Early surgery for epiretinal membrane preserves more vision for patients

Preoperative Visual Acuity Thresholds in Pars Plana Vitrectomy for Epiretinal Membrane: A Systematic Review

BACKGROUND AND OBJECTIVE

This review consolidates findings from studies that used a preoperative visual acuity (VA) threshold as an indication for epiretinal membrane (ERM) surgery.

METHODS

The literature was systematically searched using Ovid MEDLINE, EMBASE, and Cochrane Library from January 2000 to October 2022 to select studies reporting on pars plana vitrectomy (PPV) for ERM that used a preoperative VA threshold as an inclusion criterion. Primary outcomes were final best-corrected visual acuity (BCVA) and change in BCVA relative to baseline. Secondary outcomes included risk of intra- and postoperative complications.

RESULTS

A total of 639 eyes from seven studies were included. The most liberal preoperative VA threshold was 20/28.5 or worse, whereas the most conservative threshold was worse than 20/60. The mean preoperative BCVA was 0.55 logarithm of the minimum angle of resolution (logMAR) (∼20/70), and the mean postoperative BCVA was 0.35 logMAR (∼20/45). Generally, VA improved relative to baseline, regardless of the preoperative VA threshold. The smallest improvement in VA was observed in a study where the pre-operative VA to consider surgery was liberal (20/30 or worse), whereas the greatest VA improvement was observed in a study that used a conservative preoperative VA threshold (worse than 20/60).

CONCLUSIONS

The greatest improvement in BCVA was observed in studies where a conservative pre-operative VA threshold was used. The decision to operate should involve a patient-centered approach with a thorough discussion of the risks and benefits of PPV, regardless of the preoperative VA threshold used. [Ophthalmic Surg Lasers Imaging Retina 2024;55:400-407.].

Interpretable detection of epiretinal membrane from optical coherence tomography with deep neural networks

This study aimed to automatically detect epiretinal membranes (ERM) in various OCT-scans of the central and paracentral macula region and classify them by size using deep-neural-networks (DNNs). To this end, 11,061 OCT-images were included and graded according to the presence of an ERM and its size (small 100-1000 µm, large > 1000 µm). The data set was divided into training, validation and test sets (75%, 10%, 15% of the data, respectively). An ensemble of DNNs was trained and saliency maps were generated using Guided-Backprob. OCT-scans were also transformed into a one-dimensional-value using t-SNE analysis. The DNNs' receiver-operating-characteristics on the test set showed a high performance for no-ERM, small-ERM and large-ERM cases (AUC: 0.99, 0.92, 0.99, respectively; 3-way accuracy: 89%), with small-ERMs being the most difficult ones to detect. t-SNE analysis sorted cases by size and, in particular, revealed increased classification uncertainty at the transitions between groups. Saliency maps reliably highlighted ERM, regardless of the presence of other OCT features (i.e. retinal-thickening, intraretinal pseudo-cysts, epiretinal-proliferation) and entities such as ERM-retinoschisis, macular-pseudohole and lamellar-macular-hole. This study showed therefore that DNNs can reliably detect and grade ERMs according to their size not only in the fovea but also in the paracentral region. This is also achieved in cases of hard-to-detect, small-ERMs. In addition, the generated saliency maps can be used to highlight small-ERMs that might otherwise be missed. The proposed model could be used for screening-programs or decision-support-systems in the future.

Mechanical impact of epiretinal membranes on the retina utilizing finite element analysis

BACKGROUND AND OBJECTIVE

Epiretinal membrane (ERM) is a transparent membrane that forms on the surface of the neurosensory retina, causing tangential traction on the retinal surface, which may contribute to cell proliferation and contraction. Epiretinal membranes (ERMs) may be asymptomatic in some patients, while in others the membranes can progress, resulting in macular thickening and macular traction, thus distorting and inducing loss of central visual function and metamorphopsia. Currently, treatment options include follow-up or pars plana vitrectomy with an ERM peel, aiming to relieve the macular traction and improve vision and metamorphopsia. No specific criteria exist for predicting which patients might progress and need early surgery to improve and maintain good vision. The decision for surgery is based on the individual's symptoms and the physician's judgment. This study aimed to evaluate the mechanical impact in terms of stress and deformations of the ERM and to qualitatively compare them with the clinical progression of fovea thickening observed through optical coherence tomography (OCT) images.

METHODS

Numerical simulation on a three-dimensional geometrical retina and ERM model was applied to isolate factors that can be used to predict its progression and prognosis. OCT images of 14 patients with ERM were used to derive the fovea thickness progression before and after vitrectomy surgery with ERM peeling.

RESULTS

The results clearly show that the increase in ERM contractility level increases the developed stress at the fovea, which spreads and advances toward its base. The highest stress level (2.1 kPa) was developed at the highest and asymmetric contractility, producing non-uniform distributed deformations that distort the fovea structure.

CONCLUSIONS

These findings imply that high and asymmetric ERM contractility should be evaluated clinically as a factor that might signal the need for early vitrectomy surgery to avoid irreversible visual loss. Moreover, the OCT images revealed that in some cases, the thickness of the fovea indeed remains high, even after ∼12 months postoperatively, which also indicates that the deformation of the fovea in these cases is irreversible.

Deep learning-based postoperative visual acuity prediction in idiopathic epiretinal membrane

BACKGROUND

To develop a deep learning (DL) model based on preoperative optical coherence tomography (OCT) training to automatically predict the 6-month postoperative visual outcomes in patients with idiopathic epiretinal membrane (iERM).

METHODS

In this retrospective cohort study, a total of 442 eyes (5304 images in total) were enrolled for the development of the DL and multimodal deep fusion network (MDFN) models. All eyes were randomized into a training dataset with 265 eyes (60.0%), a validation dataset with 89 eyes (20.1%), and an internal testing dataset with the remaining 88 eyes (19.9%). The input variables for prediction consisted of macular OCT images and diverse clinical data. Inception-Resnet-v2 network was utilized to estimate the 6-month postoperative best-corrected visual acuity (BCVA). Concurrently, a regression model was developed using the clinical data and OCT parameters in the training data set for predicting postoperative BCVA. The reliability of the models was subsequently evaluated using the testing dataset.

