Prevalence and associations of epiretinal membranes. The Blue Mountains Eye Study, Australia

[Proliferative vitreoretinopathy (PVR) minimal: same, same but different. Characteristics and surgical treatment of PVR-associated macular pucker]

BACKGROUND

Epiretinal membrane formation resulting in a macular pucker is among the typical complications associated with proliferative vitreoretinopathy (PVR) in retinal detachment and has a major impact on the functional outcome after surgical treatment.

METHODS

A literature search was carried out in PubMed.

RESULTS

Approaches to the surgical treatment of PVR-associated macular pucker include complete membrane removal within the vascular arcades aimed at relieving retinal traction at the posterior pole and peeling of the internal limiting membrane (ILM). As a further option it has been suggested that primary ILM peeling in rhegmatogenous retinal detachment repair may reduce or even prevent postoperative epiretinal membrane formation. In addition, correct timing of surgery is a factor that may contribute to successful treatment.

DISCUSSION

Due to the particularly strong adhesion and the frequent occurrence of concurrent retinal detachment, the surgical approach to PVR-associated macular pucker is particularly challenging. As with idiopathic epiretinal membranes, surgical removal has the potential to improve functional outcomes; however, visual improvement depends largely on whether the macula was involved in the original retinal detachment.

Prevalence of epiretinal membrane in the phakic eyes based on spectral-domain optical coherence tomography

The prevalence of epiretinal membrane (ERM) and associated factors in the phakic eyes have not been fully elucidated yet. This cross-sectional study included 2,354 phakic eyes without retinal diseases or surgical history. Ocular parameters, such as uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), spherical equivalent (SE), intraocular pressure (IOP), white-to-white corneal diameter (WTW), mean keratometric value (Km) of total corneal refractive power at 4-mm diameter (TCRP4), astigmatism of TCRP4, total corneal irregular astigmatism (TCIA), pupil diameter, axial length (AXL), anterior chamber depth (ACD), lens thickness (LT), and posterior vitreous detachment (PVD) were compared between ERM group and control group. Additionally, an age-matched control group was selected by individual matching and compared with the ERM group to eliminate the confounders. Multiple logistic regression analysis was performed to evaluate the factors associated with the presence of ERM. Among 2,354 eyes, 429 eyes (18.2%) had ERM based on spectral-domain optical coherence tomography. The ERM group showed higher prevalence of PVD, worse CDVA, higher astigmatism of TCRP4, higher TCIA, smaller pupil size, longer AXL, and thicker LT than control group (P < 0.001, P < 0.001, P = 0.011, P < 0.001, P = 0.023, P < 0.001, and P < 0.001, respectively). Only PVD, CDVA, SE, astigmatism of TCRP4, TCIA, and AXL maintained the significance when compared with the age-matched control group (P < 0.001, P = 0.026, P < 0.001, P = 0.001, P = 0.003, and P < 0.001, respectively). Multivariate logistic regression analysis showed that age, PVD, CDVA, and TCIA were independently associated with the presence of ERM (P < 0.001, P < 0.001, P = 0.011, and P = 0.002). The prevalence of ERM detected using SD-OCT was 18.2% in the middle aged phakic population. Eyes with TCIA, in addition to older age and PVD, were more likely to have ERM.

Epiretinal Membrane Surgery: Structural Retinal Changes Correlate with the Improvement of Visual Function

Several parameters have been studied for identifying the visual outcomes after pars plana vitrectomy (PPV) for epiretinal membrane (ERM) peeling. This retrospective study aimed to analyze structural retinal changes with spectral domain-optical coherence tomography (SD-OCT) and their correlations with visual acuity improvement in patients with ERM undergoing PPV. Twenty-one pseudophakic eyes were enrolled in the study. Ophthalmic evaluations included best corrected visual acuity (BCVA) and retinal layer thickness measurements with SD-OCT. The segmentation of the retina was divided into four parts: the inner retinal layer (IRL), composed of an internal limiting membrane, retinal nerve fiber layer, ganglion cell layer, and inner plexiform layer; inner nuclear layer (INL); outer plexiform layer (OPL); and outer nuclear layer (ONL). Correlations between changes in retinal layer thicknesses and BCVA were explored over a 6 month follow-up period. The postoperative thickness decrease of the INL was significantly correlated with thickness changes in all other measured retinal layers (p < 0.001). Non-parametric linear regression showed that postoperative improvement in BCVA was associated with a postoperatively decreased thickness in the IRL (p = 0.021), INL (p = 0.039), and OPL (p = 0.021). In eyes undergoing PPV, postoperative thickness decreases of the IRL, INL, and OPL were correlated with visual acuity improvements. Re-compaction of these retinal layers after relieving ERM-induced traction may be an important factor in postoperative visual function improvement.

Correlation between Visual Acuity and Optical Coherence Tomography Angiography Parameters in Unilateral Idiopathic Epiretinal Membrane

Background: The tangential traction by idiopathic epiretinal membrane (iERM) may alter the hemodynamics of the macula. We investigated the correlation between visual acuity and the optical coherence tomography angiography (OCTA) parameters in unilateral iERM. Methods: We included 61 eyes of 61 consecutive patients with unilateral iERM between January 2018 and December 2018. The flow area of the retinal superficial capillary plexus (SCP), deep capillary plexus (DCP), and choroidal capillary plexus (CCP) were measured using OCTA. The normal fellow eyes were used for comparison. The iERM patients were divided into those with a presence of foveal concavity and those with a loss of foveal concavity. Results: When compared with fellow eyes, the flow areas showed a statistically significant decrease in the SCP and CCP of those with iERM (p = 0.037 and p = 0.011, respectively). In the DCP, no significant reduction in flow area was found in iERM (p = 0.054). The flow area of the CCP was the only factor significantly associated with best vision (p = 0.012). No significant differences in the flow areas of the SCP, DCP, and CCP were found between the presence and loss of foveal concavity. Conclusions: The flow area of the CCP is an important determinant of vision, emphasizing the crucial role of choroidal circulation in iERM. Moreover, mechanical stretch by iERM is not the only mechanism affecting the flow area.

Secondary epiretinal membrane after Ex-Press glaucoma filtration device implant

Purpose

To estimate the frequency of epiretinal membrane (ERM) in eyes with primary open-angle glaucoma (POAG) treated with Ex-Press shunt implant. Secondarily, we aimed to assess the role of concomitant cataract surgery and the impact of the ERM on central foveal thickness and macular volume.

Methods

In this prospective, consecutive, case-control study, we enrolled 54 patients affected by PAOG and scheduled for Ex-Press device implant with or without contemporary phacoemulsification. Contralateral eyes affected by POAG and receiving anti-glaucomatous eyedrops constituted the control group. Complete ophthalmologic evaluation and spectral-domain optical coherence tomography (OCT) were performed before and 1, 3 and 6 months after surgery.

Results

Twenty-six eyes received the Ex-Press implant alone, and 28 eyes underwent the combined procedure. Six months postoperatively, we observed 18 (33%) cases of ERM: 15 (28%) of cellophane macular reflex (CMR) and 3 (6%) of pre-macular fibrosis (PMF). In the control group, 9 (17%) eyes developed an ERM: 8 (15%) were CMR, and 1 (2%) was PMF. The frequency of ERM statistically differs between treated and contralateral eyes (P = 0.032, χ² test). The ERM frequency did not statically differ between eyes subjected to simple or combined surgery (P = 0.846, χ² test). Mean central foveal thickness and mean macular volume did not significantly differ between groups.

Conclusion

The Ex-Press glaucoma shunt may increase the risk of ERM onset regardless of the concomitant cataract surgery; however, most cases were cellophane macular reflex with limited functional and anatomical impact.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00417-020-05025-8.

Intraretinal microvascular changes after ERM and ILM peeling using SSOCTA

BACKGROUND

To prospectively investigate retinal vascular changes in patients undergoing epiretinal membrane (ERM) and internal limiting membrane (ILM) peeling using swept source optical coherence tomography angiography (SSOCTA).

METHODS

Consecutive patients were grouped based on ERM severity and followed using SSOCTA up to month 3 after surgical intervention. Superficial and deep foveal avascular zone (s/dFAZ) as well as foveal and parafoveal vessel density (VD) were correlated with ERM severity and visual acuity. Differences between groups were evaluated.

RESULTS

Significant correlations were found between ERM severity and baseline sFAZ, dFAZ and best corrected visual acuity (BCVA), central retinal subfield thickness (CST) and ΔCST (r = -0.52, r = -0.43, r = -0.42, r = 0.58, r = 0.39; all p<0.05). Vascular flow parameters did not correlate with age, peeling size, pseudophakia or CST, but correlated with intraretinal cysts presence. No associations of BCVA with any of the OCTA parameters across time were found. Significant differences between ERM severity groups 1 and 2 were found for sFAZ at baseline (p = 0.005) and at the 3-month follow-up (p = 0.014), and for dFAZ at baseline (p = 0.017). Superficial foveal and parafoveal VD were not significantly different between groups (all p>0.05).

CONCLUSIONS

This study clearly shows that ERM severity based on ERM staging has to be taken into account when undertaking studies in patients with idiopathic ERM using SSOCTA. Further, specific changes in the superficial and deep retinal vasculature in eyes undergoing ERM and ILM peeling were found. However, the clinical usefulness and prognostic value for post-surgical treatment BCVA of the SSOCTA-derived variables (sFAZ and dFAZ area, as well as foveal and parafoveal VD) used remains questionable.

