clinical features at follow-up examination 9 months after surgery.

LONG-TERM OUTCOME OF EPIRETINAL MEMBRANE SURGERY IN YOUNG CHILDREN

PURPOSE

To describe the clinical characteristics of epiretinal membranes (ERMs) secondary to nonprogressive diseases in very young children and to assess their surgical outcome.

METHODS

Retrospective interventional case series study of 13 pediatric patients (aged less than 12 years) operated on for ERM more than a 6-year period. Visual acuity measurement, ophthalmic examination, and optical coherence tomography imaging were assessed preoperatively and postoperatively.

RESULTS

Mean age was 6.5 years (3-12 years). Mean follow-up duration was of 28.5 months (12-69 months). Among the 13 patients, there were 7 cases of idiopathic ERM, 4 cases of combined hamartoma of the retina and retinal pigment epithelium, and 2 cases of posttraumatic ERM. The diagnosis of ERM was fortuitous in 10 cases (77%). Twelve children (92%) experienced a functional improvement. All patients received adjuvant treatment of amblyopia. Best-corrected visual acuity improved significantly after surgery from 20/160 to 20/40 (P = 0.001).

CONCLUSION

Even in very young children, surgery resulted in a significant long-term improvement. Children screening was essential for diagnosis and treatment in most cases.

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.

Spontaneous release of epiretinal membrane in a young weight-lifting athlete by presumed central rupture and centrifugal pull

This patient presented for surgery at the age of 32 years, 14 months after his initial complaint of metamorphopsia and visual loss in the right eye. Past tests demonstrated a whitish epiretinal membrane (ERM) with translucent stress lines over a thickened macula. Visual acuity was found on last presentation to be normal with minimal alteration on Amsler grid testing. A torn ERM was found in the center with left-over ERM temporally and rolled-over ERM nasally at the site of the epicenter with no posterior vitreous detachment. Visual recovery occurred gradually over several days 2 months prior to presentation apparently following heavy weight-lifting with a sensation of severe eye pressure. Sequential funduscopy and optical coherence tomography scans demonstrated the peeling of an ERM accompanied by normalization of foveal thickness. Valsalva maneuver had put excessive tension on ERM which tore in its center at the weakest line with gradual contraction of the ERM away from the fovea towards the peripapillary area. This is a new mechanism of self-separation of ERM induced by Valsalva. ERM in young subjects is subject to rupture and subsequent separation by tangential traction. There are three mechanisms for spontaneous separation of ERM: 1) posterior vitreous detachment with pulling of ERM by detaching vitreous (most common in adults); 2) the contracting forces of the immature ERM become stronger than its adhesions to the retina resulting in slow tangential traction on the edges of the ERM and gradual separation from the edges towards the center (remodeling common in youngsters); and 3) acute tearing of ERM at its weakest central point and retraction of part of the membrane towards the epicenter (current case report).

Hyperreflective foveal lesion observed with optical coherence tomography in cases of epiretinal membranes with a firm foveal attachment

PURPOSE

To report the optical coherence tomography (OCT) findings of the firmly attached foveal area and to investigate the functional results and predictive values in correlation to the degree of firmness of the foveal adherence of the epiretinal membrane (ERM).

METHODS

We retrospectively reviewed the medical records regarding 167 eyes of 166 patients who underwent vitrectomy for the removal of the ERM between January 2009 and December 2012. We evaluated the degree of foveal attachment in all the patients based on the surgical video and reviewed the OCT images. The main and secondary outcome measures were OCT findings including the presence and the size of a highly reflective lesion, visual acuity, and the mean duration of the ERM before surgery.

RESULTS

An abnormal highly reflective lesion was observed beneath the ERM in the foveal area. We termed this type of finding a "hyperreflective foveal lesion" (HFL). This HFL was present in 22 of 23 eyes (95.7%) with a firm foveal attachment (FFA) and in 2 of 144 eyes (1.4%) without an FFA (P < 0.001). The HFL showed a sensitivity of 96%, specificity of 99%, positive predictive value of 92%, and negative predictive value of 99%, as a predictor of FFA. The mean duration of the ERM before surgery was significantly longer in the group with an FFA than in the group without an FFA (P = 0.029). Regarding the degree of firmness of the adherence in the eyes with an FFA, the group with a greater degree of firmness had a larger HFL as observed with OCT before surgery (P < 0.05). The visual acuity in patients with an FFA was significantly lower than that in patients without an FFA after surgery (P = 0.031).