RESULTS

The prediction DL algorithm exhibited a mean absolute error (MAE) of 0.070 logMAR and root mean square error (RMSE) of 0.11 logMAR in the testing dataset. The DL model demonstrated a robust promising performance with R2 = 0.80, notably superior to R2 = 0.49 of the regression model. The percentages of BCVA prediction errors within ± 0.20 logMAR amounted to 94.32% in the testing dataset.

CONCLUSIONS

The OCT-based DL model demonstrated sensitivity and accuracy in predicting postoperative BCVA in iERM patients. This innovative DL model exhibits substantial potential for integration into surgical planning protocols.

Enhancing Intermediate Vision in Patients Affected by Epiretinal Membrane Treated by Phaco-Vitrectomy

BACKGROUND

The aim of this research was to see if a refractive enhanced monofocal IOL (Eyhance IOL, IOL Abbott Medical Optics, Inc., Santa Ana, CA, USA) can provide better intermediate vision in patients undergoing phaco-vitrectomy due to cataract and epiretinal macular membrane (ERM).

METHODS

A nonrandomized prospective observational comparative study enrolled patients affected by cataract and ERM undergoing phaco-vitrectomy. A follow up of 6 months was established. Corrected and uncorrected visual acuity of both monocular and binocular types were assessed regarding intermediate and far distances. The CATQUEST 9-SF questionnaire was administered preoperatively and at the last follow-up.

RESULTS

Twenty-three eyes of twenty-three patients were enrolled, with 11 in the enhanced monofocal group. The uncorrected and corrected distance visual acuity after 6 months was not statistically different. Both monocular and binocular uncorrected intermediate visual acuity after 6 months were higher in the enhanced monofocal group (p < 0.001). The corrected intermediate visual acuity after 6 months was higher in the enhanced monofocal group (p = 0.01). The CATQUEST-9SF questionnaire showed significant differences in the variation between the preoperative condition and six-month postoperative results (p < 0.001).

CONCLUSIONS

This refractive enhanced monofocal IOL can provide better intermediate vision compared to a standard monofocal IOL in patients undergoing phaco-vitrectomy due to cataracts and ERM. Further studies are necessary to confirm these results.

Effects of physiological fluctuations on the estimation of vascular flow in eyes with idiopathic macular pucker

OBJECTIVES

To evaluate the macular vascular flow in eyes with idiopathic macular pucker (EyeiMP), pre and post pars plana vitrectomy with epiretinal and limiting membranes peeling, and to compare it with the vascular flow in the healthy fellow eyes (Eyefellow), taken as physiological reference value.

METHODS

40 eyes of 40 patients were recruited. Best-corrected visual acuity (BCVA) was evaluated. Spectral domain optical coherence tomography (SD-OCT) and OCT-angiography parameters were central foveal thickness (CFT), choroidal thickness (CT), foveal avascular zone (FAZ) area, vessel area density (VAD), vessel length fraction (VLF), vessel density index (VDI) of superficial capillary plexus (SCP) and deep vascular complex (DVC), choriocapillaris (CC) flow. Absolute and relative difference calculation was applied to evaluate macular vascular flow in EyeiMP adjusted for physiological changes detected in Eyefellow.

FOLLOW-UP

6 months.

RESULTS

BCVA improved (p = 0.003) in all cases following surgery. CFT reduced postoperatively (p = 0.0138). FAZ area was smaller in EyeiMP than Eyefellow (p = 0.0071) preoperatively and postoperatively it shrank further (p = 0.0027). After surgery, inverse correlation between FAZ area and BCVA was detected (r-0.683). VAD of SCP was pre- and post-operatively higher in EyeiMP than Eyefellow (baseline p = 0.0344, 6th month p = 0.0466). Relative difference of VDI of SCP (p = 0.0096) and CC flow (p = 0.0013) at 6 months reduced. DVC flow changed significantly only in Eyefellow. CT increased post-operatively in both EyeiMP (p = 0.0345) and Eyefellow (p = 0.00423), but relative difference did not change.

CONCLUSIONS

Vascular flow indices monitoring demonstrated significant changes in both eyes: EyeiMP and Eyefellow. Relative difference of vascular flow provided objective estimate of changes due to iMP surgery taking into account physiological changes in Eyefellow.

Evaluating the effect of vitreomacular interface abnormalities on anti-vascular endothelial growth factor treatment outcomes in diabetic macular edema by optical coherence tomography: a systematic review and meta-analysis

PURPOSE

To evaluate the effect of vitreomacular interface (VMI) configuration on treatment outcomes after intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy for diabetic macular edema (DME) using optical coherence tomography (OCT).

METHODS

A systematic literature search was performed on PubMed, Embase, web of science and clinicaltrials.gov. The primary outcome parameters were central macular thickness (CMT), best-corrected visual acuity (BCVA) and mean injection numbers. We performed this meta-analysis by Review Manager (RevMan) 5.4.1.

RESULTS

The impact of epiretinal membrane (ERM), vitreomacular traction (VMT) and vitreomacular adhesion (VMA) on the treatment outcomes were analyzed separately. 9 clinical studies involving 699 eyes were eligible for the meta-analysis for evaluating the effect of ERM/VMT on efficacy. And 7 studies with 610 eyes were included to access whether VMA affected the response to anti-VEGF therapy in patients with DME. The ERM/VMT group had poorer CMT reductions than the control group at 1 month ([MD] 52.91mm, P<0.00001), while no significant difference at 3 months ([MD] 43.95 mm, P=0.22) and over 12 months ([MD] 30.51 mm, P=0.45). No statistically significant difference in the mean BCVA change at 1 month ([MD] -0.03 Log MAR, P=0.79), whereas ERM/VMT group had poor visual acuity gains at 3 months ([MD] 0.08 Log MAR, P=0.003), and a tendency of poor vision improvement over 12 months follow-up ([MD] 0.07 Log MAR, P=0.11). There was no significant difference in the visual and anatomical results over 3 months in DME patients with or without VMA ([MD] -21.92 mm, P = 0.09; [MD] 1.79 letters, P=0.22). Besides, VMI configuration was not found to affect mean injection numbers.

CONCLUSION

The limited evidence suggested that ERM/VMT was associated with worse CMT reduction at 1 month, poor BCVA gain at 3 months and a tendency of limited vision improvement over 12 months follow-up in DME patients treated with anti-VEGF agents. And VMA may not adversely affect the anatomic and functional outcomes. However, the results of this meta-analysis should be interpreted with caution because of the heterogeneity among study designs.

