Surgical outcome after removal of idiopathic macular 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.

Epiretinal membrane: A review

The prevalence of epiretinal membrane (ERM) is 7% to 11.8%, with increasing age being the most important risk factor. Although most ERM is idiopathic, common secondary causes include cataract surgery, retinal vascular disease, uveitis and retinal tears. The myofibroblastic pre-retinal cells are thought to transdifferentiate from glial and retinal pigment epithelial cells that reach the retinal surface via defects in the internal limiting membrane (ILM) or from the vitreous cavity. Grading schemes have evolved from clinical signs to ocular coherence tomography (OCT) based classification with associated features such as the cotton ball sign. Features predictive of better prognosis include absence of ectopic inner foveal layers, cystoid macular oedema, acquired vitelliform lesions and ellipsoid and cone outer segment termination defects. OCT-angiography shows reduced size of the foveal avascular zone. Vitrectomy with membrane peeling remains the mainstay of treatment for symptomatic ERMs. Additional ILM peeling reduces recurrence but is associated with anatomical changes including inner retinal dimpling.

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.

Does internal limiting membrane peeling during epiretinal membrane surgery induce microscotomas on microperimetry? Study protocol for PEELING, a randomized controlled clinical trial

Background

The epiretinal membrane (ERM) is a degenerative condition associated with age, which can cause loss of vision and/or metamorphopsia. The treatment of symptomatic ERM involves surgical removal including a vitrectomy followed by peeling of the ERM using a microforceps. As the internal limiting membrane (ILM) is adherent to the ERM, it is sometimes removed with it (spontaneous peeling). If ILM remains in place, it can be removed to reduce ERM recurrence. However, it is important to clarify the safety of ILM peeling, while it increases surgical risks and cause histological disorganization of the retina that can lead to microscotomas, may be responsible for definitive visual discomfort.

Methods

PEELING is a prospective, randomized, controlled, single-blind, and multicentered trial with two parallel arms. This study investigates the benefit/risk ratio of active ILM peeling among individuals undergoing ERM surgery without spontaneous ILM peeling. Randomization is done in the operating room after ERM removal if ILM remains in place. After randomization, the two groups—“active peeling of the ILM” and “no peeling of the ILM”—are compared during a total of three follow-up visits scheduled at month 1, month 6, and month 12. Primary endpoint is the difference in microscotomas before surgery and 6 months after surgery. Patients with spontaneous peeling are not randomized and are included in the ancillary study with the same follow-up visits and the same examinations as the principal study.

Relevant inclusion criteria involve individuals aged > 18 years living with idiopathic symptomatic ERM, including pseudophakic patients with transparent posterior capsule or open capsule or lensed patients with age-related cataracts. The calculated sample size corresponds to 53 randomized eyes (one eye/patient) per arm that means 106 randomized eyes (106 randomized patients) in total and a maximum of 222 included patients (116 spontaneous peeling).

Discussion

ILM peeling is often practiced in ERM surgery to reduce ERM recurrence. It does not impair postoperative visual acuity, but it increases the surgical risks and causes anatomical damages. If active ILM peeling is significantly associated with more microscotomas, it may contraindicate the ILM peeling during primitive idiopathic ERM surgery.

Trial registration

ClinicalTrials.gov, NCT02146144. Registered on 22 May 2014. Recruitment is still ongoing.

Gradual resolution of foveal herniation after epiretinal membrane peeling

We demonstrate the gradual resolution of foveal herniation with optical coherence tomography (OCT) images after epiretinal membrane (ERM) removal. A young male presented with diminished vision in the left eye (OS). Examination of OS revealed an ERM and thickening of the foveal region. OCT delineated the ERM clearly. It also showed a central defect in the ERM through which the inner retinal layers had prolapsed into the vitreous cavity leading to foveal herniation. The patient underwent vitrectomy and surgical removal of the ERM. After removing the source of macular traction, over a period of 4 months, gradual reduction in height of the elevated central foveal tissue was observed. At 6 months, the foveal bulge had reduced remarkably and remained stable. The resolution of foveal herniation after ERM removal is a slow process. The OCT images convey that it may take few months for the foveal bulge to decrease in height. When the outer retinal layers are normal, visual recovery, though delayed, is appreciable.