STRUCTURAL AND FUNCTIONAL CHARACTERISTICS OF LAMELLAR MACULAR HOLES

PURPOSE

Lamellar macular holes (LMHs) can been subdivided into tractional and degenerative subtypes. This cross-sectional cohort study compared structural and functional characteristics in these subtypes hypothesizing that tractional LMH has a higher prevalence of vitreopapillary adhesion and tangential traction (macular pucker), whereas degenerative LMH has more ellipsoid zone disruption and worse vision, measured three different ways.

METHODS

Tractional LMH (n = 22) and degenerative LMH (n = 15) were distinguished by optical coherence tomography criteria. Separate spectral domain optical coherence tomography scanning of the macula and optic disk was performed. Visual acuity, contrast sensitivity function (Weber Index, %W), and the degree of visual distortions (3-dimensional threshold Amsler grid; % volume lost [%VL]) were quantified.

RESULTS

Vitreopapillary adhesion was present in 14/22 (64%) tractional, but in only 3/15 (20%) degenerative LMH (P = 0.006). Macular pucker was present in 19/22 (86%) tractional, but in only 8/15 (53%) degenerative LMH (P = 0.011). Ellipsoid zone disruption was present in 13/15 (87%) degenerative, but in only 2/22 (9%) tractional LMH (P = 0.0001). Visual acuity was better in tractional than degenerative LMH (P = 0.006), as was contrast sensitivity function (tractional = 3.44 ± 1.07 %W, degenerative = 4.66 ± 1.73 %W; P = 0.015). Visual distortions were less in tractional (0.33 ± 0.61 %VL) than in degenerative (0.85 ± 0.68 %VL) LMH (P = 0.014).

CONCLUSION

Structure and visual function differ significantly in subtypes of LMH. Tractional LMH has 3-fold higher prevalence of vitreopapillary adhesion and 2-fold higher prevalence of macular pucker. Degenerative LMH has 9-fold more ellipsoid zone disruption, worse visual acuity and contrast sensitivity function, and 3-fold more distortions. Thus, outer retinal integrity seems more closely correlated with vision than anterior structural abnormalities in LMH.

Outer Plexiform Layer Angle: A Prognostic Factor for Idiopathic Macular Pucker Surgery

Purpose. To investigate the efficacy of idiopathic macular pucker (epimacular membrane) surgery and to identify the possible prognostic factor. Methods. This was a retrospective study which enrolled 38 patients with idiopathic macular pucker who underwent 23-gauge pars plana vitrectomy (PPV) with indocyanine green-assisted peeling of epiretinal membrane (ERM) and internal limiting membrane (ILM). Visual outcomes were assessed at the baseline and during the follow-up including best-corrected visual acuity (BCVA) and metamorphopsia score, as well as outer plexiform layer (OPL) angle and central retinal thickness (CRT) using spectral-domain optical coherence tomography (SD-OCT). A comparison was made between patients with the prepeeling CRTs ≥500 μm and those <500 μm. A comparison was also made between patients with the prepeeling OPL angles ≥130° and those <130°. Based on the prepeeling parameters, the correlations between various prepeeling and postpeeling visual functions were analyzed. Results. Mean follow-up was 36.07 ± 4.62 months (range 1.30–96.70 months). BCVA was significantly improved from 0.26 ± 0.03 to 0.67 ± 0.04 $\left(p<0.001\right)$ ; metamorphopsia score was significantly reduced from 1.42 ± 0.16 to 0.61 ± 0.08 $\left(p<0.001\right)$ ; CRT was significantly decreased from 519.62 ± 13.41 μm to 385.37 ± 8.97 μm $\left(p<0.001\right)$ . Greater prepeeling OPL angle (≥130°) was associated with significantly greater BCVA improvement (Snellen E/LogMAR: $p=0.01/0.03$ ) and greater metamorphopsia reduction $\left(p=0.03\right)$ , as compared to smaller OPL angle (<130°) with less BCVA improvement and less metamorphopsia reduction. However, the final BCVA improvement and metamorphopsia reduction relevant to the prepeeling smaller CRT (<500 μm) did not significantly differ from that relevant to the prepeeling greater CRT (≥500 μm; $p>0.05$ ). Endophthalmitis, retinal tear, or retinal detachment was not observed after peeling. Conclusion. Indocyanine green-assisted ERM/ILM peeling combined with small gauge vitrectomy is associated with significant visual acuity improvement and metamorphopsia reduction in patients with idiopathic macular pucker. Greater prepeeling OPL angle rather than CRT might act as a useful prognostic factor in predicting better final visual functional outcomes.

Identification of microvascular and morphological alterations in eyes with central retinal non-perfusion

Purpose

To evaluate the characteristics and morphological alterations in central retinal ischemia caused by diabetic retinopathy (DR) or retinal vein occlusion (RVO) as seen in optical coherence tomography angiography (OCTA) and their relationship to visual acuity.

Methods

Swept-source optical coherence tomography (SSOCT) and OCTA (Topcon, Triton) data of patients with central involving retinal ischemia were analyzed in this cross-sectional study. The following parameters were evaluated: vessel parameters, foveal avascular zone (FAZ), intraretinal cysts (IRC), microaneurysms (MA), vascular collaterals in the superficial (SCP) and deep plexuses (DCP), hyperreflective foci (HRF), epiretinal membrane (ERM), external limiting membrane (ELM) and ellipsoid zone (EZ) disruption, as well as the disorganization of retinal inner layers (DRIL). Best-corrected visual acuity (BCVA), age, gender, disease duration and ocular history were also recorded.

Results

44 eyes of 44 patients (22 with RVO, 22 with DR) were analyzed. The mean age was 60.55 ± 11.38 years and mean BCVA 0.86 ± 0.36 (Snellen, 6m). No significant difference was found between DR subgroups (non proliferative vs. proliferative). Between RVO subgroups (CRVO vs. BRVO) a significant difference was found in term of collateral vessel of the DCP (p = 0.014). A pooled DR and RVO group were created and compared. Significantly more MAs (p = 0.007) and ERM (p = 0.007) were found in the DR group. Statistically significant negative correlation was demonstrated between FAZ and BCVA (p = 0.45) when analyzing all patients with retinal ischemia.

Conclusion

This study has shown that the best predictor of visual outcome in center involved ischemic diseases is the size of FAZ. Besides the presence of MAs and ERM, all other OCT and OCTA parameters were present in a similar extent in DR and RVO group despite the completely different disease origins. Our results suggest that as soon as retinal ischemia in the macular region is present, it has a similar appearance and visual outcome independently of the underlying disease.

Rates of Reoperation in 10 114 Patients with Epiretinal Membranes Treated by Vitrectomy with or without Inner Limiting Membrane Peeling

PURPOSE

To compare rates of reoperation in patients with idiopathic epiretinal membrane (ERM) who received pars plana vitrectomy (PPV) with or without inner limiting membrane (ILM) peeling and to assess trends in the overall use of ILM peeling over time.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients included in the IBM Marketscan database between January 1, 2008, and December 31, 2016, who underwent surgery for idiopathic ERM.

METHODS

Procedure claims with laterality codes were used to determine patients with idiopathic ERM who received PPV with or without ILM peel between 2008 and 2016, and to identify cases of reoperation and subsequent retinal detachment within 1 year of index surgery.

MAIN OUTCOME MEASURES

The primary outcome was rate of reoperation for recurrent ERM according to whether or not patients receive an ILM peel during their index ERM surgery. We also assessed trends for index ERM surgery (ILM peel or no ILM peel) between 2008 and 2016, and the risk of developing retinal detachment within 1 year of the index ERM surgery.

RESULTS

A total of 10 114 patients received ERM surgery and met inclusion criteria (5310 without ILM peel and 4804 with ILM peel). The reoperation rate was significantly lower among patients who received PPV with ILM peel (0.88%) compared with patients without ILM peel (1.48%; P = 0.007). In 2008, PPV without ILM peel represented 70% of ERM procedures, but PPV with ILM peeling accounted for 52% and 70% of ERM procedures in 2013 (P < 0.001) and 2016 (P < 0.001), respectively. The rates of retinal detachment were similar between patients who received an ILM peel (0.79%) and patients who did not receive an ILM peel (0.92%) during their primary ERM surgery (P = 0.474).

CONCLUSIONS

The increasing use of PPV with ILM peeling to address ERM removal is associated with significantly reduced reoperation rates within 1 year. Future studies are needed to determine the cost-effectiveness of performing an ILM peel for initial idiopathic ERM repairs and evaluate long-term visual and structural changes related to ILM peeling.

Prevalence of epiretinal membranes in the ageing population using retinal colour images and SD-OCT: the Alienor Study

PURPOSE

To analyse and compare the prevalence of epiretinal membranes (ERMs) obtained using either standard retinal colour images or spectral-domain optical coherence tomography (SD-OCT) in a population-based setting of French elderly subjects.

METHODS

Six hundred twenty-four subjects of the Alienor cohort aged 75 years or older underwent both colour fundus imaging and SD-OCT examinations. The ERMs were graded from retinal images and SD-OCT macular scans in a masked fashion. On SD-OCT images, the early ERMs, mature contractile ERMs without foveal modifications and mature contractile ERMs with foveal alterations were distinguished.