Remote patient monitoring of central retinal function with MACUSTAT®: A multi-modal macular function scan

INTRODUCTION

There is significant unmet need for patient-centric remote monitoring of visual function for chronic retinal diseases, as demonstrated by the COVID-19 pandemic. The Macustat® central retinal function scan is a novel cloud-based digital health application for remote monitoring. The aim of this study is to assess the efficacy of the Macustat® compared to traditional in-office retinal evaluations.

MATERIALS AND METHODS

Patients with underlying macular pathology underwent office-based retinal and visual acuity examinations and OCT macula imaging followed by remote tele-monitoring assessment with the Macustat. Central visual function was assessed with the multi-modal Macustat test using dynamic virtual Amsler grid testing, hyperacuity perimetry and visual acuity testing. The results were compared to the findings of the in-office comprehensive retina exam and OCT evaluation.

RESULTS

The foveal acuity potential registered with the Macustat test showed high correlation with the office Snellen acuity potential 96% of eyes registered Macustat acuity within 0.2 LogMAR of office acuity measurement. In Wet AMD eyes with CNV pathology documented on OCT, the Macustat foveal function scan showed a corresponding abnormality in 89% of any CNV eyes and 100% of all visually significant CNV. In normal eyes without any visually significant edema or CNV, more than 92% showed corresponding normal retinal function scan.

CONCLUSION

The Macustat demonstrates high concordance with clinical findings using traditional diagnostic devices. Home monitoring with the Macustat® may offer complementary clinical utility as a telehealth tool for the assessment of visual acuity and macular function in patients at high risk for macular disease.

Idiopathic Epiretinal Membranes: Visual Outcomes and Prognostic Factors

Objectives

To evaluate the associations between anatomical changes and visual outcomes in patients with idiopathic epiretinal membrane (ERM).

Materials and Methods

We performed a prospective study of 130 consecutive idiopathic ERM patients and report their visual outcomes and the factors associated with visual outcome and anatomical changes.

Results

Of 130 eyes of 130 patients, 87 eyes underwent surgery, while the remaining 43 eyes were observed. At 6-month follow-up, the best-corrected visual acuity (BCVA) increased in the whole population. Mean Early Treatment Diabetic Retinopathy Study letter score changed from 51 to 65 in the surgical group and from 67 to 68 in the non-surgical group. The surgical group had improvement in BCVA at all ERM stages and grades of disorganization of the retinal inner layers (DRIL) (p<0.01). In multivariable analysis of the surgical group, factors associated with BCVA of ETDRS 60 letters or more were no or mild DRIL and the absence of ellipsoid zone disruption at baseline (p=0.002 and p=0.034, respectively) and this statistically significant positive correlation was still maintained at 12-month follow-up.

Conclusion

Baseline DRIL grade and presence of ellipsoid zone disruption were the most informative prognostic factors in patients with idiopathic ERMs. Patients with severe DRIL and/or advanced ERMs had improved vision after ERM removal.

Visual outcomes after vitrectomy for epiretinal membrane in pseudophakic eyes with a diffractive trifocal intraocular lens: a retrospective cohort study

BACKGROUND

Diffractive intraocular lenses (IOLs) could affect visual acuity in patients with macular pathologies such as epiretinal membrane (ERM) and could influence the results of pars plana vitrectomy (PPV) for ERM removal in pseudophakic eyes with these IOLs. The aim of this study is to evaluate the effect on visual outcomes of a diffractive trifocal IOL in PPV for ERM peeling.

METHODS

This is a retrospective cohort study on 20 eyes with a single model of trifocal IOL that underwent PPV for removal of ERM between January 2015 and September 2018 in our clinics. Follow up was at least 1 year. Primary outcome measure was mean change in visual acuity. Secondary outcome measures were mean change in central macular thickness (CMT), recovery of the external retinal layers, and change in spherical equivalent (SE).

RESULTS

Mean corrected distance visual acuity (CDVA) was 0.03 ± 0.03 logMAR after phacoemulsification; this worsened to 0.23 ± 0.10 logMAR with ERM, improving to 0.10 ± 0.04 log MAR 12 months after PPV (p = 0.001). Mean uncorrected near visual acuity (UNVA) was Jaeger 2.62 ± 0.51 after lensectomy. This worsened to Jaeger 5.46 ± 1.67 with ERM and improved to the initial Jaeger 2.69 ± 0.84 after PPV (p = 0.005). CMT decreased significantly, from 380.15 ± 60.50 μm with the ERM to 313.70 ± 36.98 μm after PPV. Mean SE after lensectomy was - 0.18 ± 0.38 D, which minimally changed to - 0.18 ± 0.47 D after PPV (p = 0.99). The only complication recorded after PPV was a case of cystoid macular edema. No difficulties in visualization due to IOL design were reported during PPV.

CONCLUSION

PPV for ERM in eyes with this trifocal IOL seems to be safe and effective, and allows recovery of the loss of UNVA.

Effectiveness of microperimetry in evaluating anti-vascular endothelial growth factor therapy for diabetic macular edema patients with relatively good vision: A retrospective observational study

No studies have evaluated the retinal sensitivity (RS) for diabetic macular edema (DME) patients with good vision. Therefore, this study aimed to determine the effectiveness of microperimetry in evaluating the effectiveness of anti-vascular endothelial growth factor (anti-VEGF) treatment for DME patients with relatively good vision.Twenty-seven eyes of 27 patients (mean age, 61.3 ± 11.2 years) with DME and decimal best-corrected visual acuity (BCVA) ≥0.6 were studied. All patients received 3 consecutive monthly injections of intravitreal anti-VEGF agents. The BCVA, central subfield macular thickness (CMT), and RS were evaluated by microperimetry (MAIA) within the 10 degree of the foveal center. To determine significant differences between the values, we used paired t tests.Patients were evaluated at baseline and 4 weeks after the third injection. The BCVA improved significantly from 0.18 ± 0.06 logarithm of the minimum angle of resolution (logMAR) units to 0.13 ± 0.13 logMAR units (P = .002; paired t test). The CMT decreased significantly from 464.3 ± 91.8 μm to 393.4 ± 129.0 μm (P = .005), and the RS also improved significantly from 21.8 ± 3.1 dB to 24.1 ± 2.8 dB at 4 weeks after treatment (P = .006). Among the patients with a decimal BCVA of 0.7 or better at baseline, there was no significant improvement in the BCVA (P = .28). However, the CMT decreased significantly from 479.5 ± 79.1 μm to 394.0 ± 99.8 μm at 4 weeks after treatment (P = .007). The RS also improved significantly from 22.0 ± 2.4 dB to 24.0 ± 3.1 dB at 4 weeks after treatment (P = .004).Measuring RS by microperimetry is a good option for evaluating the effectiveness of anti-VEGF treatment for DME patients with a relatively good BCVA.