CONCLUSION

Visual acuity after surgery was significantly lower in patients with an FFA. The presence of an HFL in the OCT demonstrated a high predictive value for firmness of the foveal attachment. The size of an HFL in the OCT was associated with the degree of firmness and allowed us to predict inner and outer retinal damages after surgery.

Longterm follow-up of children with traumatic optic nerve avulsion

PURPOSE

We report the longterm follow-up of children with optic nerve avulsion (ONA) caused by traumatic events. The remarkable differences in courses and outcomes may elucidate the spectrum of ONA-associated symptoms and injuries.

METHODS

During the last 15 years, three children with ONA were referred to our department. These cases are presented with special attention to their longterm follow-up.

RESULTS

Two patients suffered from complete ONA after head injury. The third patient presented with partial ONA caused by a bicycle accident. Longterm follow-up varied between 7 and 15 years. In the first patient, a pale swollen retina without any visible retinal vasculature was observed early in the course of follow-up. The retina later completely detached. In the second patient, extended fibroglial scarring occurred and an extremely large epiretinal membrane formed and was finally released spontaneously into the vitreous. The third patient developed only mild fibroglial scarring and retinal pigment epithelium hyperplasia. The optic nerve head in this patient came to resemble a morning glory disc.

CONCLUSIONS

Optic nerve avulsion can adopt different courses and outcomes in different patients. Final visual outcome seems to depend on the degree of visual acuity immediately after injury. Substantial intraocular architecture changes can occur as a result of ONA.

Incidence and clinical characteristics of epiretinal membranes in children

OBJECTIVE

To describe the incidence and clinical characteristics of epiretinal membranes (ERMs) in children.

METHODS

The medical records of all pediatric (aged < 19 years) patients diagnosed as having an ERM from January 1, 1976, through December 31, 2005, at Olmsted Medical Group and Mayo Clinic were retrospectively reviewed.

RESULTS

Five of the 44 patients were residents of Olmsted County, Minnesota, at the time of their diagnosis, yielding an annual age- and sex-adjusted incidence of 0.54 per 100,000 patients, or 1 in 20,896 patients younger than 19 years. The mean age at diagnosis of the study patients was 12.4 years (range, 4 months to 18 years), with a preponderance of boys (31 [70%]). The presenting visual acuity in the affected eye was 20/60 or less in 22 patients (50%), and 10 patients (23%) displayed strabismus. Common causes of ERMs were trauma (17 patients [39%]), idiopathic conditions (13 patients [30%]), and uveitis (9 patients [20%]). Of the 44 patients, 8 (18%) underwent pars plana vitrectomy with membrane peel, with at least 5 of the 8 experiencing an improvement in their postoperative visual acuity.

CONCLUSIONS

Epiretinal membranes are rare in children and are most frequently associated with a traumatic, idiopathic, or uveitic cause. Patients treated surgically generally have a favorable outcome.

[Epiretinal membranes: reasons not to perform vitreoretinal surgery]

Functional results after surgical removal of epiretinal membranes are good; most often, visual acuity improves and the macular syndrome disappears. Transconjunctival vitrectomy to perform peeling of epiretinal membrane has reduced postoperative impairment; however, the surgical complications remain the same. Epiretinal membranes are not uncommon in elderly. The surgical decision is not only based on visual acuity, but many other parameters are also considered. We provide a decision-making algorithm where the elements that suggest foregoing surgery are emphasized.

Surgical outcome after removal of idiopathic macular epiretinal membrane in young patients

PURPOSE

To report the clinical features of the eye of young patients with an idiopathic macular epiretinal membrane (ERM), and the visual outcomes after the surgical removal of the ERM.

METHODS

A retrospective review of the medical records of eight young patients (age, 23-39 years; mean, 32.5 years) with an idiopathic macular ERM was performed. The patients underwent vitrectomy and removal of the ERM with peeling of the internal limiting membrane (ILM). The pre- and postoperative visual acuity and intra- and postoperative complications were investigated.

