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IntroductIon

Idiopathic epiretinal membrane (ERM) usually develops in patients over 50 years of age,1 after the occurrence of posterior vitreous detachment (PVD).2,3 Epidemiological studies have shown that ERM preva-lence varies between 4 and 18%, depending on the population.2,4–6 Prevalence increases significantly with age, from less than 1% in people under 50 years to 15% or more in those over 70 years of age.2,5 The mean patient age in published studies dealing with idiopathic ERM surgery is between 62 to 73 years.7–21

Treatment of ERMs associated with significant visual disturbances includes pars plana vitrectomy (PPV) and membrane peeling (MP), with about 80% of patients achieving visual acuity (VA) improvement of 2 or more lines.2,7,8,22–24 Moreover, studies investigating vision- related quality of life in patients undergoing vitrectomy for ERM and other ocular conditions demonstrated a

significant improvement in vision and in quality of life.25–28 However, it is a common observation that old age is sometimes a barrier for the acceptance of surgery for various ocular conditions. This is probably particu-larly true for conditions such as ERM, which is often monocular and associated with only moderate visual deterioration, while surgery is associated with a risk for significant complications such as retinal detachment or endophthalmitis. In addition, several studies have demonstrated that final VA after PPV for ERM peeling was inversely correlated to age,9,10 though no postop-erative complication has been specifically attributed to older age, including cataract progression.29

The purpose of this study was to evaluate the clini-cal course and visual prognosis of patients 75 years or older who underwent surgery for idiopathic ERM peeling. With higher percentage of population achiev-ing older age, and the higher percentage of patients

Current Eye Research, 37(1), 50–54, 2012Copyright © 2012 Informa Healthcare USA, Inc.ISSN: 0271-3683 print/ 1460-2202 onlineDOI: 10.3109/02713683.2011.614373

Received 14 May 2011; accepted 10 August 2011

Correspondence: Elad Moisseiev, Department of Ophthalmology, Tel Aviv Sourasky Medical Center, 6 Weitzman St., Tel Aviv, Israel, 64239. Tel: +972-3-6973408. Fax: +972-3-6973870. E-mail: elad_moi@netvision.net.il

14 May 2011

10 August 2011

© 2012 Informa Healthcare USA, Inc.

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original article

Vitrectomy for Idiopathic Epiretinal Membrane in Elderly Patients: Surgical outcomes and Visual Prognosis

Elad Moisseiev1, Zvi Davidovitch3, Michael Kinori2, Anat Loewenstein1,3, Joseph Moisseiev2,3, and Adiel Barak1,3

1Department of Ophthalmology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, 2Department of Ophthalmology, Sheba Medical Center, Tel Hashomer, Israel, and 3Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

AbStrAct

Purpose: To evaluate the clinical course and visual prognosis of elderly patients over 75 years of age who underwent PPV and peeling of idiopathic ERM. Design: Retrospective case series. Methods: A retrospective chart review of patients that underwent vitrectomy for idiopathic ERM in two public hospitals. Twenty nine eyes of 29 patients 75 years and older who underwent PPV and ERM peeling were included in the study series. Patients with additional ocular vision-limiting conditions other than cataract were excluded. Main outcome measures included VA improvement, OCT changes and complications. Results: Mean patient age was 79.6 years, the highest in published literature. Mean change in VA was 0.23 log-MAR units, and 65.5% patients gained 2 or more lines of vision. Eight of the 10 patients aged 80 years or older gained 2 lines or more. Fourteen patients (48.3%) achieved final VA of 20/40 or better, and only 2 (6.9%) had final VA of 20/200 or worse. Concurrent cataract extraction was performed in 73% of the phakic eyes, and at the end of the follow up 93% were pseudophakic. Complication rates were similar to those reported in the literature. Conclusions: Pars plana vitrectomy with ERM peeling is safe and effective in restoring VA in elderly patients, and the results are comparable to those previously reported for younger patients with idiopathic ERM. Old age should not hinder surgery in patients with idiopathic ERM who seek to improve their vision and quality of life.

