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Epiretinal Membrane

UpdateVictoria Conference 2018

James Kundart OD MEd FAAO FCOVD-A

Pacific University College of Optometry

Financial Disclosure: Nothing to Disclose

Images from Cirrus OCT

Learning Objectives

1. How is epiretinal membrane (ERM) best diagnosed?2. How is ERM differentially diagnosed from central serous

retinopathy and cystoid macular edema?3. Which ERM cases can be monitored, and which will need surgical

intervention?4. What are the expected outcomes of macular peel microsurgery

for ERM?5. Which symptoms are expected to remain after successful

surgery, and will need optical treatment?

Case Study #1, First Visit: Macular Cube OCT, 2014

-6.00 SE OD, OSBCVA 20/60 OD, OS

Images from Cirrus OCT

Case Study #1: Macular Cube OCT 2014

BP 175/113BMI 23

Images from Cirrus OCT

Case Study #1: 10-2 Matrix Visual Fields 2014

Images from Humphrey Matrix

Case Study #1, Second Visit: Macular Cube OCT 2015

Images from Cirrus OCT

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Case Study #15-Line Raster

OCT 2015

BP 166/84BMI 23

BCVA 20/50 OD, OS

Images from Cirrus OCT

Case Study #1, Third Visit: Macular Cube OCT Spring 2016

BCVA 20/60 OD and OS Images from Cirrus OCT

Case Study #1: Macular Cube OCT Spring 2016

Images from Cirrus OCT

Case Study #1: 5-Line Raster Macular OCT Spring 2016

Images from Cirrus OCT

Case Study #1:Macular Cube OCT Summer 2016

Images from Cirrus OCT

Case Study #1: Corneal Topography and 10-2 Matrix Visual Fields 2016

Images from Medmont Topographer and Humphrey Matrix

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Case Study #1: Before ERM Peel/Vitrectomy5-Line Raster OCRT 2017

BCVA 20/70 OD, OS

Images from Cirrus OCT

Case Study #1: Post-Op Peel OS

BCVA 20/50 OD, OS

Case Study #1: Post-Op Peel OS

BCVA 20/50 OD, OS

Case Study #1, Last Visit:10-2 Matrix Visual Fields and Summary

BP 130/88, BMI 22

Other Causes of ERM:Adult-Offset Coats’ Disease Pre-Op

• “(a) Color fundus photograph of the right eye of a 38-year-old man with epiretinal membrane along supertemporal arcade• (b) Ultra-wide-field color

photograph showing exudation and telangiectatic vessels in temporal periphery.”• The patient was 20/25 OD with

metamorphopsia OD

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5678313/

Other Causes of ERM: Adult-OffsetCoats’ Disease Post-Op (Peel/Vitrectomy)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5678313/

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Other Causes of ERM: Eales Disease

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5859602/

Other Causes of ERM: Eales Disease

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5859602/

• (a) Fundus photograph and (b) fluorescein angiogram of a 22-year-old male with Eales disease Stage 3A and best-corrected visual acuity 0.1 showing fibrovascular proliferation at the disc• (c) spectral domain optical coherence

tomography showed cystoid macular edema• (j) spectral domain optical coherence

tomography showed epiretinal membrane and macular edema

Epiretinal Membrane Differential Diagnoses:Cystoid Macular Edema (52 YOM and 13 YOF)

http://www.ojoonline.org/article.asp?issn=0974-620X;year=2012;volume=5;issue=3;spage=187;epage=188;aulast=Garoon

ERM DDx: Cystoid Macular Edema (CME) Using NSAIDs Post-Cataract Surgery

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5319126/

ERM DDx: Cystoid Macular Edema (CME)Do Steroids Help?