RESULTS

610 (97.8%) subjects had gradable SD-OCT examinations, and 511 (81.9%) had gradable fundus images in at least one eye. According to colour photographs, 11.6% of participants had definite ERMs. From SD-OCT images, 52.8% of the subjects had early ERMs, 7.4% had mature ERMs without foveal involvement, and 9.7% had mature ERMs with foveal alterations. Regardless of the imaging method used, the ERMs were more often observed in pseudophakic eyes than in phakic eyes. Comparison of ERM assessment using fundus photographs versus SD-OCT images demonstrated that the specificity of retinal colour images was good (>89.3%), whereas the sensitivity remained low even though it increased with ERM severity on SD-OCT images.

CONCLUSIONS

Spectral-domain optical coherence tomography (SD-OCT) examinations have high feasibility in this elderly population and are much more sensitive than standard colour images for ERM assessments, especially in the early stages of the disease. Our results further highlight the need to use SD-OCT instead of colour retinal photographs for the classification of ERMs in epidemiological studies.

Effect of Phacoemulsification on Outcomes after Vitrectomy with Membrane Peeling regarding New Intraretinal Cystoid Changes and Transient Macular Edema

PURPOSE

The aim of the present study was to analyze the effect of phacoemulsification on outcomes among patients undergoing vitrectomy with membrane peeling for idiopathic epiretinal membranes, with respect to new postoperative intraretinal cystoid changes and early transient macular edema.

PROCEDURES

This retrospective analysis included patients from 6 prospective studies, examining outcomes of 23G pars plana vitrectomy with membrane peeling due to idiopathic epiretinal membranes. Phacovitrectomy with membrane peeling was performed only in the case of coexisting vision affecting cataract. Optical coherence tomography was performed prior to surgery, in the first week, and 3 months after surgery.

RESULTS

In total, 183 patients were included. The occurrence of new postoperative intraretinal cystoid changes and early transient macular edema showed a trend toward being higher among patients undergoing phacovitrectomy with membrane peeling, compared to vitrectomy with membrane peeling alone, but it did not reach statistical significance (p = 0.5 and p = 0.186). The final best corrected distance visual acuity (BCVA) 3 months after surgery was significantly lower among patients with new postoperative intraretinal cystoid changes compared to patients without (with a median difference of 1 line between groups; p = 0.016).

CONCLUSIONS

New postoperative intraretinal cystoid changes and early transient macular edema are more frequent among patients undergoing phacovitrectomy with membrane peeling compared to patients with vitrectomy with membrane peeling alone.

Prevalence and associations of non-retinopathy ocular conditions among older Australians with self-reported diabetes: The National Eye Health Survey

AIM

To determine the prevalence and associations of non-retinopathy ocular conditions among older Australian adults with diabetes.

METHODS

Multistage random-cluster sampling was used to select 3098 non-indigenous Australians aged 50y or older (46.4% male) and 1738 indigenous Australians aged 40y or older (41.1% male) from all levels of geographic remoteness in Australia. Participants underwent a standardised questionnaire to ascertain diabetes history, and a clinical examination to identify eye disease. We determined the prevalence of uncorrected refractive error, visually significant cataract, cataract surgery, age-related macular degeneration, glaucoma, ocular hypertension, retinal vein occlusion and epiretinal membrane among those with and without self-reported diabetes.

RESULTS

Participants with self-reported diabetes had a higher prevalence of cataract surgery than those without diabetes (28.8% vs 16.9%, OR 1.78, 95%CI: 1.35-2.34 among non-indigenous Australians, and 11.3% vs 5.2%, OR 1.62, 95%CI: 1.22-2.14 among indigenous Australians). Diabetic retinopathy (DR) increased the odds of cataract surgery among self-reported diabetic indigenous and non-indigenous Australians (OR 1.89, P=0.004 and OR 2.33, P<0.001 respectively). Having diabetes for ≥20y and having vision-threatening DR increased the odds of cataract surgery among indigenous Australians with diabetes (OR 3.73, P=0.001 and 7.58, P<0.001, respectively).

CONCLUSION

Most non-retinopathy ocular conditions are not associated with self-reported diabetes. However, to account for Australia's worsening diabetes epidemic, interventions to reduce the impact of diabetes-related blindness should include increased cataract surgery services.

Inverted internal limiting membrane flap technique in the surgical treatment of macular holes: 8-year experience

PURPOSE

To evaluate the ellipsoid zone (EZ) structural recovery, hole closure rate, and visual acuity improvement after inverted internal limiting membrane (ILM) flap technique.

METHODS

Retrospective cohort of eyes affected by idiopathic macular holes (MH) that underwent pars plana vitrectomy combined with inverted ILM flap technique in a tertiary center, over an 8-year period (2011-2019). The main outcomes were the postoperative qualitative analysis of EZ structure on spectral-domain optical coherence tomography, hole closure rate, and best-corrected visual acuity (BCVA) improvement of ≥ 0.3 units in the logarithm of minimal angle of resolution (logMAR) scale.

RESULTS

Our study included 76 eyes of 72 patients; 65% were female, with a mean age of 70 ± 8 years-old. Median (range) follow-up was 21 (3-92) months. Hole closure rate was 92%. Structural defects in EZ were observed in 66% of closed holes (EZ atrophy in 33%, EZ disruption in 22%, and EZ thinning in 11%). The mean final BCVA was 0.5 ± 0.4 logMAR (Snellen 20/63), but visual acuity improvement occurred in 80% of the eyes. Final BCVA was significantly worse in eyes with EZ atrophy compared with eyes with EZ disruption (0.75 vs. 0.36 logMAR, p = 0.004) and EZ thinning (0.75 vs. 0.32 logMAR, p = 0.015). In multivariate regression, minimum linear diameter (OR 1.01; IC 95% 1.01-1.02) independently predicted a final BCVA (logMAR) < 0.3 units.

CONCLUSION

Inverted ILM flap technique provided a hole closure rate above 90%, similar to previous studies. Although the modest value of the final BCVA, a significant visual acuity improvement occurred in most eyes. Structural defects of EZ were found in more than half of closed MHs after surgery. Evidence of postoperative retinal atrophy was associated with a worse visual outcome.

Association of foveal avascular zone with the metamorphopsia in epiretinal membrane

This study was to investigate the relationship between the metamorphopsia and foveal avascular zone (FAZ) parameter in eyes with epiratinal membrane (ERM). We studied patients with an ERM visited retinal service unit at the Kagoshima University Hospital or Shirai Hospital. The best-corrected visual acuity (BCVA), and the degree of metamorphopsia by M -CHARTS™ were evaluated. The 3 × 3 mm optical coherence tomography angiography (OCTA) images of the superficial layer were obtained. Area (mm²), the circularity, eigen value were calculated using ImageJ software. The relationship between visual function, such as best corrected visual acuity (BCVA) and metamorphopsia, and FAZ parameters were studied by Pearson's correlational coefficient. Fifty-four eyes of 51 patients (24 men and 27 women) with an ERM were studied. The mean age of the patients was 69.6 ± 8.20 years. The mean BCVA and metamorphopsia score was 0.31 ± 0.29 logMAR units and 0.49 ± 0.42. There was no significant relationship between BCVA and FAZ parameters. While, metamorphopsia score was significantly and negatively correlated with all of FAZ parameters (area R = - 0.491, P < 0.001; circularity R = - 0.385, P = 0.004; eigenvalue ratio R = - 0.341; P = 0.012). Multiple regression analysis showed the FAZ area was solely and significantly correlated with metamorphopsia score (β - 0.479, P < 0.001). The size but not the shape of the FAZ was significantly correlated with the degree of metamorphopsia suggesting that it could be an objective parameter of metamorphopsia in ERM patients.

Pedicle internal limiting membrane flap technique for very large macular holes: a preliminary report

Background

Conventional vitrectomy technique for macular hole surgery has a good outcome in small and medium macular holes, but for very large macular holes (minimum linear diameter higher than 700 μm) other techniques were developed aiming to achieve greater rates of closure and visual acuity gain. The purpose of this article is to report the anatomical and functional outcomes of four very large macular hole (MH) cases which have undergone vitrectomy with the pedicle internal limiting membrane (ILM) flap technique.

Methods

This is a retrospective series of four patients with large MH who were treated with vitrectomy and the pedicle ILM flap technique. Comprehensive ophthalmologic evaluation was performed before surgery and included ETDRS best-corrected visual acuity (BCVA) and spectral domain optical coherence tomography (SD-OCT) for MH measures: height, minimum linear diameter (MLD) and external base diameter. The particular detail of this technique is related to ILM flap creation. During the peeling, the ILM was not removed completely from the retina but was left attached to the edges of the macular hole and subsequently trimmed with the vitrectomy probe using the scissors mode.

Results

Four patients with very large MH underwent PPV and the pedicle ILM flap technique was used to pursue macular closure. Median preoperative BCVA was 20/400 (range: 20/320 to 20/400) and median postoperative BCVA was 20/200 (range: 20/320 to 20/200). Of the 4 cases reported, 3 obtained anatomical closure (75%), and also presented BCVA improvement after surgery, considering the last follow-up visit of each case. No additional procedures were performed in either case. One patient demonstrated no anatomic and functional improvement.