Keywords: Epiretinal membrane, Vitrectomy, Elderly, Visual acuity, Age

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ERM Surgery in Elderly Patients 51

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in this age group with ERM, knowledge of the surgical outcome may help clinicians when considering surgery in this subgroup of patients.

MEthodS

The records of the ophthalmology departments in two large public medical centers in Israel, The Tel-Aviv Sourasky Medical Center and The Sheba Medical Center, were retrospectively reviewed. All patients 75 years or older who underwent PPV and MP for idiopathic ERM removal from January 1, 2006 to June 31, 2009, and had at least 3 months of follow-up, were included in the study series. Patients who had previously undergone vitrec-tomy or any other ocular surgery except cataract extrac-tion were excluded. Patients with prior vision-limiting ocular conditions such as amblyopia, glaucoma, retinal detachment (RD), retinal vascular occlusions, optic neuropathy or trauma were excluded. Patients with vitreomacular traction (VMT) were excluded. Diabetic patients who had no or mild non-proliferative diabetic retinopathy (NPDR) and were not previously treated with laser or intraocular injections were included, patients with more advanced retinopathy, presence of CSME or prior treatment were excluded. Patients with early non-neovascular age-related macular degeneration (AMD) were included, but patients with more advanced disease or prior treatment were excluded.

The study was approved by our institutional review board. Data were retrieved from the medical notes before the surgery, the surgical reports, the in-patient department charts and the outpatient clinic charts. The parameters recorded included demographic information, history of any other ocular conditions, preoperative VA, preoperative and postoperative opti-cal coherence tomography (OCT) scans, details of the vitrectomy surgery, length of follow-up, occurrence of postoperative complications cystoid macular edema, elevated intraocular pressure, RD, cataract progres-sion and recurrence of ERM) and the final VA. All OCT scans were performed on spectral domain instruments, Cirrus (Carl Zeiss Inc.) at the Sheba Medical Center and Spectralis (Heidelberg engineering) at The Tel Aviv Sourasky Medical Center.

For statistical analysis, all VA values were converted to the logMAR scale. According to Holladay30 and the University of Freiburg study group results,31 blindness was set at 0.00125/2.9 (decimal/logMAR), light percep-tion at 0.0025/2.6, hand movements at 0.005/2.3 and counting fingers at 0.014/1.85. Correlations between continuous variables were analyzed using Pearson’s correlation coefficient, and T-tests were used to analyze associations between categorical parameters. Data were analyzed using SPSS for windows version 17. A p value of 0.05 was used to declare statistically significant dif-ference between groups.

rESultS

Our series includes 29 eyes of 29 patients who met the inclusion criteria. Twenty-two patients were males (75.9%) and 7 were females (24.1%), there were 11 right eyes (37.9%) and 18 left eyes (62.1%). The age range was 75 to 92 years, with a mean of 79.6 ± 4.2 years. Ten patients (34.5%) were 80 years or older. Follow-up time after surgery ranged from 3 to 48 months, with a mean follow-up of 12.9 ± 10.9 months. Only 4 (13.7%) patients had follow-up shorter than 6 months. Seven patients (24.1%) were diabetic but without significant diabetic retinopathy, and 2 (6.9%) had early AMD. At the time of surgery, 15 patients (51.7%) were phakic and 14 (48.3%) were pseudophakic. Eleven patients (37.9%) underwent phacoemulsification with posterior chamber intraocular lens (IOL) implantation combined with the vitrectomy, representing 73.3% of the 15 phakic patients. Two addi-tional patients underwent cataract surgery during the follow-up. At the final postoperative visit, 27 patients were pseudophakic (93%). Individual patient details are presented in Table 1.

The surgery was performed by five different surgeons in the two medical centers, and as this is a retrospective study, the surgical approach varied among the sur-geons. The surgical technique included 20G PPV in 13 eyes (44.9%) and 23G PPV in 16 eyes (55.1%). The ERM was usually peeled using Tano diamond-dusted mem-brane scraper and Eckhart forceps, with use of either Triamcinolone Acetonide or Trypan blue for staining the ERM. The internal limiting membrane (ILM) was not peeled. Peripheral prophylactic laser treatment was per-formed in 12 cases (41.4%) due to surgeon preferences.