Optical coherence tomography images of cystoid macular edema (CME)• Top: Preoperative and postoperative

findings of definite CME• Middle: Preoperative and postoperative

findings of probable CME• Bottom: Preoperative and postoperative

(cataract surgery) findings of possible CME

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5636715/

Where ERM Comes From: Latanoprost, CME, and ERM

A. Optical coherence tomography of right eye before latanoprost administration. No pathology is detected.B. Seven months after treatment with preservative free latanoprost optical coherence tomography in right eye revealed cystoid macular edema with well-defined, intraretinal cystic areas of low reflectivity in the macula with serous retinal detachmentC. Two months after latanoprost discontinuation optical coherence tomography demonstrated complete resolution of cystoid macular edemaA subtle epiretinal membrane is noted

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ERM DDx: Does Latanoprost Cause CME?(after cataract surgery OD)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5360021/pdf/13104_2017_Article_2448.pdf

Niacin and CME

http://www.hindawi.com/journals/criopm/2013/713061/

ERM DDx: Microcystic Macular Edema

http://iovs.arvojournals.org/article.aspx?articleid=2190200

ERM DDx: Microcystic Macular Edema (MME)

• An example of a normal retina compared with the retina of a patient with MME. (A) A normal retina from a healthy control subject

• The pseudo-colored surface image is the infrared surface photo; the vertical stacked gray image an OCT B-scan

• (B) Optical coherence tomography image taken from a 76-year-old woman with a 3-year history of AMD, for which she received regular injections with ranibizumab and bevacizumab

• At time of imaging, her best corrected VA OS was 0.7 (20/30)

http://iovs.arvojournals.org/article.aspx?articleid=2190200

ERM DDx: Microcystic Macular Edema (MME)

http://iovs.arvojournals.org/article.aspx?articleid=2190200

• Representative OCT images of patients with MME from the clinical spectrum are shown

• The infrared surface photo and OCT image are presented to the left and the manually segmented INL to the right

(A) Microcystic macular edema in the right eye of a 70-year-old male patient with a history of proliferative diabetic retinopathy treated with panretinal photocoagulation (VA OD 0.3 or 20/60)(B) Optical coherence tomography image showing MME 8 months after occlusion of the vena temporalis superior OD in a 66-year-old female patient (VA OD 0.7 or 20/30)• Microcystic macular edema was located in the temporal

superior quadrant of the inner 3-mm EDTRS grid• However, INL thickening extended to the periphery. In addition,

hyperreflective spots were observed in all inner retinal layers

ERM DDx: Microcystic Macular Edema

http://iovs.arvojournals.org/article.aspx?articleid=2190200

• (D) Microcystic macular edema in a 58-year-old female patient with a newly diagnosed pucker in the right eye (VA OD 0.2 or 20/100)

• Again, there were multiple hyperreflective spots in the inner retinal layers

• (E) Microcystic macular edema 3 months after vitrectomy, in a 71-year-old female patient with a retinal detachment in the left eye (VA OS 0.05 or 20/400)

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ERM DDx: Microcystic Macular Edema

http://iovs.arvojournals.org/article.aspx?articleid=2190200

• Microcystic macular edema in a patient with multiple sclerosis and a history of optic neuritis and branch retinal vein occlusion in the right eye

• This 55-year-old female patient was diagnosed with clinical definite MS in 1992

• Magnetic resonance imaging showed multiple periventricular brain lesions, and spinal T2 hyperintense lesions

• In 2001, she experienced one episode of optic neuritis OD; coincidentally, an occlusion of the vena temporalis superior was found (VA 0.4 or 20/50)

ERM DDx: Microcystic Macular EdemaPropensity for the Nasal/Temporal Quadrants

http://iovs.arvojournals.org/article.aspx?articleid=2190200

• Most frequently, MME was observed in patients with ARMD (27.1%) followed by patients with preceding ophthalmic surgery (20.3%) or presence of an epiretinal membrane (18.8%)

Last ERM DDx: Case Study #2

• A 62-year-old male first reported to our clinic with a chief concern was a larger image size OS

• The patient had no history of eye surgery of any sort

• There was a history of blunt trauma to the right nasal canthus almost 40 years previously

• The patient reported that he was generally healthy with a history of hay fever

https://journals.lww.com/optvissci/Abstract/2018/03000/Retinal_Nerve_Fiber_Layer_Thickness_in_Various.11.aspx

