Clinical course and surgical treatment of macular epiretinal membranes in young subjects

Epiretinal membrane in uveitis: Rate, visual prognosis, complications and surgical outcomes

BACKGROUND

Epiretinal membrane (ERM) is a common finding in patients with uveitis that contributes to visual impairment. We describe the long-term visual acuity (VA) and morphometric progression in patients with uveitis and epiretinal membrane (ERM).

METHODS

Retrospective cohort study of patients with uveitic ERM from a tertiary centre database. Multivariate analysis of risk factors for ERM progression was calculated using a marginal Cox regression model to estimate hazard ratios (HR).

RESULTS

Two hundred and sixteen eyes (4%) of a total 5450 eyes with uveitis were identified to have an ERM. The most common diagnosis was idiopathic uveitis in 45 patients (28.7%), followed by sarcoidosis in 21 (13.4%), HLAB27-related uveitis in 15 (9.6%) and toxoplasmosis in 15 (9.6%). Risk factors for ERM development include age (HR 1.03), intermediate uveitis (HR 2.33), posterior uveitis (HR 1.53) and ERM fellow eye (HR 18.28). Anterior uveitis (HR 0.53) and alternating disease (HR 0.53) were protective. Median VA was 20/40 at diagnosis of ERM and 20/40 at final follow up. Progression of ERM grade occurred in 17 eyes (7.9%) during the study period. ERM peel was performed in 44 eyes (20.4%). Median VA was 20/60 and 20/40 at baseline and 12 months after surgery, respectively. Improvement in visual acuity occurred in 23 eyes (60.5%) following surgery.

CONCLUSIONS

In addition to intermediate and posterior uveitis, fellow eye involvement is a strong risk factor for ERM development. In treated uveitis, the majority maintain their long-term vision and rates of ERM progression are low.

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.

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.

Long-term natural history of the idiopathic epiretinal membrane in children and young adults

PURPOSE

To evaluate the natural history of the idiopathic epiretinal membrane (ERM) in children and young adults.

METHODS

This retrospective study included 52 patients younger than 40 years who had been diagnosed with idiopathic ERM. Best-corrected visual acuity (BCVA) and central retinal thickness (CRT) measured at diagnosis were compared with those at the final visit. Incidence and factors predictive of the spontaneous release of ERM were additionally investigated. Moreover, the proportion of eyes that eventually underwent surgery was identified.

RESULTS

The mean age of the patients was 32.5 ± 6.7 years, and the mean follow-up duration was 34.5 ± 23.4 months. The mean logarithm of the minimal angle of resolution BCVA (0.05 ± 0.10, Snellen equivalents = 20/22) and CRT (340.6 ± 61.6 μm) at diagnosis were not different from BCVA (0.06 ± 0.10, 20/23) (P = 0.928) and CRT (326.6 ± 70.8 μm) (P = 0.079) at the final follow-up. Two lines or greater deterioration in the BCVA was noted in 2 eyes (3.8%). Spontaneous release of ERM was noted in 14 eyes (26.9%). The release of ERM was more frequently noted in eyes without cystoid intraretinal edema or retinoschisis (P = 0.020) or eyes with loss of foveal concavity at diagnosis (P = 0.008). During the follow-up period, 5 eyes (9.6%) underwent surgery.

CONCLUSIONS

The natural history of the idiopathic ERM in children and young adults was generally favorable with definite deterioration in visual acuity noted only in a limited proportion of patients. Baseline retinal morphology may be predictive of the spontaneous release of ERM.

Posterior segment conditions associated with myopia and high myopia

Myopia, and especially high myopia, is associated with a number of posterior segment changes that are considered to be mostly a consequence of the increased axial elongation. This can result in mechanical strain, attendant vascular changes, stretching and thinning of tissues, and atrophy/deformation of tissues in later or more advanced stages. Such myopia-related changes are observed as changes and/or abnormalities in the vitreous, choroid, retina and peripheral retina, sclera and/or optic disc. Although many of these changes are benign, at times they may be associated with significant vision impairment that either requires active intervention or may suggest future progression of the disease. This review systematically addresses the posterior segment conditions seen in myopic eyes, describes the features associated with the condition and details management pathways.

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.].

[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.