Conclusion

The present study describes the first Brazilian case series of very large MH treated by the inverted pedicle ILM flap technique. This technique was associated with anatomic and visual improvement in most cases, and represents an alternative therapeutic approach for large macular holes.Trial Registration Project registered in Plataforma Brasil with CAAE number 30163520.0.0000.5440 and approved in ethics committee   from  Ribeirão Preto Medical School Clinics Hospital, University of São Paulo-Ribeirão Preto, São Paulo, Brazil (appreciation number 3.948.426 gave the approval).

Optical coherence tomography biomarkers as predictive factors for postoperative visual acuity in patients with epiretinal membrane treated with vitrectomy

BACKGROUND:

The purpose of this retrospective study was to evaluate potential predictive factors of postoperative visual outcome in patients with idiopathic epiretinal membrane (iERM), treated with pars plana vitrectomy (PPV).

METHODS:

Participants in the study were 46 patients diagnosed with iERM, who underwent PPV. Best-corrected visual acuity measurement and spectral domain-optical coherence tomography (OCT) were performed at baseline (preoperatively), and at months 6 and 12 postoperatively. Demographic characteristics and OCT parameters were assessed as potential predictive factors for postoperative visual outcome.

RESULTS:

Increasing age, retinal thickness, presence of disorganization of inner retinal layers, ellipsoid zone disruption, and presence of vitreomacular traction were found to be negatively associated with postoperative visual acuity. Gender, presence of subretinal fluid, cysts in the inner or outer nuclear layer, and hyperreflective foci were not found to affect visual acuity. There was statistically significant improvement in visual acuity and central retinal thickness between baseline and months 6 and 12 in the study sample.

CONCLUSIONS:

It is important to determine predictive factors for visual outcome, so as to inform patients about prognosis and help in the decision-making of patients' management.

Combined pars plana vitrectomy (PPV) and phacoemulsification (phaco) versus PPV and deferred phaco for phakic patients with full-thickness macular hole (FTMH) and no significant cataract at baseline: 1-year outcomes of a randomized trial combined PPV/phaco vs PPV/deferred phaco for MH

PURPOSE

To compare functional and anatomic outcomes of combined pars plana vitrectomy (PPV) and phacoemulsification (phaco) versus PPV and deferred phaco in patients with full-thickness macular hole (FTMH) and no significant cataract.

METHODS

Thirty-four patients were randomized to group 1 (combined PPV/phaco) and 34 to group 2 (PPV/deferred phaco). Group 2 patients could undergo phaco any time after FTMH surgery if significant cataract developed.

RESULTS

Sixty-five patients (33 group 1 and 32 group 2) completed the 12-month visit. Mean ± SEM logMAR best-corrected visual acuity (BCVA) was 0.92 ± 0.04 and 0.90 ± 0.04 at baseline and improved significantly to 0.60 ± 0.05 and 0.58 ± 0.05 at month 12 (p < 0.0001) in groups 1 and 2, respectively. There was no significant difference between the groups in mean BCVA at baseline or at month 12. Mean macular sensitivity (dB) was 18.22 ± 0.93 and 16.72 ± 0.93 at baseline and increased to 21.13 ± 0.86 and 21.07 ± 0.85 in groups 1 and 2, respectively (p < 0.05) with no significant difference between the groups (p = 0.449) at month 12. FTMH closure rate was 73% and 75% in groups 1 and 2, respectively (p = 0.834).

CONCLUSION

Among patients with FTMH and no significant cataract at baseline, combined PPV/phaco was associated with similar BCVA, microperimetry, and FTMH closure outcomes at 1-year compared with PPV/deferred phaco.

TRIAL REGISTRATION

( clinicaltrials.gov.br ): Ensaios clínicos brasileiros: RBR-3wmd9s; UTN number: U1111-1190-5013; Plataforma Brasil CAAE number: 50455415.3.0000.5440; IRB number: 1.433.000.

Long-Term Outcome of Epiretinal Membrane Surgery in Patients with Internal Limiting Membrane Dehiscence

PURPOSE

To identify the effect of internal limiting membrane (ILM) dehiscence on surgical outcomes in eyes that have undergone epiretinal membrane (ERM) removal.

METHODS

Consecutive eyes with performed vitrectomy for ERM removal were included. Subjects were divided into two groups: patients with ILM dehiscence (group 1) and without ILM dehiscence (group 2). The best-corrected visual acuity (BCVA) and retinal layer thickness before and after surgery were compared between the two groups.

RESULTS

A total of 86 eyes were enrolled. Forty-six eyes (53.5%) showed ILM dehiscence before surgery. The baseline BCVAs were 0.46 ± 0.29 and 0.45 ± 0.25 in groups 1 and 2, respectively (p = 0.801). The BCVAs at 3, 6, and 12 months after surgery differed significantly between the two groups. The subfoveal thickness and inner retinal layer thickness (IRLT) of group 1 vs. 2 were 507.4 ± 80.0 vs. 417.6 ± 63.6 μm, and 270.2 ± 74.3 vs. 182.6 ± 60.4 μm, respectively (both p < 0.001). These differences between the groups remained significant until 12 months after surgery. In multivariate analyses, the location of ILM dehiscence (B = -0.105, p = 0.034) and final IRLT (B = 0.001, p = 0.046) were significant factors affecting the final BCVA.

CONCLUSIONS

ILM dehiscence is a relatively common finding and associated with preoperative and postoperative increased IRLT, which results in worse surgical outcomes compared to the absence of ILM dehiscence in patients with ERM. Additionally, the final BCVA was significantly affected by its location and final IRLT in patients with ILM dehiscence.

One-year follow-up evaluation of combined phacovitrectomy for idiopathic epiretinal membrane

AIM

To evaluate the therapeutic effect of combined phacovitrectomy with membrane peeling and intraocular lens (IOL) implantation in patients with severe idiopathic epiretinal membrane (iERM) and concurrent cataract.

METHODS

A total of 34 eyes from 34 patients who underwent phacovitrectomy and epiretinal membrane (ERM) peeling at the First Affiliated Hospital of Zhejiang University between 2015 and 2017. The best-corrected visual acuity (BCVA) and central foveal thickness (CFT) were measured preoperatively and at 1, 3, 6mo and 1y postoperatively. Temporal changes and bivariate correlations of these parameters were analyzed.

RESULTS

Mean logMAR BCVA improved and CFT decreased significantly (P<0.001) until 6mo after surgery. Correlation analysis revealed a positive correlation between preoperative and postoperative logMAR BCVA (r=0.716, P<0.001 at 1mo, r=0.417, P=0.014 at 3mo, r=0.359, P=0.037 at 6mo, and r=0.369, P=0.032 at 12mo post-op respectively), but preoperative CFT was neither associated with postoperative CFT nor with postoperative logMAR BCVA. There was a positive correlation between CFT and logMAR BCVA at 1mo (r=0.346, P=0.045), 6mo (r=0.347, P=0.045), and 12mo (r=0.342, P=0.048) post-operatively. The intra- and postoperative complications were relatively mild, and the incidences were generally low.

CONCLUSION

For severe iERM patients with significant visual symptoms, combined phacovitrectomy with membrane peeling and IOL implantation is safe and effective in improving BCVA and decreasing CFT. Early surgery in selected patients may help preserving better visual function.

Long-term natural history of the idiopathic epiretinal membrane in children and young adults

PURPOSE

To evaluate the natural history of the idiopathic epiretinal membrane (ERM) in children and young adults.

METHODS

This retrospective study included 52 patients younger than 40 years who had been diagnosed with idiopathic ERM. Best-corrected visual acuity (BCVA) and central retinal thickness (CRT) measured at diagnosis were compared with those at the final visit. Incidence and factors predictive of the spontaneous release of ERM were additionally investigated. Moreover, the proportion of eyes that eventually underwent surgery was identified.

RESULTS

The mean age of the patients was 32.5 ± 6.7 years, and the mean follow-up duration was 34.5 ± 23.4 months. The mean logarithm of the minimal angle of resolution BCVA (0.05 ± 0.10, Snellen equivalents = 20/22) and CRT (340.6 ± 61.6 μm) at diagnosis were not different from BCVA (0.06 ± 0.10, 20/23) (P = 0.928) and CRT (326.6 ± 70.8 μm) (P = 0.079) at the final follow-up. Two lines or greater deterioration in the BCVA was noted in 2 eyes (3.8%). Spontaneous release of ERM was noted in 14 eyes (26.9%). The release of ERM was more frequently noted in eyes without cystoid intraretinal edema or retinoschisis (P = 0.020) or eyes with loss of foveal concavity at diagnosis (P = 0.008). During the follow-up period, 5 eyes (9.6%) underwent surgery.

CONCLUSIONS

The natural history of the idiopathic ERM in children and young adults was generally favorable with definite deterioration in visual acuity noted only in a limited proportion of patients. Baseline retinal morphology may be predictive of the spontaneous release of ERM.

Characteristics and pathologies of the vitreo-macular interface-results from the Gutenberg Health Study

PURPOSE

We aimed to determine the prevalence of characteristics and pathologies of the vitreo-macular interface within the general population.

METHODS

The Gutenberg Health Study is a population-based study in Germany, including an ophthalmological examination with refraction, biometry and optical coherence tomography (OCT) imaging. Characteristics of the vitreo-macular interface were graded on volume scans including visibility of an epiretinal membrane, full-thickness macular hole, lamellar hole and pseudohole. Overall and age-specific prevalences including 95% confidence intervals [95%-CI] were calculated. Association analyses were conducted to determine systemic and ocular factors that are associated with epiretinal membranes (the most common pathology) using multivariable logistic regression.