Case Study #2: Optic Nerve Head OCT

Images from Cirrus OCT

Case Study #2: Optic Nerve and RNFL

Images from Cirrus OCT

Case Study #2: Optic Nerve Head OCTCompare OD to OS

Images from Cirrus OCT

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Case Study #2: Optic Nerve OCT

Images from Cirrus OCT

Case Study #2: Retinal Nerve Fiber Layer OCT

Images from Cirrus OCT

Case Study #2: Nerve Fiber Layer Analysis

Images from Cirrus OCT

Case Study #2: Optic Nerve OCT Summary

Images from Cirrus OCT

Case Study #2: Matrix N-30-5 Screener is Unremarkable

• Why did we run a frequency-doubling visual field screening?• There are two reasons:

both related to cranial nerves• Which two nerves were we

checking with his screening field?

Images from Humphrey Matrix

Case Study #2: 24-2 SITA Standard Visual Fields

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Case Study #2: Pachymetry with Ant Seg OCT

Images from Cirrus OCT

Case Study #2: Assessment & Initial Plan

http://opticaldiagnostics.com/info/aniseikonia.htmlhttp://cdn.iofferphoto.com/img3/item/568/007/701/o_xalatan-

eye-drops-latanoprost-0-005-anti-glaucoma-3932.jpg

Case Study #2, Second Visit: Contact Lens Telescope and New discovery

https://www.flonase.com/allergies/is-flonase-a-nasal-steroid-spray/

http://gogadgetplus.blogspot.com/2014/02/terminator-telescopic-contact-lens.html

Case Study #2: Macular OCT OD and OS

Images from Cirrus OCT

Case Study #2, Visit 1: Macular OCT OU

Images from Cirrus OCT

Case Study #2, Second Visit: Macular OCT OD

Images from Cirrus OCT

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Case Study #2, Visit 2: Macular OCT OS

Images from Cirrus OCT

Case Study #2: Macular OCT OD and OS

Images from Cirrus OCT

Case Study #2: What’s Your Diagnosis OS?

Images from Cirrus OCT

Case Study #2: Macular OCT 5-Line Raster

Images from Cirrus OCT

Case Study #2 Dx: Central Serous Retinopathy (CSR) OS

Images from Cirrus OCT

Case Study #2: Macular OCT OD and OS

Images from Cirrus OCT

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Summary: Epiretinal Membrane

• Epiretinal membrane can be concurrent and confused with:• Eye disease, like Coats’ and Eales• Cystoid and Microcystic Macular Edema• Central Serous Retinopathy

• Systemic hypertension leads to some of these conditions, but not necessarily ERM

• Aniseikonia is a presenting and residual symptom, uniquely treated by optometry

• ERM causes macropsia, magnify the fellow eyehttp://iovs.arvojournals.org/a

rticle.aspx?articleid=2458795

Questions? Thank You!

James Kundart OD MEd FAAO FCOVD-A

Professor, Pacific University College of

Optometry3D Performance Clinic,

Beaverton, OregonKundart@pacificu.edu

Additional References

1. Xiao W, Chen X, Yan W, Zhu Z, He M Prevalence and risk factors of epiretinal membranes: a systematic review and meta-analysis of population-based studies. BMJ Open. 2017 Sep 25;7(9):e014644. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5623383/

2. Shen Z, Duan X, Wang F, Wang N, Peng Y, Liu DT, Peng X, Li S, Liang Y. Prevalence and risk factors of posterior vitreous detachment in a Chinese adult population: the Handan eye study. BMC Ophthalmol. 2013 Jul 16;13(1):33. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3726418/

3. Daruich A, Matet A, Dirani A, Bousquet E, Zhao M, Farman N, Jaisser F, Behar-Cohen F. Central serous chorioretinopathy: Recent findings and new physiopathology hypothesis. Prog Retin Eye Res. 2015 Sep;48:82-118. https://www.sciencedirect.com/science/article/pii/S1350946215000336?via%3Dihub