Transcript Epiretinal Membranes, CME and Macular Holes Laura S. Gilmore, MD Grand Rounds November 14, 2003 Texas Tech University HSC Lubbock, TX.

Epiretinal Membranes, CME and
Macular Holes
Laura S. Gilmore, MD
Grand Rounds
November 14, 2003
Texas Tech University HSC
Lubbock, TX
History
• Chief Complaint: VA OD “fading away” x 68 months
• HPI: 81yo male referred for evaluation of
chronic CME OD s/p CE 3 years ago
• PMH: newly diagnosed DM with BS 120s140s. HTN. Hypothyroidism. Arthritis.
Hypercholesterolemia.
• Ocular History: CE OD 99; KNOWN CME x
3 years
• FH: diabetes, sister
• SH: no alcohol. Quit smoking >30 years ago
Physical Exam
• VS: BP 115/79, P 74
• VA: OD 20/50 -1+2PH NI, OS 20/50 -1+1PH
20/40-2; VF FTFC OU x small central scotoma;
AMSLER normal
• IOP: OD 10, OS 14
• PCIOL OD, 3+ NSC OS
• Anterior segment clear, without pupil distortion,
PSC, synechiae, lens dislocation
• DFE: OD-ERM; macular hole with flap of retinal
tissue; multicystic CME; cryo scar superonasally; PVD with Weiss ring. OS-appears flat
Additional History
• 1978: blunt trauma OD-champagne cork vs
eye
• Resultant RD, per patient
• Treated in San Diego VA Hospital with
cryotherapy, pneumatic retinopexy?
• Still awaiting records from San Diego
Note dragging of vessels, tortuosity, color
changes
Dragging, tortuosity
Cystic spaces evident in this incidence
Cystic rupture in another incidence
Hypotheses
• Senile macular hole
• Blunt trauma caused retinal tear and/or
detachment, and hole directly or indirectly
• CME with ruptured cyst
• Vitreofoveal traction syndrome 1st, then
ERM
• ERM 1st, leading to 1) tractional macular
hole or 2) CME from ERM traction, then
hole
Unlikely Choices
• Typical senile hole- not likely, since usually
shows early hyperfluorescence
• Direct result of trauma in 1978? symptoms
would have appeared within 6-12 months
• CME with ruptured cyst
• Not likely result of CE, or symptoms would
have been evident within 6-8 months postop. CE was over 3 years ago.
Most Likely Choice
• RD repair/cryo, with resultant ERM 1st,
leading to 1) tractional macular hole or 2)
CME from ERM traction, then hole
Macular Dysfunction Caused by
Epiretinal Membrane Contraction
• Distortion
• Intraretinal edema, CME
• Degeneration of underlying retina
Classification by Distortion
• Grade 0: Cellophane Maculopathy-translucent with
no distortion of retina; cellophane light reflex
• Grade 1: Crinkled Cellophane Maculopathyirregular retinal folds and light reflex, radiating
retinal folds; no to mild VA c/o, 20/40 at worst, +/metamorphopsia, insidious onset
• Grade 2: Macular Pucker-grayish membrane;
marked retinal crinkling and puckering of macula;
PVD in 90%; may see edema, retinal heme, CWS,
SRD, leakage by FA; VA 20/200 or less, insidious to
sudden onset, usually with metamorphopsia
ERM Following Retinal
Tear/Detachment Repair
• Grade 1 or 2 frequently seen s/p RT/RD repair
• usually occurs 8-16 weeks post-op
• VA in 20% of pts improves due to relaxation or
partial peeling of ERM and resolution of
intraretinal edema
• Traction on macula can lead to hole or CME
Clinical Features of CME
• Visual acuity is reduced according to
severity and duration
• Longstanding cases usually result in
coalescence of fluid-filled microcysts into
large cystic spaces
• Lamellar holes form at fovea, causing
irreversible damage to central vision
• SLE shows loss of foveolar depression,
thickening of retina, and multiple cysts in
sensory retina
Signs of Macular Hole
• Watzke-Allen-beam on foveola appears broken
• round, red spot in the center of the macula, 1/3
to 2/3 DD, surrounded by a gray halo
• lose foveolar depression; yellow spot in macula.
• Small, yellow precipitates in hole subretinally
• retinal cysts at the margin of the hole or a small
operculum above the hole, anterior to the retina
(stage 4) or both
• May be caused by vitreous or epiretinal
membrane traction on the macula, trauma, or
cystoid macular edema
Fluorescein Angiography
• CME-Dye accumulates in outer plexiform
layer; Dye leaks into parafoveal region
during the arteriovenous phase, coalesces
into flower-petal pattern in late AV phase;
hyperfluorescence from dye pooling in
microcystic spaces persists through late
phase
• Macular/lamellar holes-EARLY
hyperfluorescence
• ERM-diffuse leakage of capillaries around
FAZ; what we see
Summary
• ERM following RD repair
• tractional macular hole vs. CME from ERM
traction, then hole
Proposed Treatment in this Case
•
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•
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Surgery at 20/50? F/U this week, 20/25 OD
No metamorphopsia, no Amsler symptoms
just small central scotoma
No; will follow. If VA decreases (at least
20/60) or pt has intolerable distortion,
proceed with PPVx, membrane peeling
Gass, J. Donald M. Stereoscopic Atlas of
Macular Diseases, Diagnosis and Treatment,
Volume II, 4th Edition. 903-916, 938-954.
Kanski, Jack J. Clinical Ophthalmology. 4th
Edition. 424-425.