Vitreomacular Traction, Epiretinal Membranes, and Macular Holes




Epiretinal Membrane


An epiretinal membrane (ERM) is a fibrocellular proliferation occurring on the retinal surface, most commonly in the macular region. ERMs typically occur following a spontaneous partial or complete posterior vitreous detachment, but secondary causes include intraocular surgery, inflammation, ischemic vascular disease, trauma, retinal tear, rhegmatogenous retinal detachment, and intraocular tumors. Cells thought to contribute to ERMs include retinal pigment epithelium (RPE), fibrocytes, myofibrocytes, and intraretinal glial elements.




These patients show the variable presentation of ERMs, ranging from semi-translucent gray (left image) to opaque white fibrosis (middle image) . Some may appear as a fibrotic white band (right image) . The appearance during the early stages of an ERM is frequently referred to as “cellophane maculopathy,” while prominent surface wrinkling following membrane maturation is referred to as “macular pucker.”





Monochromatic imaging (red-free) can enhance the details of the vitreoretinal interface. Commonly, there is incomplete detachment of the posterior hyaloid with persistent adherence around the disc in the right image (arrows) .





Infrared reflectance imaging (left) and en face swept source optical coherence tomography (OCT) imaging (right) also provide valuable information about the morphologic and topographic features of ERMs. The margins of the ERM are clearly delineated on swept source images (arrows) .

Images courtesy of Dr. Michael Engelbert





Fluorescein angiography can aid surgical planning and is useful for identifying complex anatomic relationships between retinal vasculature and ERMs. In the above cases, retinal vasculature is observed to be embedded within the ERM tissue complex. Fluorescein angiography is also useful for excluding secondary causes of ERM, such as retinal vein occlusion.





With spectral-domain OCT imaging, an ERM appears as a thin, hyper-reflective line on the inner surface of the retina (top left image). Tractional effects of the membrane include retinal thickening (top right image), wrinkling of the surface of the retina (bottom left image), and intraretinal cystic spaces (bottom right image). These tractional effects are responsible for the patient’s symptoms of visual loss and metamorphopsia.





Three-dimensional volume rendered OCT images demonstrate wrinkling and traction of the inner surface of the retina due to ERM.

Images courtesy of Dr. Richard Spaide





Note the widespread fibrotic membrane in this patient. There are semilunar, ovoid, and circular defects in the epiretinal tissue (arrows) .





A subtle ERM may manifest as a thin hyper-reflective line on the inner retinal surface on OCT (right image) . Infrequently these lesions are secondary to a peripheral retinal tear or hole (arrow) as shown on the ultra-widefield color photograph.





This patient with severe ERM and cystoid macula edema was found to have peripheral occlusive vasculitis in the inferotemporal retina on fluorescein angiography. This case illustrates the importance of a thorough peripheral retina examination to exclude secondary causes of ERM.

Images courtesy of Dr. David Maberley





The above patients with proliferative diabetic retinopathy have severe fibrotic proliferation. The fibrovascular tissue usually adopts a curvilinear distribution along the vascular arcades.





This patient has an ERM surrounding the optic disk secondary to a combined hamartoma of the retina and retinal pigment epithelium. The OCT shows a hyper-reflective vitelliform lesion that exhibits hyperautofluorescence at the fovea with fundus autofluorescence imaging. Folds on the surface of the macula are due to tractional forces around the optic disk.





This patient has severe fibrotic proliferation secondary to multiple hemangioblastomas in von Hippel Lindau syndrome.

Images courtesy of Dr. David Maberley




Spontaneous Release of Epiretinal Membrane


Cases of spontaneous release of ERMs have been reported. Although uncommon, occurring in approximately 1-3% of cases, it is more frequently observed in young, female, myopic patients.




This patient had a thick ERM at the disc and papillomacular bundle (left) . The membrane released spontaneously, leaving a legacy of peripapillary fibrous tissue (arrow) .





This patient with metamorphopsia due to an ERM experienced spontaneous improvement of symptoms four years later. Color photos and OCT demonstrate spontaneous release of the ERM from the macula. A small remnant of fibrotic tissue is seen along the superior arcade (arrow) .





The above patient experienced subjective improvement in metamorphopsia and was noted to have spontaneous release of a macular ERM (arrow) that was present on the initial examination. Image on the right was taken 1 month after the baseline examination.