MICROVASCULAR LEAKAGE IS A POOR PROGNOSTIC FACTOR FOR IDIOPATHIC EPIRETINAL MEMBRANE: A Fluorescein Angiography Study

PURPOSE

To investigate the angiographic findings assessed using fluorescein angiography and their prognostic values of idiopathic epiretinal membrane.

METHODS

Seventy-three eyes of idiopathic epiretinal membrane that had been followed up for 6 months after surgical treatment were included. Midphase fluorescein angiography images were obtained at baseline. Structural changes, including central subfield macular thickness, intraretinal cystic lesion, and ectopic inner retinal layer on the fovea, were assessed using optical coherence tomography. The main outcome measures were microvascular leakage (ML) and its association with optical coherence tomography findings and best-corrected visual acuity (BCVA).

RESULTS

Of a total of 73 eyes, 37 showed ML and had worse BCVA (P = 0.040), greater central subfield macular thickness (P = 0.028), and more ectopic inner retinal layer (P < 0.001) than those without ML at baseline. Also, ML was associated with worse postoperative BCVA (P < 0.001) and ectopic inner retinal layers (P < 0.001; P = 0.034) at baseline and 6 months. The baseline factors associated with postoperative BCVA of ≥20/25 were better BCVA (P = 0.027) and the absence of ML (P < 0.001).

CONCLUSION

Half of the idiopathic epiretinal membrane eyes showed that ML was associated with inner retinal deformity and poor visual recovery. Fluorescein angiography helped to predict visual prognosis after idiopathic epiretinal membrane surgery.

Incidence and Risk Factors of Epiretinal Membrane after Cataract Surgery

Purpose: To investigate the incidence and risk factors of epiretinal membrane (ERM) after cataract surgery.Methods: We reviewed the medical records of patients who underwent cataract surgery between January 2016 and December 2018. Eyes with ERM, as observed by optical coherence tomography performed 1-2 months after surgery, were excluded from the study. ERM was diagnosed by fundus photography. The incidence rate was determined 2-6, 6-12, and 12-24 months after surgery. The cumulative incidence rate of ERM was calculated by Kaplan-Meier analysis. Data were analyzed using logistic regression to determine the associations between ERM development and various factors.Results: The study included 218 eyes of 161 patients with a mean age of 66.6 ± 9.7 years at the time of surgery. ERM was observed in 3 of 218 eyes (1.4%) between 2 and 6 months, 15 of 176 eyes (8.3%) between 6 and 12 months, and 14 of 150 eyes (10.3%) between 12 and 24 months after surgery. The cumulative incidence rate of ERM was 11.7% over the 24-month period after surgery. In multivariate logistic regression analysis, older age (≥65 years; odds ratio [OR], 8.59, 95% confidence interval [CI], 1.43-51.49), fellow eye with ERM (OR, 3.63; 95% CI, 1.04-12.73), longer axial length (≥26 mm; OR, 8.02; 95% CI, 1.08-59.66), and complete posterior vitreous detachment development (OR, 7.48; 95% CI, 1.64-34.14) were significantly associated with ERM development.Conclusions: ERM is not rare after cataract surgery. Long-term retinal examination should be required after cataract surgery.

Comparison of Anatomical and Functional Results of Surgeries Performed with Nitinol Flex Loop or Forceps in Primary Epiretinal Membrane

Purpose: To compare surgery's effect with nitinol flex loop (NFL) or forceps on retinal layers and functional outcomes in the primary epiretinal membrane (ERM).Methods: The operations were classified according to the use of the NFL or forceps. Automatic segmentation of the individual inner retinal layers was performed by spectral-domain optical coherence tomography software, and best-corrected visual acuity (BCVA) before surgery and at the last follow-up visit postoperatively were compared.Results: Forty-two eyes of 42 patients were included with a mean age of 66.9 ± 5.7 years. 45.2% of the surgeries were NFL assisted, 54.8% were forceps assisted. The mean follow-up duration was 9.8 ± 1.3 months. The mean BCVA was 0.79 ± 0.42 vs 0.77 ± 0.39 logMAR in the preoperative period and 0.42 ± 0.27 vs. 0.40 ± 0.21 logMAR at last follow-up in the NFL vs forceps group respectively (p= .403). The retinal nerve fiber layer (RNFL)(32.5% vs. 50.1%, p= .009), ganglion cell layer (18.1% vs. 41.4%, p= .021), inner plexiform layer (13.5% vs. 32.7%, p= .031) and inner nuclear layer (15.5% vs. 30.3%, p= .011) thickness decreased significantly more in the forceps group. The mean surgical time was not significantly different (45.2 ± 5.1 vs. 51.1 ± 6.1 minutes) in the NFL vs. forceps groups, respectively (p= .331).Conclusion: Following primary ERM surgery, the inner retinal layers become thinner; RNFL impacted the most, which was found higher in forceps assisted surgeries. This result shows that the NFL can be used safely in macular surgery.

Epiretinal Membrane Surgery: Structural Retinal Changes Correlate with the Improvement of Visual Function

Several parameters have been studied for identifying the visual outcomes after pars plana vitrectomy (PPV) for epiretinal membrane (ERM) peeling. This retrospective study aimed to analyze structural retinal changes with spectral domain-optical coherence tomography (SD-OCT) and their correlations with visual acuity improvement in patients with ERM undergoing PPV. Twenty-one pseudophakic eyes were enrolled in the study. Ophthalmic evaluations included best corrected visual acuity (BCVA) and retinal layer thickness measurements with SD-OCT. The segmentation of the retina was divided into four parts: the inner retinal layer (IRL), composed of an internal limiting membrane, retinal nerve fiber layer, ganglion cell layer, and inner plexiform layer; inner nuclear layer (INL); outer plexiform layer (OPL); and outer nuclear layer (ONL). Correlations between changes in retinal layer thicknesses and BCVA were explored over a 6 month follow-up period. The postoperative thickness decrease of the INL was significantly correlated with thickness changes in all other measured retinal layers (p < 0.001). Non-parametric linear regression showed that postoperative improvement in BCVA was associated with a postoperatively decreased thickness in the IRL (p = 0.021), INL (p = 0.039), and OPL (p = 0.021). In eyes undergoing PPV, postoperative thickness decreases of the IRL, INL, and OPL were correlated with visual acuity improvements. Re-compaction of these retinal layers after relieving ERM-induced traction may be an important factor in postoperative visual function improvement.

