Retina — Macular disease

Epiretinal membrane: diagnosis and treatment

An epiretinal membrane is a thin fibrous layer that develops on the surface of the macula, causing progressive visual distortion. Treatment is surgical when it affects vision.

What is an epiretinal membrane?

The epiretinal membrane (ERM), also called macular pucker or epimacular membrane, is a thin layer of fibrocellular tissue that forms on the surface of the retina at the level of the macula — the central zone of precise vision. As it gradually contracts, it distorts the retinal layers and impairs central vision.

It is described as idiopathic when it occurs in the context of an age-related posterior vitreous detachment, most often after age 50. It can also be secondary to a retinal condition : a tear, a detachment, diabetic retinopathy, uveitis or venous occlusion.

Its prevalence increases with age : around 7 % after age 60 and 12 % after age 70 in epidemiological studies.

Symptoms

The main symptom is metamorphopsia : straight lines appear distorted, wavy or curved. Patients describe doors or windows that seem to « lean », or a line of writing that is not straight.

  • Metamorphopsia — distortion of straight lines, assessed with the Amsler grid
  • Progressive decline in central visual acuity — especially for reading
  • Blurred or veiled vision in the centre of the visual field
  • Monocular diplopia in some advanced cases

The Amsler grid allows for self-monitoring at home : stare at the central dot of the grid with one eye closed. If any lines appear curved or missing, consult an ophthalmologist. This test does not replace macular OCT but indicates the need for an examination.

Diagnosis by macular OCT

The diagnosis is confirmed by macular OCT, which directly visualises the membrane on the surface of the retina, quantifies macular thickness and assesses the integrity of the underlying photoreceptor layers — a determining factor in estimating the potential for visual recovery after surgery.

Cachan

OCT Zeiss Cirrus 6000 — macular mapping, analysis of the retinal layers, central thickness.

Paris 13

OCT Toward Pi YAlkai — macular follow-up of patients with a membrane secondary to diabetic retinopathy or venous occlusion.

Surgical indication

Bothersome metamorphopsia + progressive decline in acuity + intact retinal layers on OCT. A slowly progressing membrane may simply be monitored.

Vitrectomy with macular peeling

The only effective treatment is surgical. It relies on pars plana vitrectomy (three microincisions of less than one millimetre) with peeling of the membrane using a micro-forceps, performed under vital staining. An associated peeling of the internal limiting membrane (ILM) is commonly performed to reduce the risk of recurrence, estimated at less than 5 % of cases.

Location & anaesthesia

Clinique Sainte-Geneviève — Paris 14 (29 rue Sarrette)
Outpatient surgery — home the same day
Loco-regional anaesthesia (peribulbar)

3D visualisation

Zeiss Artevo 800 microscope — digital 3D heads-up visualisation on a 55″ 4K screen. It includes an intraoperative OCT allowing the membrane peeling to be monitored in real time during the procedure.

Results and visual recovery

Visual recovery is progressive over 3 to 12 months. In a large series of 504 eyes, a gain of at least two lines of acuity was observed in 48 % of cases at 12 months (PMID 25574782). The improvement is maintained over the long term : a prospective study confirmed a lasting positive effect on visual quality of life at 2 years (PMID 35169203).

The outcome depends mainly on the state of the photoreceptor layers before surgery : a membrane diagnosed early with intact layers gives better results. The preoperative OCT analysis makes it possible to assess this potential during the consultation.

Postoperative course

  • Home the same day
  • No particular positioning required after the operation (unlike with a macular hole)
  • Antibiotic and anti-inflammatory eye drops for 4 to 6 weeks
  • Time off work of 1 to 2 weeks depending on the activity
  • Postoperative follow-up : D1, D7, D30, D90 with control macular OCT

References

1. Schechet SA et al. Results and prognostic factors for visual improvement after pars plana vitrectomy for idiopathic epiretinal membrane. Retina. 2015;35(5):880–886. PMID 25574782

2. Khanna RK et al. Long-term functional outcomes and vision-related quality of life after vitrectomy for epiretinal membrane: a prospective cohort study. Sci Rep. 2022;12:2470. PMID 35169203

3. Mahmoudzadeh R, Khan MA. Pars Plana Vitrectomy for Idiopathic Epiretinal Membrane: OCT Biomarkers of Visual Outcomes in 322 Eyes. Ophthalmol Retina. 2022. PMID 34718218

Frequently asked questions

Very rarely. In rare cases, it detaches spontaneously, but as a rule it remains stable or slowly thickens. There is no medical treatment (eye drops, supplement) capable of making it disappear.

No. A thin, minimally symptomatic membrane is simply monitored with macular OCT. Vitrectomy with peeling is only offered when the visual disturbance (line distortion, decline in acuity) becomes significant for the patient.

The procedure stabilises vision and often improves distortion and acuity, but recovery is progressive (several months) and sometimes partial, especially if the membrane had been developing for a long time. The outcome depends on the initial state of the macula.

The procedure is performed under local or loco-regional anaesthesia and is not felt during the operation. Sensations of grit in the eye or moderate discomfort are possible for a few days afterwards, relieved by the prescribed eye drops.

In patients who have not yet had cataract surgery, vitrectomy often accelerates its appearance in the months or years that follow. This cataract can then be operated on in the usual way, with excellent results.

Recurrence after complete peeling is rare. Follow-up with macular OCT (D1, D7, D30, D90 then annual) makes it possible to detect it should it occur and to adapt the management.

Diagnosis & Surgery

Consult for an epiretinal membrane

Macular OCT and surgical decision in Cachan or Paris 13. Vitrectomy with peeling under the Artevo 800 3D microscope at the Clinique Sainte-Geneviève (Paris 14).

Cachan — Doctolib
Paris 13 — Doctolib

Understand in pictures

Vitrectomy, step by step

On the same topic