RESULTS

A total of 1890 people aged 40-80 years were included in the study. Of these, 4.7% (95%-CI: 3.8%-5.8%) had an epiretinal membrane in at least one eye, 0.1% a full-thickness macular hole, 0.6% a lamellar hole and 0.6% a pseudohole. The presence of an epiretinal membrane was associated with higher age, myopic refractive error and prior retinal laser therapy, but not with gender, body height, body weight, smoking, prior cataract surgery or intraocular pressure.

CONCLUSIONS

Epiretinal membranes are more frequent in older and myopic subjects and in those with prior retinal laser therapy.

Incidence of acute postoperative endophthalmitis following macular surgery in France between 2006 and 2016

PURPOSE

To report the incidence of acute postoperative endophthalmitis (POE) after macular surgery in France between 2006 and 2016 and to identify associated factors.

METHODS

This retrospective database study included all hospital discharge records involving a surgical procedure for an epiretinal membrane or a macular hole in France from January 2006 to October 2016. Acute POE was identified by two codes in the tenth edition of the International Classification of Diseases within 42 days of a macular surgical procedure in the French national administrative database.

RESULTS

In France, 152 034 macular surgical procedures for epiretinal membranes or macular holes were recorded from 1 January 2006 to 31 October 2016. Suspected acute POE was reported in 381 cases. The incidence of POE was 0.25% overall, 0.30% for epiretinal membrane surgery and 0.14% for macular hole surgery. In multivariable Poisson regression analysis, epiretinal membrane surgery was associated with POE [incidence rate ratio (IRR), 2.24; 95% CI, 1.62-3.11; p < 0.001]. For epiretinal membrane surgery, the 2010-2011 period was significantly associated with a higher risk of POE (IRR, 1.66; 95% CI, 1.13-2.42; p = 0.03).

CONCLUSION

The incidence of POE after macular surgery was 0.25% overall in France between 2006 and 2016 and twice higher for epiretinal membrane surgery than for macular hole surgery. For epiretinal surgery only, the incidence of POE was higher in 2010-2011 (period of the switch to transconjunctival vitrectomy) than in the rest of the study period.

FIVE-YEAR INCIDENCE AND RISK FACTORS FOR IDIOPATHIC EPIRETINAL MEMBRANES

PURPOSE

The aim of this was to determine the 5-year incidence of idiopathic epiretinal membrane (ERM) and its risk factors in Korean adults.

METHODS

A total of 2,152 participants aged 50 years or older enrolled in a health screening program. All participants underwent baseline ophthalmic and systemic examinations in 2006, and were reexamined after 5 years. Epiretinal membranes were diagnosed using fundus photographs taken at baseline and at the 5-year follow-up. The incidence of idiopathic ERM was calculated in this study cohort, and then age-standardized to the 2010 Korean Census. Epiretinal membranes were classified as preretinal macular fibrosis with prominent retinal folds or cellophane macular reflex without retinal folds. Associated risk factors for idiopathic ERM were also analyzed.

RESULTS

Idiopathic ERM developed in 82 of 2,152 participants who had no previous ERM in either eye at baseline. The overall age-standardized incidence was 3.8% (95% confidence interval, 2.8-4.8), including 2.3% with cellophane macular reflex and 1.5% with preretinal macular fibrosis. Multivariate logistic regression analyses revealed that the factors related to the development of idiopathic ERM were age (adjusted odds ratio, 1.04; 95% confidence interval, 1.00-1.08) and hypertriglyceridemia (250 mg/dL or more; adjusted odds ratio, 3.16; 95% confidence interval, 1.54-6.49) after adjusting for confounding factors.

CONCLUSION

Our results suggest that the 5-year incidence of idiopathic ERM in Korean adults is relatively similar to that in similar-aged white persons. Age and hypertriglyceridemia may increase the risk of developing idiopathic ERM.

Effect of Internal Limiting Membrane Peeling on Macular Structure and Metamorphopsia Scores in Idiopathic Epiretinal Membrane Surgery

Backgrounds and Objective:

Pars Plana Vitrectomy (PPV) and epiretinal membrane (ERM) peeling is the standard surgical procedure of ERM surgery. However, the effect of adding Internal Limiting Membrane (ILM) peeling to the standard surgery on macular function and structure remains still controversial. This study was aimed at investigating the effect of ILM peeling on the macular function and structure in idiopathic ERM surgery.

Method:

Thirty-six eyes of 34 patients were evaluated in this prospective study. The patients were divided into two groups (ILM peeling and non-ILM peeling group). While the removal of ERM was undergone alone in 19 eyes, it was combined with ILM peeling in 17 eyes. Metamorphopsia scores Vertical Metamorphopsia (VM) and Horizontal Metamorphopsia (HM), were measured at preoperative and 4 months postoperatively.

Results:

There was a statistically significant decrease in metamorphopsia (VM and HM) scores in both groups after the surgery. However, no statistically significant difference was found between the two groups in terms of reduction in VM scores and HM scores after surgery.

Conclusion:

Our study indicated that ILM peeling combined with ERM did not affect metamorphopsia scores.

Predicting Progression of Untreated Macular Pucker Using Retinal Surface En Face Optical Coherence Tomography

PURPOSE

To review visual outcomes in untreated premacular membrane (PMM) with macular pucker (MP) and evaluate novel predictors of progression.

METHODS

In this retrospective observation study, we included 342 eyes with untreated PMM with MP between 2012 and 2015. PMMs were characterized by spectral-domain optical coherence tomography (SD-OCT) imaging based on foveal morphologies, number of retinal contraction centers, central subfield thickness (CST), inner segment ellipsoid band integrity, and photoreceptor deformation index. Additionally, the thickened retina portion was identified by en face OCT and processed digitally to calculate its area. Parameters were retrospectively analyzed using multiple regression analyses to identify associations with change in visual acuity (VA) between initial to final follow-up visit.

RESULTS

In 468 eyes with untreated PMM, VA and CST did not change significantly during a mean observation period of 448 days (p = 0.52 and 0.35, respectively). Specifically, VA improved or stayed the same in 80% and worsened by 2 lines or more in 20% of eyes. The only consistent predictor of PMM progression was area of retinal thickening: for every 1 mm2 of retinal thickening at baseline, the odds of having worsened vision at follow-up increased by 6% (OR 1.0606, 95% CI 1.0031-1.1214, p = 0.0387).

CONCLUSIONS

The majority of eyes with PMM and good visual function at baseline remain stable or spontaneously improve in VA and macular thickness. Area of retinal thickening as evaluated by en face OCT may be a novel predictor of vision loss in untreated PMM with MP.

Assessment of the Vitreomacular Interface Using High-Resolution OCT in a Population-Based Cohort Study of Older Adults

PURPOSE

To describe the prevalence of vitreomacular interface (VMI) features and their associated risk factors in the Northern Ireland Cohort for the Longitudinal Study of Ageing (NICOLA) Study.

DESIGN

Cross-sectional population-based study.

PARTICIPANTS

Noninstitutionalized Northern Irish adults 40 years of age or older.

METHODS

Using geographic stratification, a representative sample of people in Northern Ireland was invited to participate in the NICOLA Study. SD OCT images of participants were graded for vitreomacular traction (VMT), macular hole (MH), and epiretinal membrane (ERM) according to the International Vitreomacular Traction Study Group. A subsample was graded in more detail to estimate the prevalence of VMA and VMA area detailing size and location of VMA. Descriptive analysis and risk factors for each VMI feature were determined using generalized estimating equations. Results were standardized to the Northern Ireland population census (2011).

MAIN OUTCOME MEASURES

Cohort profile, standardized prevalence, and risk factor associations of each VMI feature.

RESULTS

Three thousand three hundred fifty-one NICOLA participants had gradable SD OCT images available for at least 1 eye. The prevalence of VMT was 0.5% (CI, 0.31%-0.70%), that for MH was 0.3% (CI, 0.23%-0.52%), and that for ERM was 7.6% (CI, 7.0%-8.3%). A detailed VMA analysis was performed on a subsample consisting of the first 1481 participants. The prevalence of VMA was 22.6% (CI, 21.1-24.2), and VMA area ranged from 0.25 to 42.7 mm² (mean, 12.53 mm²; standard deviation, 6.90 mm²). In multivariate analyses, increased age was associated with an increased odds ratio (OR) of VMT, MH, and ERM. VMA area was positively associated with younger age and normal blood pressure. ERM and MH were present more often in more myopic eyes, associated with an increase in levels of high-density lipoprotein (HDL) cholesterol and triglycerides.

CONCLUSIONS

The epidemiologic characteristics of VMI features indicated that VMI interactions throughout life are age dependent. Vitreous separation reduced to a greater extent in the horizontal meridians compared with the vertical, differing from previous studies. Future longitudinal studies of the evolution of these VMI changes over time would be of great interest.

To Peel or Not to Peel: Pars Plana Vitrectomy with Macular Membrane Peel in Eyes with Abnormalities of Vitreomacular Interface and Coexisting Dry Age-Related Macular Degeneration

Purpose

To evaluate the outcome of macular surgery with ILM- and epiretinal membrane peel associated with significant dry age-related macular degeneration (AMD) as defined by the Age-Related Eye Disease Study (AREDS).

