epiretinal Membrane ( Macular Pucker ) Retina

A Major Review By Molika

1. Epiretinal
Membrane
Presented by:
Y2, Resident: Sim Molika, YemSopha

2. Contents
1.Introduction
2.Anatomy reviews
3.Risk factor
4.Epidemiology
5.Pathogenesis
6.Clinical feature
7.Differential Diagnosis
8.Imaging and Investigation
9.Management
10.Complication
11.Prognosis
12.Reference

3. 1,Introduction
■Epiretinal membrane is transparent,
avascular, fibro cellular that proliferate
on the inner surface of retina (ILM)
■Visual symptoms associated ERMs
base on severity, opacity of the
membrane and amount of macular
distortion by the contracting fibro
cellular tissue.

4. 1,Introduction
■Synonyms of the epiretinal membranes
(ERMs)
1.Macular pucker
2.Paramacular fibrosis
3.Gliosis
4.Cellophane maculopathy
5.Surface wrinkling retinopathy
6.Epi macular membrane

5. 2,Anatomy Review
■Retina is the innermost tunic of the
eyeball Thin, purplish red, transparent
membrane
■Retina has the highest rate of oxygen
consumption (high metabolic activity).
■The retina can be described as having
2 parts :
• Neurosensory retina
• Retinal pigment epithelium (RPE)

6. 2,Anatomy Review
RETINA LAYER
Neurosensory RPE
RPE: monolayer of pigmented,
hexagonal cells derived from the
outer layer of the optic cup.
Location: between choriocapillaris
and photoreceptor segment
4-6 Million RPE per eye
In the macula RPE cells are taller and
denser than in the periphery retina.

7. RETINA Region
Posterior
Pole
Peripheral
Retina

8. 2,Anatomy Review

9. 2, Anatomy Review
■Retinal neurons :
1.Photoreceptor cells (rods & 3 types of cones)
2.Bipolar cells (rod on-bipolar & cone on & off-
bipolar cells)
3.Horizontal & Amacrine cells (interneurons)
4.Ganglion cells
■Glial cells :
1.Müller cells
2.Astrocytes
3.Microglia
■Vascular cells :
1.Endothelial cells and Pericytes

10. 2,Anatomy Review
■Blood Supply of retina
•Outer 4 layers : Choriocapillaris
•Inner 6 layer : Central Retinal artery

11. 3,Risk Factor
■ERM Classification according to risk factor
Idiopathic ERM :
1.No pathology
2.PVD ( 78% to 95% ) of ERM
Secondary
1.Iatrogenic ( Cataract surgery , Vitrectomy , Cryopexy)
2.VMT
3.Macular hole
4.Uveitis
5.RRD
6.Intraocular Trauma , tumor

12. 4, Epidemiology
■The Blue Mountains Eye Study (BMES) and the
Beaver Dam Eye Study (BDES):
1.From 50-70 Year ( BDES ) Decrease After 70 Year
2.Gender Not Major risk factor ( Female > Male )
3.Higher in 3 years after cataract surgery ( PVD )
4.Prevalence ERM 7-11%
■Higher in Hispanic Group
■The Melbourne Collaborative Cohort Study
(MCCS) increase in prevalence when 80 years or
older Compare to Beaver Dam Eye Study
Decrease Prevalence after 70 Years .
Base on study they propose that it depend on life style but
not yet evidence exist

13. 4.Epidemiology
■Prevalence in Asian population
Prevalent in Asian

14. 5,Pathogenesis
■The pathogenesis of ERMs is not
completely understood.
■PVD > VMT > ILM defec>migration of
retinal glial cells > subsequent
proliferation > contraction on the inner
retinal surface> ERM ( Hypothesis ) 1974
by Foos.
■Some( 10-15%) ERM PVD Might not
exist due to thinning of ERM .

15. 5,Pathogenesis
■ERMs that develop in eyes that have retinal breaks a mild form of proliferative
vitreoretinopathy caused by RPE cells that are > the vitreous cavity > ERM
■With deficiencies in each of these theories, there is currently no universal agreement .

