Updates on Epiretinal Membrane (ERM) Surgery
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Updates on Epiretinal Membrane (ERM) Surgery

  • Overview of Epiretinal Membrane (ERM):
    • ERM is a fibrocellular membrane over the internal limiting membrane (ILM) due to myofibroblast proliferation, also known as macular pucker or cellophane maculopathy.
    • Prevalence: 34.1% by OCT (Beaver Dam Eye Study) vs. 7–11% by clinical exam/fundus photos.
    • Types: Primary/idiopathic (posterior vitreous detachment, PVD) vs. secondary (uveitis, retinal vascular disease, trauma, retinal tear/detachment, intraocular tumors).
    • Symptoms: Micropsia, macropsia, decreased vision, metamorphopsia.
    • Surgical indication: Visual function reduction, similar to cataract surgery, though ectopic inner foveal layers (EIFL) on OCT may suggest surgery regardless of symptoms.
  • Surgical Approach:
    • Standard technique: Pars plana vitrectomy (PPV) with membrane peel.
    • Variations:
      • Vitrectomy gauge: No significant outcome difference between 23- and 27-gauge.
      • Staining dyes: Brilliant Blue FCF and indocyanine green (ICG) commonly used; ICG has rare retinal toxicity risk (mostly in animal models).
      • ILM peeling: Controversial; reduces ERM recurrence but recurrences are often nonvisually significant. Associated with delayed visual recovery, microscotomas (via microperimetry), and retinal displacement due to centrifugal foveal traction. PEELING trial: Spontaneous ILM peeling common, avoids deficits of active peeling.
      • Microserrated ILM forceps: Preferred over conventional forceps, with fewer deep retinal grasps and higher ILM grasp success.
  • Visual and Safety Outcomes:
    • Visual acuity predictors: Long-term visual outcomes (5–9 years) tied to ellipsoid zone integrity and external limiting membrane presence.
    • Endophthalmitis: Low risk (<1%) in small-gauge PPV; higher in ERM surgery (0.44% in Korea cohort vs. 0.15% overall vitrectomies), possibly due to fluid-filled eyes (vs. gas tamponade in other retinal surgeries).
  • OCT in ERM Management:
    • Preoperative OCT:
      • Ectopic inner foveal layers: Extent correlates with worse visual outcomes.
      • Disorganized retinal inner layers (DRIL): Associated with intraoperative hemorrhage, worse visual outcomes, and delayed functional recovery.
      • Foveal herniation: Severe protrusion predicts worse baseline and final visual acuity, though improvements still occur.
    • Postoperative OCT:
      • Retinal layer thickness changes: Increased retinal nerve fiber layer (RNFL) thickness linked to faster visual recovery.
      • Choroidal changes: Transient postoperative fluctuations in choroidal vascularity index/thickness due to traction relief.
    • Deep learning models: Predict postoperative OCT and visual outcomes from preoperative OCT with high accuracy (structural similarity index).
  • Intraoperative OCT (IOCT):
    • Evaluates real-time retinal architecture (e.g., full/partial thickness distortions, subretinal fluid).
    • No correlation between macular stretching and final visual acuity, but affects central macular thickness.
    • Novel techniques: Peeling under perfluorocarbon liquid (PFCL) reduces ERM grabs and neurofiber layer disassociation, with comparable visual outcomes.
    • Limited adoption due to focus on anatomic confirmation rather than surgical maneuver adjustments.
  • ERM and Retinal Detachment:
    • Post-retinal detachment ERM: Risk factors include older age, worse baseline visual acuity, macula-off detachments. Occurs in 22% of scleral buckle cases (nonvisually significant) and 12% of PPV with silicone oil (risk factors: oil duration, diabetes, photocoagulation).
    • No significant difference in ERM formation between scleral buckle vs. vitrectomy.
  • Novel Surgical Techniques:
    • Autologous platelet concentrate: No significant benefit in ERM surgery.
    • Intravitreal steroids (dexamethasone implant, triamcinolone): Temporary reduction in central macular thickness at 1 month, no lasting benefit by 3 months.
    • Robot-assisted surgery: Feasible but increases operative time with fewer forceps movements; outcomes comparable to standard techniques.
  • Cataract Surgery Timing and Lens Selection:
    • Concurrent vs. sequential ERM/cataract surgery: No significant difference in visual outcomes, cystoid macular edema, or ERM recurrence.
    • Lens selection: Advanced monofocal lenses (e.g., Eyhance) show no reduction in distance vision, improved intermediate vision, and no worse contrast sensitivity vs. standard monofocal lenses, though data is limited.
  • Unique ERM Profiles:
    • Uveitic ERM: 4% prevalence in uveitic eyes; intermediate and posterior uveitis strongly associated, anterior uveitis protective. 60.5% of surgical cases show visual improvement.
    • Pediatric ERM: Diffuse central ERM correlates with greater postoperative visual acuity improvement compared to localized foveal ERM.
  • Testable Associations:
    • ILM peeling: Reduces recurrence but may cause microscotomas and delayed recovery; nonvisually significant recurrences are key for exam questions.
    • OCT biomarkers: Ectopic inner foveal layers, DRIL, and foveal herniation predict outcomes and are high-yield.
    • Endophthalmitis risk: Slightly higher in ERM surgery, likely due to fluid-filled eyes.
    • Uveitic and pediatric ERM: Specific associations (intermediate/posterior uveitis, diffuse central ERM) are testable.
    • Deep learning and IOCT: Emerging technologies likely to appear in clinical vignettes.

Citation Address of the Uploaded Paper

  • Abraham JR, Talcott KE. Approach and surgical management of epiretinal membrane. Curr Opin Ophthalmol. 2025;36(3):205-209. doi:10.1097/ICU.0000000000001135. Corresponding author: Katherine E. Talcott, MD, Cole Eye Institute, Cleveland Clinic, 9500 Euclid Avenue, i32, Cleveland, OH 44195, USA (talcotk@ccf.org).