Patients and Methods

Institutional. Retrospective case-control study. A total of 42 pseudophacic eyes of 39 patients (7 with full thickness macular hole and 35 with epiretinal membrane) with coexisting dry AMD underwent pars plana vitrectomy (PPV) with internal limiting membrane (ILM) and epiretinal membrane peel. Preoperative and postoperative data including best corrected visual acuity (BCVA), AMD grade according to AREDS, central retinal thickness (CRT), development of choroidal neovascularization (CNV), and central retinal atrophy have been evaluated. Twenty-eight fellow eyes with dry AMD of the included 39 patients served as a control group.

Results

A significant improvement in the visual acuity could be observed after surgery (initial BCVA 0.47±0.31 logarithm of the minimal angle of resolution (logMAR) vs 0.33±0.29logMAR 9 months postoperatively; p=0.006). CRT decreased significantly after surgery (p<0.001). In the surgery group, there were 4 eyes (9.5%) with CNV and 1 eye (2.5%) with new central retinal atrophy development after surgery. All these eyes had preoperative AREDS 3 (4 eyes) or AREDS 4 (1 eye) AMD category. In the control group, there was 1 eye (4%) with CNV and 4 eyes (14%) with new central retinal atrophy development during the follow-up of 9 months. These eyes had initially AREDS 2 (1 eye), AREDS 3 (3 eyes) or AREDS 4 (1 eye) AMD category.

Conclusion

Eyes with dry AMD of AREDS 3 and AREDS 4 with coexisting VMI abnormalities improve significantly after PPV with membrane peel. While there is a higher risk of CNV development after surgery (9.5%) in these eyes, the vitrectomy does not seem to accelerate central retinal atrophy progression compared to the fellow eyes course.

Are There Funduscopic and Optical Coherence Tomography Preoperative Characteristics to Predict Surgical Difficulty of Epiretinal Membrane Removal?

PURPOSE

To identify the correlation between preoperative funduscopic and optical coherence tomography characteristics of epiretinal membranes and the difficulty of surgical removal.

METHODS

Fifty eyes of 50 patients with an idiopathic epiretinal membrane (ERM) scheduled for pars plana vitrectomy (PPV) and ERM peeling were included. Surgical videos were analyzed and the difficulty of ERM removal (easy or difficult) determined subjectively by an independent surgeon. Furthermore, the peeling time and amount of grasping were measured on the videos to provide an objective factor of surgery difficulty. Preoperative spectral-domain optical coherence tomography (OCT) images and color fundus photos were analyzed to identify predictive factors for membrane removal difficulty.

RESULTS

The subjective surgical difficulty of ERM removal was strongly associated with fibrillary changes between the ERM and retinal nerve fiber layer (RNFL), severe retinal vascular tortuosity and severe glinting fundus reflex. Higher fundus pigmentation was associated with fewer and cystoid spaces with more attempts of grasping ERM. No other preoperative signs were found to be associated with the duration of the peeling time.

CONCLUSION

The presence of fibrillary changes between the ERM and RNFL, severe retinal vascular tortuosity and severe glinting reflex are preoperative findings that have a strong association with the difficulty in ERM peeling.

Perioperative intraretinal fluid observed using optical coherence tomography in the epiretinal membrane

Background

Postoperative intraretinal fluid (IRF) is reportedly associated with visual outcomes after epiretinal membrane (ERM) surgery. However, preoperative IRF is common, and persistent IRF would have different impact on visual function from postoperative newly developed IRF. Therefore, we aimed to investigate the incidence rate and clinical implications of perioperative IRF in ERM.

Methods

Medical records of patients who underwent vitrectomy for idiopathic ERM between January 2014 and January 2017 were reviewed retrospectively. The incidence of IRF was analyzed using optical coherence tomography preoperatively and 1, 3, and 6 months postoperatively. On the basis of the presence or absence and the time of detection of IRF, patients were divided into three groups, namely preoperative IRF group, New IRF group, and IRF(−) group. Correlations of various parameters including age, sex, baseline visual acuity (VA), central subfield macular thickness, lens status, and surgical factors with IRF, along with the effect of IRF on VA, were evaluated.

Results

This study included 155 eyes from 155 patients. Thirty-six (23.2%) and 49 (31.6%) eyes demonstrated preoperative and newly developed IRF, respectively. Seventy eyes (45.2%), which did not exhibit IRF during the study period, were assigned to the IRF(−) group. At baseline, the IRF(−) group showed a better VA than the other two groups. Postoperatively, VA improved significantly in all three groups. There was no difference in VA between the IRF(−) and new IRF groups at 6 months; however, the preoperative IRF group had significantly lower VA than the other two groups.

Conclusion

IRF associated with ERM was frequently observed preoperatively and postoperatively, but it did not prevent postoperative vision improvement. Preoperative IRF was related to lower postoperative vision improvement.

Relationship between nerve fiber layer defect and the presence of epiretinal membrane in a Japanese population: The JPHC-NEXT Eye Study

The study subjects were residents of Chikusei city, Japan, aged 40 years or older who attended annual health check-up programs and participated in the JPHC-NEXT Eye Study which performed non-mydriatic fundus photography of both eyes. The relationship of glaucomatous fundus changes such as optic disc cupping (cup to disc ratio ≥ 0.7) and retinal nerve fiber layer defect (NFLD) with the presence of epiretinal membrane (ERM) were examined cross-sectionally. A total of 1990 persons gave consent to participate in this study in 2013. The overall prevalence of ERM was 12.9%. Of these, 1755 had fundus photographs of sufficient quality and no history of intraocular surgery (mean age: 62.3 ± 10.0 years). After adjusting for age, sex and refractive error, NFLD was positively associated with the presence of ERM (odds ratio [OR]: 2.48; 95% confidence interval [CI]: 1.24, 4.96; P = 0.010), but optic disc cupping was not (OR: 1.33; CI: 0.71, 2.48; P = 0.37). The results did not necessarily suggest an association between glaucoma and ERM, but indicated an association between NFLD and ERM.

Choroidoscleral Interface Irregularity Index: A novel optical coherence tomography-based parameter in patients with epiretinal membrane

This study aimed to assess the regularity of the choroidoscleral interface (CSI) using a novel parameter, CSI irregularity index, before and after epiretinal membrane (ERM) surgery. This study included 36 patients with idiopathic ERM who underwent pars plana vitrectomy and ERM removal. All subjects underwent ocular examinations at baseline and at 1, 2, 4, and 6 months after surgery. The regular contour of the CSI was found in 14 patients (38.9%); mean CSI irregularity index was 14.84 ± 11.01 in this group. The irregular contour of the CSI was found in 22 patients (61.1%); mean CSI irregularity index was 33.96 ± 20.64 in this group. The CSI irregularity index decreased gradually after ERM surgery, and was correlated with postoperative best-corrected visual acuity. The CSI irregularity index could serve as a surrogate marker to quantitatively represent the CSI morphology. We observed the gradual decrease of the CSI irregularity index after ERM surgery in quantitative manner. This study showed correlations between the CSI irregularity index and visual outcomes after ERM surgery. Our results suggest that the CSI irregularity index might be an intuitive anatomic indicator of the CSI and might be useful as a possible prognostic marker for patients undergoing ERM surgery.

Internal limiting membrane peeling with different dyes in the surgery of idiopathic macular hole: a systematic review of literature and network Meta-analysis

AIM

To evaluate the effect of internal limiting membrane (ILM) peeling with indocyanine green (ICG), brilliant blue G (BBG), triamcinolone acetonide (TA), trypan blue (TB), or without dye for the treatment of idiopathic macular hole (IMH).

METHODS

A search was conducted using PubMed, EMBASE, and CENTRAL (Cochrane Central Register of Controlled Trials) for related studies published before October 2018.

RESULTS

A total of 29 studies and 2514 eyes were included in this network Meta-analysis. For IMH closure, the rank from the best to the worse treatment was: BBG, TB, TA, ICG, and no dye. There was a significant difference in postoperative IMH closure rate between BBG and no dye. The rank of the best to the worse treatment to improve visual acuity was: BBG, TB, no dye, TA, and ICG. The improvement rate of visual acuity after using BBG was significantly higher than ICG. The improvement rate of visual acuity was more favorable with TB than ICG, TA, and no dye.

CONCLUSION

BBG can contribute to better anatomical and functional outcomes compared to other dyes for ILM peeling in patients with IMH. The results show that the best treatment of ILM peeling with dyes is BBG.

Efficacy and Safety of Combined Vitrectomy with Intravitreal Dexamethasone Implant for Advanced Stage Epiretinal Membrane

Purpose

To evaluate the efficacy and safety of combined 25-gauge (G) pars plana vitrectomy (PPV) with intravitreal dexamethasone implant (DXI) for the treatment of advanced stage epiretinal membrane (ERM).

Methods

Forty consecutive pseudophakic eyes with idiopathic stage 3-4 ERM and intraretinal cysts were randomly assigned to two treatment groups. Twenty eyes underwent combined 25-G PPV, ERM peeling and slow-release DXI (DEX group), whereas 20 eyes underwent standard 25-G PPV with ERM peeling only (control group). Differences in postoperative best-corrected visual acuity (BCVA), intraocular pressure (IOP), central macular thickness (CMT) were evaluated.