Images courtesy of Dr. Michael Engelbert




Surgical Treatment





Patients with visually significant ERMs may be treated with pars plana vitrectomy and membrane peeling. Pre-operative (left) and post-operative (right) images are provided from a patient that presented with a visually significant ERM. Visual acuity was measured as 20/80 pre-operatively and returned to 20/25 following membrane peeling.

Images courtesy of Dr. Michael Engelbert





Anatomical outcomes following surgical intervention are best evaluated using OCT. This patient suffered disabling metamorphopsia and visual reduction due to traction from a broad vitreomacular adhesion (VMA). An associated ERM is also seen in the pre-operative OCT (arrow) as is frank intraretinal edema. Pre-operative visual acuity was measured as 20/100. Two years following vitrectomy and membrane peeling (bottom image) , the normal foveal contour was restored and visual acuity has returned to 20/25.

Images courtesy of Dr. Michael Engelbert





Surgical management of tractional membranes due to systemic vascular diseases such as diabetes mellitus can be more challenging. In the above patient, multiple points of macular traction, secondary to proliferative diabetic retinopathy, are evident. The surgical goal in this instance is to release all points of macular traction as illustrated in the post-surgical image on the right. Remnants of fibrous tissue can be seen on the surface of the retina; however, these structures are typically not visually significant.

Images courtesy of Dr. Yale Fisher






Vitreomacular Traction (VMT)


Vitreomacular traction (VMT) is defined as persistent vitreous attachment to the central macula due to an incomplete posterior vitreous detachment. Histologically, VMT specimens obtained from surgery show a variety of cell types including fibrous astrocytes, myofibroblasts, and fibrocytes, similar to those found in ERMs. In fact, many eyes with VMT have a concurrent ERM and there is considerable overlap between the two entities. With the advent of spectral-domain OCT and vitreolytic agents, an International Vitreomacular Traction Study Classification System for VMA and VMT has been proposed.


Vitreomacular Adhesion (VMA)


VMA is defined as elevation of the cortical vitreous above the retina surface with the vitreous remaining attached within a 3 mm radius of the fovea. There is no change to the inner retina contour on OCT. VMA can be further subclassified by the size of adhesion into focal or broad.




These patients have focal VMA ≤1500 µm (left image) and broad VMA > 1500 µm (right image) .




Vitreomacular Traction (VMT)


In VMT, all of the following criteria must exist:



  • (1)

    Perifoveal vitreous cortex detachment from the retinal surface


  • (2)

    Macular attachment of the vitreous cortex within a 3 mm radius of the fovea


  • (3)

    Distortion of the foveal surface, intraretinal structural changes, elevation of the fovea above the RPE or a combination thereof, without full-thickness interruption of retinal layers at sites of vitreous adhesion.

Like VMA, VMT can be further subclassified by the size of adhesion into focal or broad.


These patients have focal VMT ≤1500 µm (left image) and broad VMT > 1500 µm (right image).

Images courtesy of Dr. Jay Duker





VMA and VMT may occur concurrently with other macular abnormalities including age-related macular degeneration (left image), retinal vein occlusion, or diabetic macular edema. Eyes with VMT frequently have a concurrent ERM (right image) .

Images courtesy of Dr. Jay Duker (left) and Dr. Edwin Ryan (right)





VMT can be graded according to the severity of the tractional effect on the retinal layers. In grade 1, there is elevation of the retina but no split in the retinal layers (left image) . In grade 2, there are intraretinal cysts, clefts, or schisis (middle image) . In grade 3, there is neurosensory elevation of the retina above the RPE resulting in subretinal fluid (right image) .

Images courtesy of Dr. Harry Flynn





Three-dimensional OCT images show broad-based VMT with retinal thickening. These images may facilitate surgical planning of membrane peeling by the vitreoretinal surgeon.

Images courtesy of Dr. Hideki Koizumi

Only gold members can continue reading. Log In or Register to continue

Related posts:

  1. Infection
  2. Inflammation
  3. Chorioretinal Toxicities
  4. Degeneration

Stay updated, free articles. Join our Telegram channel
Tags:
Jul 30, 2019 | Posted by in OPHTHALMOLOGY | Comments Off on Vitreomacular Traction, Epiretinal Membranes, and Macular Holes

Full access? Get Clinical Tree
Get Clinical Tree app for offline access