VA results

Mean preoperative VA was 0.71 ± 0.29 logMAR (equiva-lent to 20/102), and the mean final VA was 0.47 ± 0.44 logMAR (equivalent to 20/59). Fourteen patients (48.3%) achieved final VA of 20/40 or better, and only two (6.9%) had final VA of 20/200 or worse. Mean change in VA was 0.23 logMAR units, approximately equivalent to a gain of 2.5 lines. Nineteen patients (65.5%) had gained 2 or more lines. Of the 10 patients 80 years or older, 80% gained at least 2 lines. Only one patient lost more than 2 lines; that patient developed RD and later PVR, and the vision deteriorated to finger counting (FC). There was no statistically significant difference in the improvement or final VA between patients who were previously pseudophakic and those who underwent a combined procedure with phacoemulsification.

oct results

Analysis of OCT scans showed mean preoperative foveal thickness of 472 ± 88 µm. Postoperative mean

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foveal thickness decreased to 376 ± 83 µm, a reduction of 20.3% from the preoperative thickness (p < 0.001). Fifteen patients (51.7%) had preoperative cystic changes on OCT. These changes resolved after surgery in most patients, but persisted to some extent in three patients.

complications

RD was observed in one eye (3.4%), 1 month after surgery. The patient underwent PPV with silicone oil injection, but the retina re-detached due to PVR. The patient declined additional surgery, and at the end of the follow-up, the vision was FC. Retinal breaks were not noted intraoperatively or postoperatively in any of the other patients.

New cystoid macular edema (CME) was documented on OCT during the follow-up in two eyes (6.9%). One patient was a diabetic who underwent PPV with pha-coemulsification, and the postoperative CME was

managed topically and resolved. The second patient received three intravitreal injections of bevacizumab, and at the end of follow-up, residual CME was still pres-ent, but the VA improved by 3 lines.

Of the four patients who remained phakic after sur-gery, two (50%) had cataract progression and underwent phacoemulsification within 12 months of surgery. Both of these patients had minimal nuclear sclerosis prior to the PPV, and gradual progression of the cataracts was documented on subsequent examinations. We therefore attributed their final VA improvement to the removal of the ERM and not to the cataract extraction. Two patients (6.9%) developed elevated intraocular pressure after surgery that was controlled medically and resolved by the end of the follow-up period. Endophthalmitis did not occur in any eye.

ERM had recurred in three eyes (10.3%) during fol-low-up but was mild and not associated with significant change in VA, which remained better than the preopera-tive VA. None were referred for repeated vitrectomy and MP.

TABLE 1 Individual patient details (patients are listed by age).

Patient no. Age Gender

Associated diseases

Preoperative VA Final VA

Preoperative lens status Phacoemulsification

Length of follow-up

Significant complications and ERM recurrence

1 75 male 6\12 FC pseudophakic 20 RD2 75 male 6\20 6\10 clear 20 3 75 male 6\30 6\10 cataract yes 6 4 75 male 6\36 6\12 cataract 6 Cataract progression5 75 female 6\15 6\12 cataract yes 9 6 76 male 6\15 6\20 cataract yes 4 7 76 male 6\15 6\15 pseudophakic 25 8 77 male 6\30 6\12 cataract 13 9 77 female 6\20 6\12 cataract yes 6 10 78 female 6\12 6\8.5 pseudophakic 36 11 78 male DM 6\60 6\30 cataract yes 6 12 78 male 6\60 6\8.5 cataract yes 8 13 78 male DM 6\36 6\30 cataract yes 7 CME, ERM