Preoperative and intraoperative prognostic factors of epiretinal membranes using chromovitrectomy and internal limiting membrane peeling

BACKGROUND AND OBJECTIVE

To evaluate the preoperative and intraoperative findings as prognostic indicators of functional and anatomic results of idiopathic epiretinal membrane (ERM) surgery.

PATIENTS AND METHODS

Vitrectomies included ERM and internal limiting membrane (ILM) removal with vital dyes. Best corrected visual acuity (BCVA), optical coherence tomography (OCT), fluorescein angiography, and autofluorescence were performed at baseline and postoperatively. Intraoperative ILM status after ERM removal was also evaluated.

RESULTS

Thirty-one eyes were monitored for a mean of 16.78 months. BCVA and central foveal thickness (CFT) improved significantly (P < .001) from baseline at 3 and 12 months. Preoperative hyperautofluorescence was associated with greater CFT reduction (P < .005). ILM status after ERM peeling did not influence visual recovery but was associated with anatomical results as measured by OCT.

CONCLUSION

Preoperative poor initial BCVA and RPE defects by FAF may not be bad prognostic factors. Preoperative hyperautofluorescence was associated with greater CFT reduction. Intraoperative classification of ILM status after ERM and ILM staining/peeling was reported and may be useful for future studies, though it was not associated neither with preoperative nor postoperative BCVA.

Long-Term Anatomical and Functional Results in Patients Undergoing Observation for Idiopathic Nontractional Epiretinal Membrane

Purpose

To evaluate the anatomical and functional course without surgical intervention in patients with nontractional epiretinal membrane (ERM) using spectral-domain optical coherence tomography (SD-OCT) in a long-term follow-up of 38.2 ± 30.6 months.

Methods

Participants were 58 patients with nontractional ERM, which was defined as a tear or rip of the ERM in at least one line of OCT scan. All patients were observed without any surgical intervention. All patients underwent ophthalmologic examination, including best-corrected visual acuity (BCVA) measurement, funduscopy, and SD-OCT. Routine follow-up visits were performed every 6 months or earlier at the discretion of the investigator.

Results

There was no statistically significant difference in BCVA or central foveal thickness (CFT) at all time points of the follow-up. About 84.4% of patients presented improvement or stabilization in BCVA at the end of the follow-up, while 53.4% of patients had a decrease in CFT. All patients had intact ellipsoid zone and none of them needed surgical intervention at the end of the follow-up of 38.2 ± 30.6 months.

Conclusions

In patients with nontractional ERM, BCVA and CFT may remain stable in a long-term follow-up. Therefore, if ellipsoid zone is intact and there is a tear or rip of ERM in at least one OCT scan, patients can be monitored and surgery may be deferred because of high percentage of structural and functional stability.

[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.

Current Trends about Inner Limiting Membrane Peeling in Surgery for Epiretinal Membranes

The inner limiting membrane (ILM) is the basement membrane of the Müller cells and can act as a scaffold for cellular proliferation in the pathophysiology of disorders affecting the vitreomacular interface. The atraumatic removal of the macular ILM has been proposed for treating various forms of tractional maculopathy in particular for macular pucker. In the last decade, the removal of ILM has become a routine practice in the surgery of the epiretinal membranes (ERMs), with good anatomical results. However many recent studies showed that ILM peeling is a procedure that can cause immediate traumatic effects and progressive modification on the underlying inner retinal layers. Moreover, it is unclear whether ILM peeling is helpful to improve vision after surgery for ERM. In this review, we describe the current understanding about ILM peeling and highlight the beneficial and adverse effects associated with this surgical procedure.

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.

Ranibizumab for idiopathic epiretinal membranes: A retrospective case series

PURPOSE

To study the effect of intravitreal ranibizumab on idiopathic epiretinal membranes (ERMs).

METHODS

A retrospective cohort study on a consecutive series of ranibizumab intravitreal injections for epiretinal membranes was performed. Four cases were identified by reviewing a claims database linked to electronic medical records. All patients received a total of three 0.05 mg/0.05 ml ranibizumab intravitreal injections at a monthly interval. The primary outcome measure was the final best-corrected visual acuity (BCVA) at the end of the injection series, and the final central macular thickness (CMT).