RESULTS

Ophthalmoscopically, the ERMs in seven eyes were white, opaque, and dense, while one was grayish-white and less dense. A posterior vitreous detachment was not present and the ERM adhered strongly to the underlying retina in all eight eyes. The mean best-corrected visual acuity (BCVA) preoperatively was 20/140 (Snellen; range: 20/250-20/63), and the BCVA improved significantly to 20/30 (range: 20/40-20/20) postoperatively with an average follow-up of 14.6 months (range: 6-42 months; Wilcoxon sign-rank test, P<0.001). An improvement of >7 lines was observed in seven of eight eyes. A recurrence of an ERM without involving the macula was detected in one eye (12.5%).

CONCLUSIONS

The clinical features of the ERMs in young patients are different from those in elderly patients, eg, thicker, more adherent to the retina, and still attached to the vitreous. Vitrectomy and removal of ERM with ILM peeling are effective and safe surgical procedures. Removal of the ILM may minimize the recurrence of an ERM.

[Juxtapapillary capillary retinal angioma with epiretinal membrane of the macula in familial Von-Hippel-Lindau-Syndrome]

A case of juxtapapillary capillary retinal angioma associated with a vascularized epiretinal membrane of the macula in a 6-year-old girl is presented. Von-Hippel-Lindau-Syndrome was revealed by molecular genetic methods, and further family members were identified as gene carriers. The retinal angioma embedded in an epiretinal membrane was removed completely with the membrane by pars plana vitrectomy with a good functional result. Histopathology confirmed the diagnosis of capillary angioma.

Pars plana vitrectomy for juxtapapillary capillary retinal angioma

PURPOSE

To describe the treatment of juxtapapillary capillary angioma by pars plana vitrectomy (PPV) and tumor excision.

DESIGN

Interventional case report.

METHODS

A 6-year-old girl with symptomatic juxtapapillary capillary retinal angioma with associated epiretinal membrane (ERM) underwent PPV and extraction of the tumor and ERM. A clinical and molecular genetic workup for the presence of von Hippel-Lindau disease (VHL) was performed.

RESULTS

A favorable functional result without tumor recurrence was achieved. Capillary retinal angioma was confirmed by histology of the surgical specimen, and familial VHL was revealed.

CONCLUSIONS

PPV and extraction of the tumor is applicable in juxtapapillary capillary retinal angioma with associated ERM. A workup for the presence of VHL is pertinent in patients presenting with this tumor entity.

Trypan blue- and indocyanine green-assisted epiretinal membrane surgery: clinical and histopathological studies

PURPOSE

To evaluate the clinical outcome and electron microscopic findings of trypan blue (Tb) and indocyanine green (ICG) assisted epiretinal membrane (ERM) surgery.

METHODS

This is a prospective consecutive noncomparative interventional case series. After pars plana vitrectomy, 0.1 ml of 0.6 mg/ml Tb solution was applied for 1 min under air for ERM staining. After ERM removal, internal limiting membrane (ILM) was further peeled after staining with 0.2 ml of 1 mg/ml ICG solution. Intraoperative specimens were sent for electron microscopy. Tb was considered useful if the edge of ERM was stained where peeling could be initiated with a clearer visualisation of the overall extent of the ERM.

RESULTS

In all, 16 eyes from 16 patients were recruited. There were nine grade 1 ERMs, five grade 2 ERMs, and two grade 3 ERMs. Tb was useful in six (67%) of the nine eyes with grade 1 ERMs and in all eyes with grade 2 or 3 ERMs. The three remaining grade 1 ERMs were removed together with surrounding ILM that was stained by ICG. The mean line of improvement was 1.3 lines with the median BCVA improved from 6/12 to 6/9. All 16 eyes had symptomatic improvement and none developed ERM recurrence. No complication related to Tb or ICG was observed clinically or angiographically. Electron microscopy of the Tb-stained ERM specimens showed fragments of ILM in all specimens.

CONCLUSIONS

Tb and ICG are useful intraoperatively to improve the visualisation and facilitate complete removal of ERM and ILM in macular ERM surgery.