Relation of anatomy with function following the surgical treatment of idiopathic epiretinal membrane: a multicenter retrospective study

PURPOSE

To investigate the prognostic factors associated with functional and anatomical outcomes and to assess the longitudinal course of visual acuity and retinal morphology after vitreoretinal surgery for idiopathic epiretinal membrane (ERM).

METHODS

This multicenter, retrospective study included a total of 634 eyes who underwent surgery for idiopathic ERM in 22 academic centers nationwide in Turkey. Data on best-corrected visual acuity (BCVA) and optical coherence tomography features (central foveal thickness (CFT), ERM and foveal contour morphology, ellipsoid zone (EZ) integrity) were collected and compared at baseline, 6-month, 12-month, and 24-month follow-ups. Prognostic factors for functional (having ≥ 20/25 Snellen BCVA) and anatomical (having normal/shallow foveal contour) recoveries after surgery were investigated by means of multivariate regression analyses. A cutoff value of preoperative BCVA optimizing functional recovery was calculated using receiver operating characteristic curve analysis.

RESULTS

At a median follow-up of 24 months, 37.4% of the eyes achieved ≥ 20/25 BCVA and 54% regained normal or shallow foveal contour. Functional recovery was more likely in eyes with better baseline BCVA and intact EZ (R² = 0.356, p < 0.001). The cutoff baseline BCVA value for good visual prognosis was 0.35 logarithm of the minimum angle of resolution (Snellen 20/44) (sensitivity 60%, specificity 85%, p < 0.001). Anatomical recovery was negatively associated with advanced age, higher baseline CFT, foveal herniation-type ERM morphology, and internal limiting membrane (ILM) peeling (R² = 0.225, p < 0.001). The negative effect of ILM peeling on anatomical recovery was not significant after the first postoperative year (p = 0.05). Mean BCVA values and foveal morphology progressively improved at each visit. Cases with convex baseline foveal contour continued to change towards normal foveal depression over 24 months of follow-up, which took longer than the eyes with shallow/flat contoured cases. One-third of eyes with severe baseline EZ defects showed recovery at follow-up and achieved significantly greater visual acuity gains than the remaining eyes with persistent defects (p < 0.001).

CONCLUSIONS

Functional and anatomical restoration of the eyes appears to be a slow process after ERM surgery. This process may take much longer in eyes with worse foveal morphology at baseline. Although photoreceptor disruption may be reversible in some eyes, full functional recovery is unlikely when it persists.

One-year follow-up evaluation of combined phacovitrectomy for idiopathic epiretinal membrane

AIM

To evaluate the therapeutic effect of combined phacovitrectomy with membrane peeling and intraocular lens (IOL) implantation in patients with severe idiopathic epiretinal membrane (iERM) and concurrent cataract.

METHODS

A total of 34 eyes from 34 patients who underwent phacovitrectomy and epiretinal membrane (ERM) peeling at the First Affiliated Hospital of Zhejiang University between 2015 and 2017. The best-corrected visual acuity (BCVA) and central foveal thickness (CFT) were measured preoperatively and at 1, 3, 6mo and 1y postoperatively. Temporal changes and bivariate correlations of these parameters were analyzed.

RESULTS

Mean logMAR BCVA improved and CFT decreased significantly (P<0.001) until 6mo after surgery. Correlation analysis revealed a positive correlation between preoperative and postoperative logMAR BCVA (r=0.716, P<0.001 at 1mo, r=0.417, P=0.014 at 3mo, r=0.359, P=0.037 at 6mo, and r=0.369, P=0.032 at 12mo post-op respectively), but preoperative CFT was neither associated with postoperative CFT nor with postoperative logMAR BCVA. There was a positive correlation between CFT and logMAR BCVA at 1mo (r=0.346, P=0.045), 6mo (r=0.347, P=0.045), and 12mo (r=0.342, P=0.048) post-operatively. The intra- and postoperative complications were relatively mild, and the incidences were generally low.

CONCLUSION

For severe iERM patients with significant visual symptoms, combined phacovitrectomy with membrane peeling and IOL implantation is safe and effective in improving BCVA and decreasing CFT. Early surgery in selected patients may help preserving better visual function.

Evaluation of pre- and post-surgery reading ability in patients with epiretinal membrane: a prospective observational study

Background

This study aimed to investigate the pre- and post-surgery reading ability in patients with idiopathic epiretinal membrane (ERM) to evaluate whether measurement of reading performance is a helpful test in addition to visual acuity (VA) as an assessment measure.

Methods

This prospective observational study involved 42 eyes of 40 patients with idiopathic ERM. Best-corrected visual acuity (BCVA), reading ability, and metamorphopsia score were evaluated at baseline and at 3, 6, and 12 months post-surgery. As the outcome measure, the reading ability of each patient (i.e., overall performance) was examined with MNREAD-J, the Japanese version of the MNREAD reading acuity (RA) charts, to determine RA, critical print size (CPS), and maximum reading speed (MRS). Generally, a difference of 0.2 logMAR or more is considered a significant change in BCVA. Thus, as a subgroup analysis, we additionally evaluated the BCVA and reading ability of the patients with a BCVA difference of 0.1 logMAR or less between at baseline and at 12 months post-surgery.

Results

Relative to their values at baseline, the subjects exhibited significantly improved BCVA, RA, and CPS throughout the post-surgery examination period (P < 0.001) and significantly improved MRS at 12 months post-surgery (P = 0.04). No significant change in the vertical metamorphopsia score was observed throughout the post-surgery follow-up period. However, and compared to the value at baseline, significant improvements in the horizontal metamorphopsia score were observed at 3, 6 (P < 0.05), and 12 months (P < 0.001) post-surgery. In the subgroup analysis of the 23 eyes that exhibited a BCVA improvement of 0.1 logMAR or less, the median BCVA did not change, but the median RA and CPS improved by 0.2 logMAR.