recurrence14 78 male DM, AMD 6\60 6\30 pseudophakic 9 15 78 female 6\30 6\30 pseudophakic 5 16 79 male 6\30 6\15 pseudophakic 20 17 79 male AMD 6\18 6\9 pseudophakic 12 18 79 male 6\120 6\8.5 pseudophakic 10 19 79 male 6\20 6\15 pseudophakic 5 20 80 male 6\20 6\8.5 cataract 15 Cataract progression21 80 male 6\20 6\20 cataract yes 6 22 82 male 6\120 6\20 pseudophakic 6 CME23 84 female DM 6\120 6\60 cataract yes 48 ERM recurrence24 85 male 6\20 6\36 cataract yes 35 25 85 female DM 1\12 6\30 pseudophakic 10 26 85 female DM 6\60 6\30 pseudophakic 3 27 85 male 6\30 6\12 cataract yes 6 ERM recurrence28 86 male 6\24 6\8.5 pseudophakic 12 29 92 male DM 6\20 6\10 pseudophakic 6 VA, visual acuity; ERM, epiretinal membrane; FC, finger counting; RD, retinal detachment; AMD, age-related macular degeneration. DM, diabetes mellitus, CME, cystoid macular edema

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ERM Surgery in Elderly Patients 53

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dIScuSSIon

The mean VA improvement in our series was 0.23 log-MAR units (approximately 2.5 lines of VA), and 65.5% of patients improved by 2 lines or more. The central macu-lar thickness on OCT also improved significantly after surgery, with a mean reduction of 96 microns (20%). These results are comparable to previously published series.2,7,8,22–24 They are also comparable with the results reported in a recent study by our group, which included 90 patients who underwent PPV and MP with a mean age of 71.5 years.32 It is important to note that the patient age in our series is the highest reported in the literature, with a mean of 79.6 years, compared to 62 to 73 years in other series.7–21 Our results indicate that PPV for ERM peeling is not less efficient in restoring VA in elderly patients than in younger patients. Moreover, eight of the ten patients (80%) aged 80 years and older in our series gained 2 or more lines. The fact that improved visual function after vitrectomy is associated with an improvement in quality of life25–28 further amplifies the need to offer this surgery even at advanced age. It is also important to note that there was no statistically significant difference in the visual results between patients who were previously pseudophakic and those who underwent a combined procedure. We therefore attribute the visual improvement in our patients to the removal of the ERM.

The postoperative complications encountered in this series included RD (3.4%), CME (6.9%), cataract pro-gression (50%, 2 of 4 phakic eyes), elevated intraocular pressure (6.9%) and recurrent ERM (10.3%). In most of the patients, these complications were successfully managed or resolved. These are comparable to compli-cation rates in previously published studies of patients who underwent PPV and ERM peeling: RD in 0 to 7% of cases,8,14,15,23,33 CME in 0 to 24% of cases,8,14,15,19,23,33 elevated IOP in 8 to 25% of cases8,34 and cataract pro-gression in as many as 80% of cases within 2 years of surgery.32,35–37 Recurrence of ERM has been reported in 0 to 18% of patients.15,23,33

Concurrent cataract extraction was performed in the majority (73%) of the phakic eyes in our series. Combination of PPV and MP with phacoemulsification and IOL implantation has been compared to PPV and MP followed by phacoemulsification when cataract has progressed and was found to be equally safe and effective.9,12 In older patients, it might be beneficial to perform concurrent cataract extraction with the vitrec-tomy in phakic eyes in order to save the patient from undergoing an inevitable additional surgery soon after the vitrectomy.

Our series is small and retrospective, and the data do not allow statistical analyses for identification of spe-cific prognostic factors in older patients or evaluation of various surgical techniques. However, our results may serve as a proof of concept that vitrectomy and MP for idiopathic ERM in elderly patients over 75 years is as

effective and as safe as it is for younger patients. The VA results and the complication rates were similar to previous studies, despite the fact that the mean age in our series was almost 80 years. Vitrectomy with ERM peeling should be offered to elderly patients, and age should not represent a barrier for the patient and the surgeon.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

rEfErEncES

[1] Wise GN. Clinical features of idiopathic preretinal mac-ular fibrosis. Schoenberg Lecture. Am J Ophthalmol. 1975;79:349–347.