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.].

The role of internal limiting membrane peeling in epiretinal membrane surgery: a randomised controlled trial

PURPOSE

To compare the anatomical and functional outcomes after primary idiopathic epiretinal membrane (ERM) peeling with or without internal limiting membrane (ILM) peeling.

DESIGN

A two-centre randomised, controlled clinical trial with 12 months of follow-up.

METHODS

One hundred and two eyes of 102 patients were included in the analysis and were randomised into two groups (ILM peeling (P) and non-ILM peeling (NP) group). Inclusion criteria were: Idiopathic ERM confirmed on optical coherence tomography, age ≥18 years, binocular distortion, best-corrected visual acuity (BCVA) ≤90 ETDRS letters, intraocular pressure ≤23 mm Hg and informed consent. The primary outcome measure was the mean change in the ETDRS distance BCVA at 12 months' follow-up for each group.

RESULTS

The mean change in distance BCVA at 12 months was 0.30±0.24 logMAR (15 ETDRS letters) in the P group and 0.31±0.23 logMAR (14 ETDRS letters) in the NP group, a change that was not statistically significant (p=0.84). No statistically significant differences were observed when comparing the changes in distance BCVA, the changes in metamorphopsia (Amsler grid) and the changes in central retinal thickness between the two groups at any of the time points studied.

CONCLUSIONS

Our analysis suggests that ILM peeling in idiopathic ERM surgery does not result in better visual improvement. The more frequent presence of an uninterrupted interdigitation zone in the P group did not result in a better functional outcome of our patients. No recurrent ERMs were noted in either group.

[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.

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.

Iatrogenic choroidal neovascularization following idiopathic epiretinal membrane peel

Choroidal neovascularization is an uncommon complication of macular surgery. The functional outcome is poor despite various treatment options, including laser photocoagulation, photodynamic therapy, and a variety of surgical procedures. We report a case of iatrogenic choroidal neovascularization in a 69-year-old woman at the site of inadvertent retinal trauma 5 weeks after an epiretinal membrane peel. Visual acuity was 6/15 at the time of diagnosis. Four intravitreal bevacizumab injections were administered over a period of 6 months; treatment was discontinued when a disciform scar was noted. At last follow-up, 21 months after surgery, the patient's visual acuity was counting fingers.

Optical coherence tomographic characteristics and surgical outcome of eyes with myopic foveoschisis

AIM

To describe the optical coherence topographic (OCT) characteristics and outcome of vitrectomy with triamcinolone acetonide (TA)-assisted epiretinal tissue removal and gas tamponade in eyes with myopic foveoschisis (MF).

METHODS

We examined 101 myopic eyes, and the OCT characteristics of 18 eyes (18%) with an MF were studied. Six eyes underwent vitrectomy with TA-assisted epiretinal tissue removal and gas tamponade. The postoperative outcome measures were best-corrected visual acuity (BCVA), resolution of the MF as determined by OCT, and complications.

RESULTS

OCT scans showed an isolated MF in three (17%) eyes, and the MF were associated with two or more macular anomalies in 15 (83%) eyes. A foveal detachment was found in 13 (72%), lamellar macular hole in 4 (22%), and a tractional epimacular membrane in 11 (61%) of the 18 eyes. Six eyes underwent surgery, in which the epiretinal tissue was made visible by intravitreal TA and completely removed. The median BCVA significantly improved from 20/400 preoperatively (range, 20/1000-20/160) to 20/160 postoperatively (range, 20/200-20/40; P=0.03, Wilcoxon signed-rank test). The mean VA improved by 5.6 lines. OCT showed a complete reattachment of the fovea in four (67%) eyes and a small subfoveal or parafoveal detachment in two (33%) eyes.

CONCLUSIONS

MF is commonly observed in highly myopic eyes and most are associated with one or more macular anomalies. Vitrectomy with TA-assisted complete removal of all tractional premacular structures followed by gas tamponade resulted in good visual and anatomical outcomes for treating MF.