Results

In all patients, BCVA significantly increased at 1, 3 and 6 months after surgery compared to baseline (all p < 0.05), but at 3 and 6 months, the visual gain was higher in the DEX group (respectively, p = 0.036, p = 0.006). CMT was significantly lower in DEX group compared to control group at 3 and 6 months after surgery (respectively, p = 0.042, p = 0.003). There was no statistically significant difference in IOP change over the course of the follow-up between groups (p > 0.05).

Conclusion

Combined 25-G PPV with DXI is associated with better anatomical and functional outcomes in patients with advanced stage ERM.

Visual Prognostic Factors of Epiretinal Membrane Surgery in Patients with Pseudophakia

PURPOSE

To evaluate the visual prognostic factors in patients with pseudophakic epiretinal membrane (ERM) after vitrectomy using spectral domain optical coherence tomography (SD-OCT).

METHOD

A retrospective review of patients with pseudophakic ERM having undergone vitrectomy was conducted. Best corrected visual acuity (BCVA) and SD-OCT were conducted before and 1, 3, and 6 months after vitrectomy. Known visual prognostic factors, such as inner-retina irregularity index, central foveal thickness (CFT), central inner retinal layer thickness (CIRLT), cone outer segment tip defect length, and photoreceptor outer segment length, were reviewed and their correlation with BCVA was analyzed.

RESULTS

Forty-three patients (mean age: 64.88 ± 10.46 years) with pseudophakic ERM were included. BCVA significantly improved after vitrectomy (logMAR 0.30 ± 0.24 vs. 0.11 ± 0.14, p < 0.001). The preoperative high inner-retina irregularity index significantly correlated with poor postoperative BCVA in patients with pseudophakic ERM (correlation coefficient 0.583, p < 0.001). Postoperative improvements of inner retinal SD-OCT findings, such as inner-retina irregularity index, CFT, and CIRLT, were significantly associated with the amount of BCVA improvement after ERM surgery (correlation coefficients were as follows: inner-retina irregularity index - 0.711, p < 0.001; CFT - 0.462, p = 0.002; CIRLT - 0.596, p < 0.001). However, preoperative outer retinal SD-OCT findings were not associated with postoperative visual prognosis.

CONCLUSION

From this study, we determined the visual prognostic factors of ERM surgery without confounding factors, such as visual acuity improvement following combined cataract surgery, and inner retinal SD-OCT findings more significantly associated with the visual prognosis of ERM surgery compared to outer retinal SD-OCT findings.

Cataract Surgery Outcomes in Eyes With Primary Epiretinal Membrane

Importance

Primary epiretinal membrane (ERM) is a common retinal disorder with a prevalence of 4% to 18.5%. Although ERM and cataracts commonly occur together, to our knowledge, no studies have investigated the outcome of cataract surgery alone in this setting.

Objective

To analyze the visual outcome and cystoid macular edema risk with cataract surgery in eyes with primary ERM.

Design, Setting, and Participants

In this retrospective clinical database study, data were collected from July 2003 to March 2015 from 8 locations in the United Kingdom. Cataract surgery data of 217 557 eyes were extracted from the electronic medical record of the UK National Health Service. After exclusion of 57 561 eyes with combined surgery, prior vitrectomy, copathology, and complications, 812 eyes with primary ERM and 159 184 reference eyes were analyzed.

Main Outcomes and Measures

We report on visual acuity (VA), the incidence of cystoid macular edema, and the need for ERM surgery.

Results

The mean (SD) age of patients in the ERM group was 73.7 (9.23) years, and 395 of 812 were men (46.8%). The mean (SD) age of patients in the reference group was 74.4 (12.19) years, and 65 265 of 159 184 were men (41%). Epiretinal membrane eyes assessed at 4 to 12 weeks postoperatively gained 0.27 (0.32) logMAR (approximately 3 Snellen lines), with 200 of 448 (44.6%) improving by 0.30 logMAR or more (≥3 Snellen lines) and 32 of 448 (7.1%) worsening by 0.30 logMAR or more. Reference eyes gained a mean (SD) of 0.44 (0.26) logMAR (approximately 4 Snellen lines), with 48 583 of 77 408 (62.8%) improving by 0.30 logMAR or more and 2125 of 77 408 (2.7%) worsening by 0.30 logMAR or more. Although all eyes with preoperative VA of 20/40 or less improved, only reference eyes with preoperative VA of more than 20/40 showed improvement. Cystoid macular edema developed in 57 of 663 ERM eyes (8.6%) (95% CI, 6.69-10.98) and 1731 of 125 435 reference eyes (1.38%) (95% CI, 1.32-1.45) (P < .001). Epiretinal membrane surgery was performed in 43 of 663 (6.5%) ERM eyes.

Conclusions and Relevance

On average, VA improved 0.27 logMAR (approximately 3 Snellen lines) in eyes with ERM. Eyes with ERM and VA of 20/40 or less showed more benefit after cataract surgery than those with better preoperative vision. However, compared with eyes without ERM, higher rates of cystoid macular edema and a lower postoperative VA gain were noted.

Prospective study of vitrectomy for epiretinal membranes in patients with good best-corrected visual acuity

Background

To evaluate the efficacy of epiretinal membrane removal in patients with good best-corrected visual acuity (BCVA) for improving visual function and quality of life (QOL).

Methods

This prospective case study compared 37 subjects with preoperative BCVA ≦ 0.046 logMAR (Good group) to 35 patients with 0.10–0.52 logMAR (Moderate group) at 3 and 6 months. Linear mixed-effect models were used for statistical analysis. The primary outcome was the horizontal metamorphopsia score (MH) at 6 months postoperatively (post-6 M), while secondary outcomes were postoperative BCVA, vertical metamorphopsia score (MV), aniseikonia, stereopsis and central foveal thickness. In the Good group, QOL was assessed using the National Eye Institute Visual Functioning Questionnaire-25 (NEI VFQ-25) at 6 and 12 months.

Results

MH was significantly improved at post-3 M and post-6 M in the both groups but there were no significant differences between the two groups. MV showed no improvement at the final observation in either group. LogMAR BCVA was significantly improved at post-6 M in the Good group, which had significantly better vision than the Moderate group. Preoperative vertical and horizontal aniseikonia scores remained unchanged in the Good group at post-6 M but worsened in the Moderate group. The NEI VFQ-25 score improved in the Good group, reflecting improved general health, general vision, and mental health.

Conclusions

Early epiretinal surgery for patients with BCVA ≦ 0.046 logMAR was effective for improvement of HM, BCVA, and QOL and prevented worsening of aniseikonia.

Trial registration

UMIN000021220. Registered 10 September 2015.

UMIN Clinical Trials Registry.

[Morphology of the vitreoretinal interface in fellow eyes of patients with full thickness macular holes]

PURPOSE

We performed a retrospective, observational clinical study to evaluate the vitreoretinal interface (VRI) in fellow eyes of patients with full thickness macular holes (FTMH) based on spectral domain optical coherence tomography (SD-OCT) examinations.

METHODS

The VRI in fellow eyes of 38 patients with idiopathic FTMH, 6 of which had concomitant vitreomacular traction (VMT) and the VRI of 32 patients with FTMH with complete resolution of VMT were examined by SD-OCT for the presence of vitreomacular adhesion (VMA), VMT and the formation of FTMH, lamellar macular holes (LMH), macular pseudoholes (MPH) or epiretinal membranes (ERM). Patients underwent complete ophthalmic evaluation, including SD-OCT at baseline and follow-up visits. To classify the morphology of the VRI, we used the international vitreomacular traction study classification system by Duker et al. (Ophthalmology 2013), evaluating the baseline SD-OCT data for significant classification parameters, including size of VMA, macular thickness and volume and structural changes of retinal layers.

RESULTS

Of the 38 eyes with FTMH, 2 (5.3%) fellow eyes also showed evidence of FTMH, 5 (13.2%) had isolated VMT while 5 (13.2%) showed formation of ERM, of which 2 demonstrated MPH. In 5 patients (13.2%) showing evidence of VMA and 17 patients (44.7%) with an unremarkable VRI, 22 fellow eyes (57.9%) showed no pathological morphology. Altogether, 16 fellow eyes (42.1%) of patients with FTMH showed pathological changes of the vitreoretinal interface.

CONCLUSION

This high-resolution SD-OCT-based retrospective study showed that fellow eyes of patients with VMT or FTMH were at increased risk of demonstrating pathological changes in the morphology of the VRI.