Conclusions

Our findings showed that the surgical removal of ERM improves reading ability, even when the BCVA score does not improve. The measurement of reading performance appears to be a helpful test in addition to VA as a measure for assessing the surgical removal of ERM.

Predicting Progression of Untreated Macular Pucker Using Retinal Surface En Face Optical Coherence Tomography

PURPOSE

To review visual outcomes in untreated premacular membrane (PMM) with macular pucker (MP) and evaluate novel predictors of progression.

METHODS

In this retrospective observation study, we included 342 eyes with untreated PMM with MP between 2012 and 2015. PMMs were characterized by spectral-domain optical coherence tomography (SD-OCT) imaging based on foveal morphologies, number of retinal contraction centers, central subfield thickness (CST), inner segment ellipsoid band integrity, and photoreceptor deformation index. Additionally, the thickened retina portion was identified by en face OCT and processed digitally to calculate its area. Parameters were retrospectively analyzed using multiple regression analyses to identify associations with change in visual acuity (VA) between initial to final follow-up visit.

RESULTS

In 468 eyes with untreated PMM, VA and CST did not change significantly during a mean observation period of 448 days (p = 0.52 and 0.35, respectively). Specifically, VA improved or stayed the same in 80% and worsened by 2 lines or more in 20% of eyes. The only consistent predictor of PMM progression was area of retinal thickening: for every 1 mm2 of retinal thickening at baseline, the odds of having worsened vision at follow-up increased by 6% (OR 1.0606, 95% CI 1.0031-1.1214, p = 0.0387).

CONCLUSIONS

The majority of eyes with PMM and good visual function at baseline remain stable or spontaneously improve in VA and macular thickness. Area of retinal thickening as evaluated by en face OCT may be a novel predictor of vision loss in untreated PMM with MP.

Subtotal vitrectomy in idiopathic macular hole surgery

Purpose

To assess the outcomes of subtotal vitrectomy in idiopathic macular hole (IMH).

Methods

The patients with idiopathic IMH who had undergone vitreoretinal surgery and followed up for at least 12 months post-operatively were included. First the posterior hyaloid was detached, then cortical vitreous was removed incompletely by leaving anterior vitreous intact. Internal limiting membrane was peeled with the aid of brilliant blue. A non-expanding volume of perfluoropropane was used as a tamponade and face-down positioning for 5 days was suggested to the patients. The main outcome measure was the closure rate of IMH.

Results

Forty-three eyes were included. The mean follow-up time was 15.0 ± 3.8 months after surgery. Single surgery anatomical success was 86.0%. The mean BCVA at baseline, month 1, 3, 6, 12 and at the last follow-up was 0.99 ± 0.33 LogMAR (0,5–1.80), 1.04 ± 0.33 LogMAR (0.5–1.8), 0.94 ± 0.46 LogMAR (0.3–3.0), 0.84 ± 0.33 LogMAR (0.3–1.5), 0.82 ± 0.35 (0.2–1.5), and 0.70 ± 0.34 (0.1–1.5) (p > 0.05, for all). The mean visual acuity increased by 2.9 lines at the last follow-up visit and 51.2% of the patients gained ≥ 3 lines of vision.

Conclusion

The results of this study indicated limited core vitrectomy as a safe and effective surgical technique in the treatment of IMH, resulting in acceptable functional and anatomical outcomes without significant intra- and post-operative complications.

Visual Prognostic Factors of Epiretinal Membrane Surgery in Patients with Pseudophakia

PURPOSE

To evaluate the visual prognostic factors in patients with pseudophakic epiretinal membrane (ERM) after vitrectomy using spectral domain optical coherence tomography (SD-OCT).

METHOD

A retrospective review of patients with pseudophakic ERM having undergone vitrectomy was conducted. Best corrected visual acuity (BCVA) and SD-OCT were conducted before and 1, 3, and 6 months after vitrectomy. Known visual prognostic factors, such as inner-retina irregularity index, central foveal thickness (CFT), central inner retinal layer thickness (CIRLT), cone outer segment tip defect length, and photoreceptor outer segment length, were reviewed and their correlation with BCVA was analyzed.

RESULTS

Forty-three patients (mean age: 64.88 ± 10.46 years) with pseudophakic ERM were included. BCVA significantly improved after vitrectomy (logMAR 0.30 ± 0.24 vs. 0.11 ± 0.14, p < 0.001). The preoperative high inner-retina irregularity index significantly correlated with poor postoperative BCVA in patients with pseudophakic ERM (correlation coefficient 0.583, p < 0.001). Postoperative improvements of inner retinal SD-OCT findings, such as inner-retina irregularity index, CFT, and CIRLT, were significantly associated with the amount of BCVA improvement after ERM surgery (correlation coefficients were as follows: inner-retina irregularity index - 0.711, p < 0.001; CFT - 0.462, p = 0.002; CIRLT - 0.596, p < 0.001). However, preoperative outer retinal SD-OCT findings were not associated with postoperative visual prognosis.

CONCLUSION

From this study, we determined the visual prognostic factors of ERM surgery without confounding factors, such as visual acuity improvement following combined cataract surgery, and inner retinal SD-OCT findings more significantly associated with the visual prognosis of ERM surgery compared to outer retinal SD-OCT findings.

Long-term natural history of idiopathic epiretinal membranes with good visual acuity

BACKGROUND/OBJECTIVES

To evaluate the long-term progression of idiopathic epiretinal membranes (iERMs) with good baseline visual acuity, and to identify predictors of visual decline.

DESIGN

Retrospective case series SUBJECTS METHODS: We reviewed records of 145 eyes with iERM and best-corrected visual acuity (BCVA) of 20/40 or greater at presentation, including BCVA, lens status, and central macular thickness (CMT) at yearly visits; as well as anatomic biomarkers including vitreomacular adhesion, pseudohole, lamellar hole, intraretinal cysts, disorganization of the inner retinal layers (DRIL), and disruption of outer retinal layers. Linear mixed effects and mixed-effects Cox proportional hazards models were used to identify clinical and anatomic predictors of vision change and time to surgery.

