Eyes with uveitic macular edema, significant epiretinal membrane likely to fail medical therapy

Eyes with no membrane or a mild membrane had a favorable and similar response to therapy.

Issue: October 10, 2014

In the majority of cases, medical therapy is not a viable option to treat patients with uveitic macular edema who also present with a significant epiretinal membrane and retinal surface wrinkling, according to a retrospective case series.

“Macular edema is the leading cause of visual impairment in patients with uveitis,” co-author Douglas A. Jabs, MD, MBA, professor and chair of the Department of Ophthalmology at Mount Sinai School of Medicine in New York, said. “The availability of spectral-domain optical coherence tomography enabled us to look very closely at features associated with uveitic macular edema and to try to understand their impact on the management of the disease.”

The study was published in the American Journal of Ophthalmology.

Three patient groups

One hundred four eyes of 77 patients with uveitic macular edema were divided into three subgroups: 32 eyes had no epiretinal membrane, 38 eyes had an epiretinal membrane without meaningful retinal surface wrinkling, and 34 eyes had an epiretinal membrane that distorted the retinal surface.

“The surprise to the results of the study is that if you look at the visual acuity of epiretinal membranes with wrinkling at presentation and 6 months later, there is no difference (20/109 and 20/110, respectively),” Jabs told Ocular Surgery News.

Furthermore, the likelihood of 20/200 or worse was 37% at 3 months and 39% at 6 months, even though the authors thought that medical therapy such as oral corticosteroids or regional corticosteroid injections might provide some benefit to this subgroup. Although Jabs predicted that these patients would have worse visual acuity than the other two subgroups, “there was the absence of any visual improvement at 6 months. Therefore, the likely solution is early surgical therapy to remove the membrane.”

Conversely, eyes with no epiretinal membrane or eyes with a mild membrane that did not distort the retinal surface responded favorably and similarly to therapy.

The mean visual acuity at presentation, 3 months and 6 months for eyes with no epiretinal membrane was 20/59, 20/35 and 20/36, respectively.

“These patients do very well,” Jabs said. “In fact, over 80% of the eyes ended up seeing 20/40 or better at both follow-up visits.”

Eyes with a mild membrane had a mean visual acuity at presentation, 3 months and 6 months of 20/64, 20/47 and 20/46, respectively.

“About 60% of these eyes maintained better than 20/40 acuity,” Jabs said.

The visual acuity results of the two subgroups were not statistically significantly different.

If a patient presents with a significant epiretinal membrane, “you can try medical therapy because about 24% of these patients achieved improvement in 3 months but dropped to 12% at 6 months,” Jabs said. “However, the overwhelming majority are likely to need surgical therapy relatively early on. Therefore, I would not persist with multiple approaches to medical therapy.”

OCT for data interpretation

The study authors acknowledged the controversy surrounding the interpretation of data by OCT.

“Some investigators feel that an epiretinal membrane without wrinkling is merely an artifact of the machine and the internal limiting membrane and think that only membranes with wrinkling should be labeled a definite epiretinal membrane,” Jabs said. “But we choose to separate out that group to show that if you observe some central subfield thickening on the internal surface of the retina that looks like it might be an epiretinal membrane, but no wrinkling of the surface, clinically it will behave similar to no epiretinal membrane, and therefore, you should attempt to treat it medically.” – by Bob Kronemyer

Reference:

Lehpamer B, et al. Am J Ophthalmol. 2014;doi:10.1016/j.ajo.2014.01.020.

For more information:

Douglas A. Jabs, MD, MBA, can be reached at Department of Ophthalmology, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1183, New York, NY 10029; 212-241-6752; email: douglas.jabs@mssm.edu.

Disclosure: Jabs has no relevant financial disclosures.