RESULTS

All four patients completed 3 months follow-up after the last ranibizumab injection. The mean baseline CMT was 509 microns (SD = 111). A trend was noticed for reduction in CMT (Δ = 41 microns) P = 0.08. Three patients improved by one line in their BCVA. The remaining patient maintained the same BCVA. No complications were noted.

CONCLUSION

In this study, intravitreal injection of ranibizumab marginally reduced retinal thickness in four patients with minimal improvement in visual acuity. No safety concerns were noticed. Further basic science and clinical studies may be warranted to assess the role of vascular endothelial growth factor and the effect of ranibizumab on idiopathic epiretinal membranes.

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.

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.

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.

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.

The role of patient age and intraocular gas use in cataract progression after vitrectomy for macular holes and epiretinal membranes

PURPOSE

To evaluate the rate of increase in nuclear sclerosis and posterior subcapsular cataracts in eyes as a function of patient age and use of intravitreal gas at the time of vitrectomy.

DESIGN

Observational case series.

METHODS

Nuclear sclerosis and posterior subcapsular cataracts were evaluated as a function of patient age and use of intravitreal gas at vitrectomy.

SETTING

A clinical practice.

STUDY POPULATION

The study population consisted of 301 consecutive eyes.

OBSERVATIONAL PROCEDURE

Nuclear sclerotic cataracts and posterior subcapsular cataracts were graded on a scale from 0 to 4.0 before and after vitrectomy.

MAIN OUTCOME MEASURE

Linear regression analysis was performed to measure and compare the rate of change in cataract score over time based on patient age and use of intraocular gas.

RESULTS

Nuclear sclerotic cataracts showed minimal increase in patients younger than 50 years of age after vitrectomy (0.13 grades/year). Nuclear sclerotic cataracts increased at a rate of 0.7 to 0.9 grades/year (mean, 0.812) in patients aged 50 to 60 years, 60 to 70 years, 70 to 80 years, and 80+ years, even though the baseline nuclear sclerosis scores were progressively greater for each decade. The increase in nuclear sclerotic cataracts in patients younger than 50 years of age was significantly less (P <.001) than in patients aged 50 years or older. Eyes with intraocular gas use had a higher rate of nuclear sclerosis progression (0.8 grades/year) compared with eyes without intraocular gas bubbles (0.5 grades/year; P <.001). Posterior subcapsular cataract scores showed minimal or no increases in all groups.

CONCLUSIONS

Patients older than 50 years of age have a similar rate of increase in nuclear sclerotic cataracts, independent of age. The rate is approximately sixfold greater than in patients younger than 50 years of age. Intravitreal gas bubbles are associated with a nuclear sclerosis increase of approximately 60% compared with eyes without use of a gas bubble.

Surgical management of epiretinal membrane in young patients

PURPOSE

To report the outcome of epiretinal membrane (ERM) surgery in young patients.

DESIGN

Interventional case series study.

METHOD

A retrospective review of 20 young patients who had undergone vitrectomy and epiretinal membrane removal. All patients had a preoperative examination, including fundus biomicroscopy, red free photographs, and fluorescein angiography.

RESULTS

Nine patients were males and 11 females (age: 7-26 years; mean: 16.3 years). Follow up ranged from 4-96 months (mean: 21.2 months). The 20 patients comprised 13 cases of idiopathic ERM, six cases in which ERM was associated with ocular inflammation and one case of combined hamartoma of the retina and retinal pigment epithelium (RPE). In 13 cases, the ERM was especially white, thick, and opaque, with localized constriction and severe retinal distortion. Final best-corrected visual acuity (VA) was significantly better than preoperatively (20/50 vs. 20/112), (P = 0.0002). Mean improvement in VA was 4.25 lines and 17 patients gained two or more lines. This improvement was better in secondary than idiopathic ERM (6 lines vs. 3.3). During follow up, five cases of recurrence were observed (25%). In another case, postoperative persistent ocular hypertension required filtering surgery.

CONCLUSION

The characteristics of ERM in young patients are quite different in many cases from those in adults in terms of thickness and adherence. Removal of ERM in young patients is feasible and safe although the membrane may focally adhere strongly to retinal vessels. VA usually improves significantly after surgery, but recurrences are more frequent than in adults.