16. 6,Clinical Feature
■Symptom :
1.Mostly asymptomatic in mild case , Blurred
Vision ,Metamorphopsiasome can Loss
stereopsis ,aniseikonia , occasionally cause
central photopsia
2.The development , symptoms depends on the
location, duration, severityand type of ERM
VA: Can be effect When ERM on Macular Epi
macular

17. 6,Clinical Feature
■Cellophane maculopathy :
1.Early ERM with asymptomatic
2.Thin and translocation
3.Best detect using redlight free filter
■Macular Pucker :
1.Membrane Thickening and contrast
2.Fold and distortion of macular
3.Metamorphopsia and Blurred vision

18. 6,Clinical Feature
■Advance ERM
1.Thicker White Fibrotic Appearance
2.Severe distortion
3.Marked retinal wrinkle and staired
4.VA Drop Metamorphopsia, Binocular vision
Central photopsia
Association Disease
-CME
-Pre-Retinal Hemorrhage
-Foveal Ectopia
-Macular Pseudo hole > TRD > Macular Hole

19. 6,Clinical Feature
■GassClassification
GassIs the universal system for classification of ERM

20. Imagining Study and Investigation
■The diagnosis of ERM is primarily clinical by Using
1.Slit Lamp examination
2.OCT ( SD-OCT) BEDS
3.FA
4.Deep learning System ( Under Developed )

21. Imagining Study and Investigation
■Slit Lamp examination : abnormal glistening light reflex from the inner retinal
surface
■OCT ( SD-OCT) : hyperreflective band anterior to the retina
1.Retinal Thickening
2.Disruption of inner and outer photoreceptor segment junction
■FA : cystoid leakage on location ERM
■Deep learning System ( Under Developed )

22. Imagining Study and Investigation

23. Differential Diagnosis
■Diabetic retinopathy: Preretinal fibrovascular tissue.
■CME :The most common diagnoses that must be differentiated from ERM.
■Macular Hole VS Pseudo hole

24. Differential Diagnosis
Macular Hole VS Macular Pseudo hole
Biomicroscopic macular pseudo-hole VS macular
hole
➢Wrinkling of the inner retinal surface that
surrounds the hole
➢retinal tissue at base of the pseudo-hole
➢Absence of full-thickness macular holes

25. Management
1,Observation :
Mild ERM (little or no progression )
CellophoneMaculopathy : VA rarely drop > VA Drop > Surgery
2,Medical Management :
Currently No medical Treatment for ERM :
1.Vitreopharmacolysisagent (biological enzyme ) for resolve ERM ( under research)
2.Intravitreal ocriplasminagent : test for ERM associated with VMT but not resolve ERM ( small
sample on phase III )

26. Management
3,Surgical Management :
Surgery is to remove the membrane and release retinal traction of ERM
❖Two main procedure for Vitrectomy peeling :
-Membrane peeling
-Double Peeling ( ERM + ILM )
➢The goal of Membrane peeling to eliminated Mechanism that cause VA loss
Best Candidate for surgery >1 year of ERM .
❖Indication for surgery :
-Vision loss: Less than Visual Acuity 6/24
-Symptom Effect Activity of Daily life (Due to metamorphopsia

27. Management
■Membrane peeling
1.Standard PPV Port ( 23, 25 ,27 Gaunge)
2.Vitrectomy
3.Stain ERM with (indocyanine green (ICG), trypan
blue, or brilliant blue G) and stain Vitreous with
triamcinolone
4.Pick and peel technique with capsulorhexis-like
technique

28. Complication and Prognosis
■Only 10%–25% of eyes show a decline in VA over time rates of progression vary
from over several months to many years.
■Visual improvement of ≥2 Snellen lines occurs in 60%–85% of eyes and may
continue for 6–12 months after surgery
■CME After surgery Poor prognosis Sign

29. Take Home message
■ERM : fibro cellular that proliferate on the inner surface of retina
■Most cause : Idiopathic ( PVD 75-95% ) and secondary
■Most common on set 50-70 Year
■Symptom : Blurred Vision , Metamorphopsia
■Investigation : SD-OCT
■Management : Observation , Surgery
■Complication : Post operative CME bad prognosis

30. Reference
■American Academy of Ophthalmology, & McCannel, C. A., MD. (2020). 2020-2021 Basic and Clinical
Science Course (BCSC), Section 12: Retina and Vitreous. American Academy of Ophthalmology.
■American Academy of Ophthalmology, & McCannel, C. A., MD. (2020). 2020-2021 Basic and Clinical
Science Course (BCSC), Section
■Yanoff, M., & Duker, J. S. (2020). Ophthalmology (Fourth ed.). Philadelphia: Elsevier Saunders.
■Khurana, A. K., Khurana, A. K., & Khurana, B. P. (2018). Comprehensive Ophthalmology includes Review of
Ophthalmology: with Supplementary Book –Review of Ophthalmology (7th ed.). Jaypee Brothers Medical
Publishers (P) Ltd.
■Fung AT, Galvin J, Tran T. Epiretinal membrane: A review. Clin Experiment Ophthalmol. 2021;1–20.
https://doi.org/ 10.1111/ceo.13914