Proteomics reveals a set of highly enriched proteins in epiretinal membrane compared with inner limiting membrane

Few data exist regarding the protein composition of idiopathic epiretinal membrane (iERM). In the present study we compared the proteome of epiretinal membrane of iERM with the proteome of the inner limiting membrane (ILM) of idiopathic macular hole (iMH). Twelve epiretinal membrane samples were obtained from patients with iERM undergoing therapeutic vitrectomy. Twelve ILM samples from patients with iMH were used as controls. Proteomic analysis was conducted with discovery-based label-free quantitative nano-liquid chromatography - tandem mass spectrometry (LFQ nLC-MS/MS). Verification of results was performed with targeted MS using selected reaction monitoring on a different set of samples. Discovery data were searched against the Uniprot Homo sapiens protein database using MaxQuant Software. Identified proteins were filtered with Perseus software. Bioinformatic analysis of the differences in protein expression between epiretinal membrane from iERM and ILM from iMH was performed using STRING. A total of 2,183 different proteins were identified. 357 proteins were found to be present in all samples. The protein profile of iERM was highly different from iMH with 62 proteins found at significantly higher levels in iERM. The proteins upregulated more than 10-fold in iERM were: fibrillin-1, tenascin, prolargin, biglycan, opticin, collagen alpha-1(II) chain, protein-glutamine gamma-glutamyltransferase 2, fibronectin, filamin-A, collagen alpha-2(IX) chain, spectrin alpha chain, transforming growth factor beta induced protein ig-h3, dihydropyrimidinase - related protein 3, endoplasmin and glutamate dehydrogenase 1. Proteins with high level in iERM consisted of proteins that especially localized to the actin cytoskeleton, the extracellular matrix and the mitochondrion. Analysis of all proteins indicated that the disease process in iERM at least in part can be characterized as skin formation with perturbation of nucleotide metabolism. Our study identified proteins that have not earlier been associated with iERM. Fifteen proteins are found at very high concentration, 10-fold or more, and amongst these four proteins, fibrillin-1, tenascin, prolargin and biglycan were found at more than a 100-fold higher content compared to ILM of iMH. These proteins may be potential therapeutic targets. Data are available via ProteomeXchange with identifier PXD014286.

Spontaneous closure of bilateral macular holes

Purpose

To present a case of a right eye spontaneous closure of a full thickness macular hole (FTMH), followed several years later by a left eye spontaneous closure of a FTMH, in an otherwise healthy woman.

Observations

We show the temporal changes and spontaneous resolution observed with Spectral-Domain Ocular Coherence Tomography (SD-OCT) of a FTMH in the right eye and a FTMH secondary to vitreomacular traction in the left eye of the same patient 5 years later, also with full spontaneous resolution. Following the resolution, SD-OCT demonstrated outer retinal layer disruption recovery and visual acuity improvement in both eyes.

Conclusions and importance

Spontaneous closure of macular holes is an uncommon event, with most descriptions in the literature being of single cases or very small series, including several reports in patients who have undergone vitrectomy for other causes, or in highly myopic eyes. Bilateral spontaneous closure of macular holes in the same patient is an even more uncommon event, described only once in one patient previously in the literature to our knowledge.

Nerve growth factor promotes the proliferation of Müller cells co-cultured with internal limiting membrane by regulating cell cycle via Trk-A/PI3K/Akt pathway

Background

Nerve growth factor (NGF), produced by Müller cells, and internal limiting membrane (ILM) have fundamental roles in the development of full-thickness macular hole (FTMH). However, the potential crosstalk between NGF and ILM in FTMH is unclear. This study aimed to explore the mechanism and effects of NGF on the proliferation of Müller cells co-cultured with ILM.

Methods

Primary Müller cells and ILM from New Zealand rabbits were extracted and authenticated with specific staining. Müller cells co-cultured with or without ILM were exposed to NGF and then analysed. Müller cell viability was estimated using cell counting kit-8. Cell cycle analysis was performed by flow cytometry. The levels of cell cycle-related gene were detected using qRT-PCR. The TrK-A/Akt signal axis and downstream signaling cascades such as p21, CyclinE, CDK2, CyclinD1, and CDK4 were investigated by western blotting.

Results

ILM treatment alone induced the proliferation of Müller cells following the promotion of phosphorylated Akt, while growth of Müller cells was enhanced by activation of the Trk-A/Akt pathway under the stimulation of NGF or NGF + ILM. Additionally, the ratio of S-phase cells was increased, while G2-phase cells decreased upon the treatment with either ILM or NGF alone, or with NGF + ILM co-treatment. Cell cycle-related genes such as CyclinD1, CyclinE, CDK2, and CDK4 were all upregulated, but p21 expression was downregulated in the presence of NGF, ILM, or NGF + ILM. There was an additive effect on cell proliferation and cell cycle in the group of Müller cells exposed to NGF co-cultured with ILM compared with either NGF or ILM treatment alone. However, both K252ɑ (inhibitors of Trk-A) and LY294002 (inhibitor for Akt) counteracted the effect of NGF or NGF + ILM on the protein levels of Trk-A, Akt, CyclinD1, CyclinE, CDK2, and p21.

Conclusions

Müller cells co-cultured with ILM or NGF promoted cell proliferation by regulating cell cycle-correlated proteins via the PI3K/Akt pathway. ILM + NGF further amplified the PI3K/Akt signaling pathway by binding to Trk-A, leading to more cell growth. This study provides new insight into the potential mechanism of NGF-mediated proliferation of Müller cells co-cultured with or without ILM, which may have considerable impact on therapies for FTMH.

Electronic supplementary material

The online version of this article (10.1186/s12886-019-1142-x) contains supplementary material, which is available to authorized users.

Epiretinal membrane profile on spectral domain optical coherence tomography in patients with uveitis

Purpose:

To study the epiretinal membrane (ERM) profile on the spectral-domain optical coherence tomography (SDOCT) in eyes with uveitis.

Methods:

In this prospective observational study, macula of uveitic eyes were evaluated by SDOCT (Cirrus, model 5000) for ERM. ERM was quantified (in microns) and were followed up along with the best-corrected visual acuity (BCVA) and treatment profile for 1 year. ERM morphology (focal, global, or mixed) and characteristics (thickness at fovea, maximum thickness, and location of maximum thickness in relation to fovea) were documented. Changes in altered foveal contour, cystoid macular edema (CME), and central foveal thickness were also noted. BCVA was noted when the inflammation subsided and it was correlated to specific ERM characteristics. SDOCT characteristics were compared in three treatment groups (no oral steroids, oral steroids with, and without immunomodulators).

Results:

Thirty-four eyes of 25 patients were evaluated. Mean logMAR BCVA decreased from 0.25 to 0.35 (P = 0.005). Foveal involvement with ERM (P = 0.011), lost foveal contour (P = 0.043), and ellipsoid layer disruption (P = 0.017) were associated significantly with reduced BCVA. Focal attachment of ERM was more commonly associated with CME (P = 0.03). Median ERM thickness showed significant increase (P < 0.001). Significant ERM progression from parafoveal to foveal (P = 0.02), significant progression of the thickest area of ERM closer to fovea (P = 0.0006) indicated a strong tendency of foveal involvement and this was correlated with worse BCVA (P = 0.009, r = −0.44) Oral steroids/immunomodulators showed no significant benefit on ERM progression.

Conclusion:

ERM progression in uveitis has a tendency to involve the fovea and is associated with significant vision loss, particularly in foveal ERM, focal attachment, and IS-OS disruption. Oral steroids and immunomodulators have no role in halting progression.

Comparison of MultiColor fundus imaging and colour fundus photography in the evaluation of epiretinal membrane

PURPOSE

To compare MultiColor fundus imaging (MC) and colour fundus photography (CFP) for the evaluation of epiretinal membrane (ERM).

METHODS

In this retrospective study, 192 eyes (181 patients) that underwent vitrectomy for ERM were imaged using Spectralis optical coherence tomography (for MC) and AFC-210 digital camera (for CFP) 1 week before vitrectomy. Two investigators independently determined the rate of delineability and ERM area for each modality.

RESULTS

The intergrader agreement rates for delineability were very high for both image modalities. The rate of delineability of ERM (%) was higher for MC than for CFP, for both investigators [70.8% versus 52.6% and 73.4% versus 53.6% (both p -)]. Epiretinal membrane (ERM) area measurement showed high agreement between investigators for MC (p = 0.466) but differed significantly between the investigators for CFP (p -). The ERM area determined on MC was significantly wider than that on CFP for both investigators (p - for investigator 1 and p - for investigator 2).

CONCLUSION

The ERM area is more clearly detectable and widely demarcated in MC than in CFP images. MultiColor imaging (MC) may be more sensitive and accurate for early detection of ERM and ERM area measurement.

Cross-Sectional Imaging Analysis of Epiretinal Membrane Involvement in Unilateral Open-Angle Glaucoma Severity

Purpose

To determine the relevance of epiretinal membranes (ERMs) in primary open-angle glaucoma (POAG) and potential risk for glaucoma severity.

Methods

Sixty eyes of 30 patients with POAG who had a unilateral ERM were analyzed; 60 nonglaucomatous eyes of 30 patients with a unilateral ERM also were recruited in this institutional cross-sectional study. Patients underwent swept-source (SS) optical coherence tomography (OCT) imaging and visual field testing. Intraindividual differences in the SS-OCT retinal nerve fiber layer (RNFL) disc cupping area measurements and visual field outcomes were analyzed in the two groups.

Results

In patients with POAG, the mean circumpapillary RNFL thickness in the eyes with an ERM was 75.6 ± 16.5 μm superiorly and 71.8 ± 26.0 inferiorly compared with the fellow eyes without an ERM (87.2 ± 23.6 μm, P = 0.0061 and 81.3 ± 27.7 μm, P = 0.034, respectively). The areas of disc cupping and cup-to-disc ratio seen on OCT horizontal and vertical B-scans were larger in eyes with an ERM than in the fellow eyes without ERM (P = 0.0004 and P = 0.0011, respectively). The average mean deviations were -11.6 ± 7.5 dB in the ERM group and -8.19 ± 6.4 dB in the group with no ERM (P = 0.029). Eyes with an ERM received more antiglaucoma eye drops (P = 0.018). Those differences were not seen between eyes with an ERM or fellow eyes in patients without glaucoma.

Conclusions

The presence of an ERM can be a potential risk factor for unilateral severity in eyes with POAG.