[2] McCarty DJ, Mukesh BN, Chikani Vet al. Prevalence and associations of epiretinal membranes in the visual impair-ment project. Am J Ophthalmol. 2005;140:288–294.

[3] Wiznia RA. Posterior vitreous detachment and idiopathic pre-retinal macular gliosis. Am J Ophthalmol. 1986;102:196–198.

[4] Mitchell P, Smith W, Chey T, Wang JJ, Chang A. Prevalence and associations of epiretinal membranes. The Blue Mountains Eye Study, Australia. Ophthalmology. 1997;104:1033–1040.

[5] Mester V, Kuhn F, Mester L. Epiretinal membranes: current management concepts. Expert Rev Ophthalmol 2007;2:131–141.

[6] Fraser-Bell S, Guzowski M, Rochtchina E, Wang JJ, Mitchell P. Five-year cumulative incidence and progression of epiretinal membranes: the Blue Mountains Eye Study. Ophthalmology. 2003;110:34–40.

[7] Bovey EH, Uffer S, Achache F. Surgery for epimacular membrane: impact of retinal internal limiting membrane removal on functional outcome. Retina (Philadelphia, Pa). 2004;24:728–735.

[8] Wong JG, Sachdev N, Beaumont PE, Chang AA. Visual out-comes following vitrectomy and peeling of epiretinal mem-brane. Clin Experiment Ophthalmol. 2005;33:373–378.

[9] Ando A, Nishimura T, Uyama M. Surgical outcome on com-bined procedures of lens extraction, intraocular lens implan-tation, and vitrectomy during removal of the epiretinal membrane. Ophthalmic Surg Lasers. 1998;29:974–979.

[10] Kumagai K, Ogino N. Results of epiretinal membrane removal combined with PEA and IOL. Semin Ophthalmol. 2001;16:151–157.

[11] Falkner-Radler CI, Glittenberg C, Hagen S, Benesch T, Binder S. Spectral-domain optical coherence tomography for monitoring epiretinal membrane surgery. Ophthalmology. 2010;117:798–805.

[12] Dugas B, Ouled-Moussa R, Lafontaine POet al . Idiopathic epiretinal macular membrane and cataract extraction: combined versus consecutive surgery. Am J Ophthalmol. 2010;149:302–306.

[13] Haas A, Seidel G, Steinbrugger Iet al. Twenty-three-gauge and 20-gauge vitrectomy in epiretinal membrane surgery. Retina (Philadelphia, Pa). 2010;30:112–116.

[14] Feldman A, Zerbib J, Glacet-Bernard A, Haymann P, Soubrane G. Clinical evaluation of the use of infracyanine green stain-ing for internal limiting membrane peeling in epimacular membrane surgery. Eur J Ophthalmol. 2008;18:972–979.

[15] Bouwens MD, de Jong F, Mulder P, van Meurs JC. Results of macular pucker surgery: 1- and 5-year follow-up. Graefes Arch Clin Exp Ophthalmol. 2008;246:1693–1697.

[16] Hikichi T, Matsumoto N, Ohtsuka Het al . Comparison of one-year outcomes between 23- and 20-gauge vitrectomy for pre-retinal membrane. Am J Ophthalmol. 2009;147:639–643.e1.

Cur

r E

ye R

es D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y U

nive

rsity

of

Que

ensl

and

on 0

9/20

/13

For

pers

onal

use

onl

y.

54 Elad Moisseiev et al.

Current Eye Research

[17] Lee JW, Kim IT. Outcomes of idiopathic macular epireti-nal membrane removal with and without internal limiting membrane peeling: a comparative study. Jpn J Ophthalmol. 2010;54:129–134.

[18] Kim J, Rhee KM, Woo SJ, Yu YS, Chung H, Park KH. Long-term temporal changes of macular thickness and visual out-come after vitrectomy for idiopathic epiretinal membrane. Am J Ophthalmol. 2010;150:701–709.e1.

[19] Konstantinidis L, Berguiga M, Beknazar E, Wolfensberger TJ. Anatomic and functional outcome after 23-gauge vitrec-tomy, peeling, and intravitreal triamcinolone for idiopathic macular epiretinal membrane. Retina (Philadelphia, Pa). 2009;29:1119–1127.

