The epiretinal membrane and its operation
An epiretinal membrane (also called an epimacular or premacular membrane) is the growth of a thin layer of cells on the center of the retina: the macula. When this layer of cells shrinks, the macula becomes wrinkled. This leads to visual distortion: metamorphopsia (distorted lines), micropsia or macropsia (vision that is too small or too large), and a decrease in vision. An epiretinal membrane is usually caused by a posterior vitreous detachment. If it causes visual impairment, treatment is exclusively surgical. The procedure is a vitrectomy: the vitreous is aspirated, the membrane is stained to allow visualization, and then peeled away, meaning it is removed with forceps. The procedure restores perfect vision in one-third of cases, improves it in one-third, and stops the deterioration in one-third of patients.
What is the epiretinal membrane?
The epiretinal membrane (also called epimacular or premacular membrane) corresponds to the formation of a thin layer of cells on the central retina called the macula.
The macula should normally lie flat at the back of the eye to function properly. If the membrane contracts, the macula wrinkles or bulges, affecting the center of your vision.
In the case of an epiretinal membrane, objects may appear wavy or you may have difficulty seeing details:
You may notice a grey, cloudy, or empty area in your central vision.
You may even experience ripples in your central vision where straight lines appear twisted or wavy.
Macular damage does not affect your peripheral (lateral) vision.
The causes
Age is the most common cause of epiretinal membrane. As we age, the vitreous humor begins to age, liquefy, and detach from the retina. Generally, the vitreous detaches without any problems. However, sometimes scar tissue forms, leading to wrinkles or a bulge of the retina and macula: the membrane.
Eye inflammation, chronic macular edema, and vascular abnormalities are also risk factors. This is referred to as secondary epiretinal membrane.
Risk factors
Posterior vitreous detachment is the main risk factor for epiretinal membrane. This is referred to as a primary membrane. However, some patients have retinal conditions that cause a secondary epiretinal membrane.
Post-retinal tear or detachment.
Post-chronic macular edema.
Chronic eye inflammation (uveitis).
Post-ocular trauma or surgery, particularly of the retina
Linked to a vascular abnormality of the retina: aneurysm, polyp, …
Symptoms
An epiretinal membrane causes macular syndrome, meaning disturbances in the center of vision that cannot be corrected with glasses. The main symptoms are:
A decrease in near and far vision.
Metamorphopsia – Distorted lines.
Micropsies or macropsies – Images that are larger or smaller compared to those of the other eye.
Evolution
Epiretinal membranes usually develop slowly. The first phase of development is asymptomatic. Therefore, it is not uncommon to diagnose an epiretinal membrane without any indication for surgery.
Symptoms may then appear gradually, over several months. Once established, the vision loss will progressively worsen.
Diagnosis
Your ophthalmologist will put drops in your eye to dilate your pupil. This allows them to look inside your eye (the fundus) through a special lens.
He will then take pictures of your eye using optical coherence tomography (OCT). With OCT, the machine creates cross-sectional images of the macula at the back of your eye. This provides highly detailed images, allowing the diagnosis to be confirmed and the impact of the membrane on each layer of the retina to be analyzed.
Treatments – Vitrectomy surgery
The indication for treatment depends on the visual impact of the membrane, your complaints, and the OCT analysis of the membrane. Treatment is exclusively surgical.
If your symptoms are mild, you may not need treatment.
Your ophthalmologist can then modify your glasses or contact lens prescription to improve your vision.
You can also choose to wear bifocals when looking at something up close.
Eye drops, medications, and laser surgery do not improve vision if you have macular degeneration.
If your symptoms are more severe, your ophthalmologist may recommend a surgical procedure called a vitrectomy .
Your ophthalmologist will remove part of the vitreous and peel, i.e. remove the membrane using microscopic forceps.
This operation allows the macula to be released and to regain its correct morphology.
Your vision will likely improve slowly over 1 to 3 months. However, your eyesight may not be as good as it was before the macular degeneration.
Before the operation
Before surgery, you will be asked to meet with the anesthesiologist to determine the type of anesthesia that will be used. For this surgery, a regional anesthetic, also known as peribulbar anesthesia, is most often recommended.
For this consultation, remember to gather your medical records and documents available: list of treatments, medical history, medical examinations, medical reports which will help the anesthesiologist to draw up a complete medical assessment.
The day of the operation
You will be required to arrive on an empty stomach, having started at 6 a.m., at the time indicated on your summons. Please note: do not consume coffee, tea, food, liquids, or cigarettes!
The procedure takes approximately one hour. Afterwards, if the surgery was performed on an outpatient basis (the most common case), you will be able to return home accompanied by your companion.
Vitrectomy
The operation takes place in the operating room, lying on the back, under sterile conditions (elimination of bacteria by disinfection and sterile equipment).
The entire globe is anesthetized, the eye cannot move. In case of anxiety, the anesthesiologist administers sedation (injection of a stress-relieving drug).
The procedure lasts approximately 30 minutes.
The surgeon aspirates the vitreous using a vitreotome.
He then colors the membrane using a suitable dye and then “peels” the membrane using micro-forceps.
At the end of the procedure, filtered air is usually injected into the eye to promote retinal healing.
Post-operative treatments and instructions
At the end of the procedure, an antibiotic and anti-inflammatory ointment is applied before the dressing is changed. Treatment should begin the following day.
Wash your hands thoroughly before each treatment.
Rinse the eye with saline solution if there are secretions.
Instill the antibiotic anti-inflammatory eye drops 3 times a day for 1 month and the ointment in the evening for 1 week.
What are the risks of vitrectomy?
Like any surgical procedure, vitrectomy carries certain risks. The surgery is extremely well-controlled, so these risks are extremely rare. Among them are:
Endophthalmitis – Intraocular infection
Vitreous hemorrhage – Bleeding in your eye
Retinal detachment – The retina detaches from the back of the eye following a tear during surgery
Recurrence of the membrane
Macular edema – The retina swells abnormally due to inflammation
Your ophthalmologist will discuss these risks with you and how vitrectomy can help you.
What visual recovery is possible?
Visual recovery is slow after epiretinal membrane surgery. Vision usually improves substantially during the first month, then very slowly over the following 2 to 3 months.
After 3 months:
⅓ of patients will have a complete visual recovery.
⅓ will be partially improved.
⅓ will not see a clear improvement in symptoms, simply a halt to their deterioration.
Frequently Asked Questions
When to operate on an epiretinal membrane?
An epiretinal membrane is operated on when it is responsible for visual symptoms: decreased acuity, metamorphopsia (distortion of lines), aniseikonia (larger or smaller vision).
Is there a natural treatment for epiretinal membrane?
Therapeutic abstention is the only natural treatment for an epiretinal membrane. No diet, eyeglass filter, or eye drops can treat the membrane without surgery.
How much does an epiretinal membrane operation cost?
Epiretinal membrane surgery is covered by social security.
Standard hospitalization is covered by social security and supplementary health insurance.
The surgeon's fees are covered up to €271.70 (no additional charges). Any further fees are at the discretion of the surgeon and the anesthesiologist.