RESULTS

At presentation, mean BCVA was 0.17 ± 0.10 logMAR units (Snellen 20/30) and mean CMT was 353.3 ± 75.4 μm. After a median follow-up of 3.7 years (range 1-7 years), BCVA declined slowly at 0.012 ± 0.003 logMAR units/year, with phakic eyes declining more rapidly than pseudophakic eyes (0.019 ± 0.003 vs. 0.010 ± 0.004 logMAR units/year). Metamorphopsia, phakic lens status, lamellar hole, and inner nuclear layer cysts were associated with faster visual decline. Cumulative rates of progression to surgery were 2.9, 5.6, 12.2, and 21.1% at years 1-4. Visual symptoms, metamorphopsia, greater CMT, and disruption of outer retinal layers were associated with greater hazard for surgery.

CONCLUSION

Eyes with iERM and visual acuity ≥ 20/40 experience slow visual decline, with 21% of eyes requiring surgery after 4 years. Clinical and anatomic predictors of vision loss may be distinct from factors associated with earlier surgical intervention.

Trans-scleral posterior capsulorhexis in combined lens extraction and silicone oil removal

AIM

The aim of this study was to study the safety and efficacy of posterior capsulorhexis in vitrectomized eyes undergoing combined phacoemulsification or irrigation/aspiration and silicone oil removal.

METHODS

This prospective non-randomized interventional study involved 115 silicone-filled eyes of 115 previously vitrectomized patients. All patients underwent combined phacoemulsification or underwent irrigation/aspiration and silicone oil removal, followed by foldable intraocular lens implantation combined with primary posterior trans-scleral capsulorhexis. A 23-gauge trans-scleral vitrectomy probe was used to form the posterior capsulorhexis (vitrectorhexis). Patients were followed for 6 months.

RESULTS

Intraocular lenses maintained good centration in the capsular bag during and after trans-scleral posterior capsulorhexis. No complications were observed in the postoperative period regarding lens centration or size of the posterior capsulorhexis. No included eyes needed YAG laser posterior capsulotomy and no recurrent retinal detachment was reported during follow-up.

CONCLUSION

Performing primary trans-scleral capsulorhexis in patients undergoing combined phacoemulsification, or irrigation/aspiration and silicone oil removal, enabled achievement of an early postoperative clear visual axis and prevented the onset of dense postoperative posterior capsular opacification in previously silicone-filled eyes. This technique is reproducible and may facilitate additional intra-operative procedures and uncomplicated postoperative follow-up of retinal detachment patients without requiring YAG laser capsulotomy.

Surgical Outcomes of Idiopathic Epiretinal Membrane: the Gülhane Experience

Objectives:

We aimed to report our experiences and outcomes of vitreoretinal surgery in idiopathic epiretinal membrane.

Materials and Methods:

We retrospectively reviewed patients who underwent vitreoretinal surgery for idiopathic epiretinal membrane between January 2012 and 2014. The patients’ pre- and postoperative visual acuity, slit-lamp examination findings, and optical coherence tomography (OCT) images were evaluated.

Results:

Forty-five eyes of 45 patients (36% male, 64% female) were included (mean age, 69±8.2 years). Mean postoperative follow-up time was 7±4 (1-12) months. The mean preoperative logMAR best corrected visual acuity was 0.58±0.32 and postoperatively 0.40±0.31, 0.33±0.33, 0.28±0.34 respectively at 3, 6, and 12 months. All OCT parameters showed statistically significant anatomical improvement at 1, 3, 6, and 12 months. Correlation analysis showed that central macular thickness (r=0.69, p<0.05) and central macular volume (r=0.69, p<0.05) were the only parameters that had strong positive correlations with visual improvement.

Conclusion:

Epiretinal membrane causes heterogeneous anatomical changes in the macula for every patient. Therefore, a correlation between visual gain and changes in central macular thickness could not yet be demonstrated. We believe that central macular volume may be a better parameter for following these patients.

The outcomes of subtotal vitrectomy in macular surgeries: a single surgeon case series

PURPOSE

To investigate the outcomes of subtotal vitrectomy in epiretinal membrane (ERM) and idiopathic macular hole (IMH) surgeries.

METHODS

The patients who underwent vitrectomy for primary ERM and IMH were included. After the truncation of posterior hyaloid, cortical vitreous was incompletely removed and anterior vitreous was left in place. The main outcome measure was the complications of the surgical technique during the postoperative 12 months of follow-up.

RESULTS

Fifty-two eyes were included. Thirty-seven eyes had ERM, and 15 had IMH. During the 12 months of follow-up period, 33% of the phakic patients showed progression in the lens opacities and required cataract surgery. Other postoperative complications were listed as follows: transient intraocular pressure increase in 3 (5.9%), endophthalmitis in 1 (2.0%), and retinal detachment in 1 patient (2.0%).

CONCLUSION

Subtotal vitrectomy seems as an effective and safe surgical technique in the treatment of macular diseases.

Epiretinal membrane: optical coherence tomography-based diagnosis and classification

Epiretinal membrane (ERM) is a disorder of the vitreomacular interface characterized by symptoms of decreased visual acuity and metamorphopsia. The diagnosis and classification of ERM has traditionally been based on clinical examination findings. However, modern optical coherence tomography (OCT) has proven to be more sensitive than clinical examination for the diagnosis of ERM. Furthermore, OCT-derived findings, such as central foveal thickness and inner segment ellipsoid band integrity, have shown clinical relevance in the setting of ERM. To date, no OCT-based ERM classification scheme has been widely accepted for use in clinical practice and investigation. Herein, we review the pathogenesis, diagnosis, and classification of ERMs and propose an OCT-based ERM classification system.

25-Gauge Vitrectomy with Epiretinal Membrane and Internal Limiting Membrane Peeling in Eyes with Very Good Visual Acuity

PURPOSE

To evaluate the efficacy and safety of pars plana vitrectomy (PPV) in patients with epiretinal membrane (ERM) and preoperative visual acuity (VA) of 20/40 or better.

METHODS

44 eyes that underwent PPV and ERM peeling were included in this retrospective study. Data retrieved included demographic information, VA and intraocular pressure (IOP) preoperatively, after 1 month, 6 months and at final visit, presence of metamorphopsia, surgical reports, and occurrence of any complications.

