Consider operating early for ERM patients with good visual acuity

Issue: April 10, 2017

FORT LAUDERDALE, Fla. — Ophthalmologists may be delaying surgery for too long to treat epiretinal membranes in patients with good visual acuity, according to a speaker here.

Perspective from Tarek S. Hassan, MD

“Even though visual acuity in patients with epiretinal membrane may decrease slowly, surgery usually improves the final visual acuity,” André V. Gomes, MD, PhD, of Brazil, said at the inaugural Retina World Congress. “There is enough evidence that shows waiting too long may favor a worse overall outcome. Therefore, we should think about offering surgery much earlier in the process.”

André Gomes

Surgeons have performed epiretinal membrane (ERM) surgery for decades, but patients rarely return to 20/20 visual acuity. Traditionally, surgeons wait to perform a procedure, and it is apparent they have been waiting too long, Gomes said.

In a recent retrospective study by Chinskey and Shah, 42 patients with visual acuity greater than 20/50 underwent ERM peeling. According to the study, 31 patients had idiopathic ERM. After the procedure, 47.5% gained one line of visual acuity, 25% stayed at their original visual acuity, and 10% lost three lines or more, Gomes said.

Surgery should be considered earlier in patients with visual acuity worse than 20/25, and observation is acceptable for patients with 20/25 visual acuity without metamorphopsia. Additionally, avoiding long periods of preoperative leakage, which can cause anatomic damage, and not leaving tissue behind can improve outcomes, he said.

Minimizing tissue stretching preoperatively and during surgery can also improve visual acuity outcomes, Gomes said. – by Robert Linnehan

Reference:

Gomes AV. Epiretinal membrane (ERM) with very good vision: Should one operate? Presented at: Retina World Congress; Feb. 23-26, 2017; Fort Lauderdale, Fla.

Disclosure: Gomes reports he has relevant financial disclosures with Novartis, Alcon, Bayer, Volk, Dutch Ophthalmic (DORC), Optovue and Allergan.

Perspective

Tarek S. Hassan, MD

André V. Gomes, MD, PhD, presented an interesting paper that highlighted the fact that most retina specialists wait to operate on eyes with epiretinal membranes (ERM) until the visual acuity is poor enough to justify the risk/benefit ratio. For the majority, that has been at approximately the 20/40 or worse level for many years. Although small-gauge surgery, membrane staining and peeling, and intraoperative viewing techniques have improved in recent years to potentially decrease the surgical risks of vitrectomy and membrane peeling, surgeons have continued to rely on older dogma that suggests waiting to perform ERM removal until the same level of visual decline is reached.

Evidence from this trial suggests that eyes in which surgery was deferred do not regain outstanding vision at rates many would find acceptable and may continue to experience metamorphopsia despite successful surgery. Gomes suggested that we should intervene when visual acuity is worse than 20/25, particularly if there is preoperative metamorphopsia and/or significant cystoid macular edema in hopes of achieving better postoperative visual results. Although this assertion seems to be a logical solution to the problem of suboptimal outcomes, it will hopefully be further supported by comparative studies that show improved outcomes after early ERM peeling.

The surgical steps of vitrectomy and membrane peeling have become more straightforward in recent years, but we must remain cognizant of the surgical risks that still exist and can be significant. Ultimately, we are still best served by treating patients based on the significance of their symptoms.

Tarek S. Hassan, MD

Oakland University William Beaumont School of Medicine

Oakland, Mich.

Disclosures: Hassan reports he is a consultant for Genentech, Regeneron, Novartis, Roche, Bayer, Insight Instruments, Alcon, Allergan and Vitreq; receives equity with Arctic Dx; and has intellectual property with Insight Instruments.