[20] Kwon SI, Ko SJ, Park IW. The clinical course of the idiopathic epiretinal membrane after surgery. Korean J Ophthalmol. 2009;23:249–252.

[21] Suh MH, Seo JM, Park KH, Yu HG. Associations between macular findings by optical coherence tomography and visual outcomes after epiretinal membrane removal. Am J Ophthalmol. 2009;147:473–480.e3.

[22] Fraser EA, Cheema RA, Roberts MA. Triamcinolone acetonide-assisted peeling of retinal internal limiting membrane for macular surgery. Retina (Philadelphia, Pa). 2003;23:883–884.

[23] Kwok AKh, Lai TY, Yuen KS. Epiretinal membrane surgery with or without internal limiting membrane peeling. Clin Experiment Ophthalmol. 2005;33:379–385.

[24] Rizzo S, Genovesi-Ebert F, Murri Set al . 25-gauge, sutureless vitrectomy and standard 20-gauge pars plana vitrectomy in idiopathic epiretinal membrane surgery: a comparative pilot study. Graefes Arch Clin Exp Ophthalmol. 2006;244:472–479.

[25] Okamoto F, Okamoto Y, Fukuda S, Hiraoka T, Oshika T. Vision-related quality of life and visual function after vitrec-tomy for various vitreoretinal disorders. Invest Ophthalmol Vis Sci. 2010;51:744–751.

[26] Fukuda S, Okamoto F, Yuasa Met al. Vision-related quality of life and visual function in patients undergoing vitrectomy,

gas tamponade and cataract surgery for macular hole. Br J Ophthalmol. 2009;93:1595–1599.

[27] Okamoto F, Okamoto Y, Hiraoka T, Oshika T. Effect of vitrec-tomy for epiretinal membrane on visual function and vision-related quality of life. Am J Ophthalmol. 2009 May;147:869–874, 874.e1.

[28] Ghazi-Nouri SM, Tranos PG, Rubin GS, Adams ZC, Charteris DG. Visual function and quality of life following vitrectomy and epiretinal membrane peel surgery. Br J Ophthalmol. 2006;90:559–562.

[29] Thompson JT. The role of patient age and intraocular gas use in cataract progression after vitrectomy for macular holes and epiretinal membranes. Am J Ophthalmol. 2004;137:250–257.

[30] Holladay JT. Proper method for calculating average visual acuity. J Refract Surg. 1997;13:388–391.

[31] Schulze-Bonsel K, Feltgen N, Burau H, Hansen L, Bach M. Visual acuities “hand motion” and “counting fingers” can be quantified with the freiburg visual acuity test. Invest Ophthalmol Vis Sci. 2006;47:1236–1240.

[32] Moisseiev E, Davidovitch Z, Loewenstein A, Barak A. Outcomes of Epiretinal Membrane Removal in Eyes with and without Concurrent Vision-Limiting Ocular Disease. Ophthalmologica. 2011;226:71–75.

[33] Graham K, D’Amico DJ. Postoperative complications of epiret-inal membrane surgery. Int Ophthalmol Clin. 2000;40:215–223.

[34] Costarides AP, Alabata P, Bergstrom C. Elevated intraocu-lar pressure following vitreoretinal surgery. Ophthalmol Clin North Am. 2004;17:507–12, v.

[35] Shousha MA, Yoo SH. Cataract surgery after pars plana vit-rectomy. Curr Opin Ophthalmol. 2010;21:45–49.

[36] Cherfan GM, Michels RG, de Bustros S, Enger C, Glaser BM. Nuclear sclerotic cataract after vitrectomy for idio-pathic epiretinal membranes causing macular pucker. Am J Ophthalmol. 1991;111:434–438.

[37] Hsuan JD, Brown NA, Bron AJ, Patel CK, Rosen PH. Posterior subcapsular and nuclear cataract after vitrectomy. J Cataract Refract Surg. 2001;27:437–444.

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