RESULTS

Mean preoperative VA was 20/36 (0.24 ± 0.08 logMAR) and had improved to 20/27 (0.13 ± 0.11 logMAR) at the final follow-up (p < 0.001). Thirty (68.1%) eyes had improved by 1 line of vision or more, and 10 (22.7%) achieved final 20/20 vision. Significant improvement in vision was achieved earlier in eyes that underwent vitrectomy combined with cataract extraction. Preoperative OCT scans demonstrated preserved outer retinal layer structure.

CONCLUSIONS

PPV and ERM peeling is a safe and effective procedure in eyes with very good preoperative VA. PPV combined with cataract extraction offers a faster improvement in VA than PPV alone with deferred cataract surgery. PPV should be considered in symptomatic eyes with ERM and VA of 20/40 or better, in order to preserve and even improve the VA.

Quantifying metamorphopsia in patients with diabetic macular oedema and other macular abnormalities

PURPOSE

To quantify subjective visual metamorphopsia in newly diagnosed patients suffering from diabetic macular oedema (DME) and other macular abnormalities and to evaluate anti-VEGF treatment effect.

METHODS

Patients with DME, subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD) or retinal venous occlusion (RVO) were recruited. Metamorphopsia score (Mscore) was calculated using M-Charts at baseline and at the end of a series of anti-VEGF injections.

RESULTS

Fifteen eyes of 10 patients with DME, 14 eyes of 13 patients with AMD-CNV and five patients with RVO were included in this study. At baseline, positive Mscore was observed in 46.6% of eyes with DME, 50% of eyes with AMD-CNV and four of five eyes with RVO. Treatment led to a complete metamorphopsia reduction (Mscore = 0) in 71.4% of DME patients, 35.7% of AMD and 0% of RVO patients.

CONCLUSION

We suggest that the M-charts may serve as an additional test for diagnosis and follow-up, complementary to morphological evaluation by imaging, in diabetic patients facing their first anti-VEGF treatment.

Efficacy of vitrectomy and epiretinal membrane peeling in eyes with dry age-related macular degeneration

Objective

To study the efficacy of epiretinal membrane (ERM) peeling in eyes with dry age-related macular degeneration (AMD).

Methods

We retrospectively analyzed patient charts on 17 eyes (16 patients) that underwent ERM peeling with a concurrent diagnosis of dry AMD.

Results

Eyes with concurrent dry AMD and with a good preoperative best-corrected visual acuity (BCVA) (better than or equal to 20/50) had a statistically significant mean BCVA improvement at 6 months after ERM peeling. There was a statistical increase in mean BCVA from 20/95 to 20/56 in dry AMD eyes, and no eyes showed worsening in BCVA at 6 months or at most recent follow-up. Five/seventeen (29.4%) eyes had cataract formation or progression. There were no other complications, reoperations, or reoccurrences.

Conclusion

ERM peeling in eyes with dry AMD may show significant improvement, especially in eyes with good preoperative BCVA. The procedure is relatively safe with low complications and reoccurrences.

Changes in Visual Acuity after Idiopathic Epiretinal Membrane Removal: Good versus Poor Preoperative Visual Acuity

Purpose: To investigate postoperative visual acuity changes following idiopathic epiretinal membrane (ERM) surgery as well as investigate the relationship between outcome and baseline visual acuity. Methods: The medical records of 159 consecutive eyes were retrospectively reviewed for best corrected visual acuity (BCVA), central subfield macular thickness (CSMT), and the ellipsoid zone (EZ) signal of the photoreceptor layer at baseline and 1, 3, and 6 months after surgery. Patients were divided into two groups: group A, with good vision of 20/50 or better, and group B, with poor visual acuity worse than 20/50. Results: Seventy-nine eyes were included in group A and 80 eyes in group B. Mean baseline BCVA was 0.28 and 0.65 logarithm of the minimum angle of resolution (logMAR), and the mean baseline CSMT was 423.7 and 505.6 μm in group A and group B, respectively. In group A, BCVA worsened to 0.39 logMAR at 1 month (p < 0.001) and gradually improved to 0.25 logMAR at 6 months, which was not different from baseline BCVA. In group B, BCVA and CSMT improved at 1, 3, and 6 months (p < 0.05). The EZ signal improved in group B (p = 0.003) but not in group A. The area under the receiver operating characteristic curve for the improvement in BCVA of ≥2 lines was significant for preoperative BCVA (0.717, 95% confidence interval 0.638-0.797; p < 0.001). The cutoff value was 0.35 on the logMAR scale. Conclusion: After ERM surgery, patients with good vision maintained visual acuity after temporary worsening of vision, and patients with poor vision achieved significant BCVA improvement.

PARS PLANA VITRECTOMY FOR SYMPTOMATIC EPIRETINAL MEMBRANES IN EYES WITH 20/50 OR BETTER PREOPERATIVE VISUAL ACUITY

PURPOSE

To evaluate pars plana vitrectomy with membrane peel for symptomatic epiretinal membranes in eyes with preoperative best-corrected visual acuity of 20/50 or better.

METHODS

Patients with symptomatic epiretinal membrane and 20/50 or better vision who underwent pars plana vitrectomy with membrane peel by a single surgeon at our institution between January 2007 and January 2014 were identified. The principal outcomes measured were best-corrected visual acuity and central subfield macular thickness at 1, 6, and 12 months of follow-up. Subjective improvement in patient symptoms and complications were also documented.

RESULTS

Thirty-three eyes of 33 consecutive patients were included in this retrospective case series. Mean preoperative best-corrected visual acuity was 20/40 and improved to 20/28 (P = 0.00008) at Month 12. Mean central subfield macular thickness improved from 437 μm preoperatively to 391 μm by Month 1 (P = 0.00006) and 388 μm at 12 months (P = 0.00142). Seventy-three percent (24 of 33) of patients (95% confidence interval: 55.6-85.1%) reported improvement of visual symptoms during the follow-up period. Of the 13 patients who were phakic preoperatively, 6 patients (46.1%, 95% confidence interval: 23.2-70.9%) underwent phacoemulsification surgery within 1 year of vitrectomy.

CONCLUSION

Patients experienced a gradual gain in acuity and improvement of symptoms after pars plana vitrectomy with membrane peel. Cataract progression necessitating cataract surgery is common in phakic patients.