What are the treatment options for an older adult with an epiretinal membrane in the left eye?

Treatment Options for Epiretinal Membrane in the Left Eye

Most patients with epiretinal membrane should be observed without surgery initially, with vitrectomy reserved for those experiencing significant visual symptoms including decreased visual acuity, metamorphopsia, diplopia, or difficulty using both eyes together. 1

Initial Management: Observation

The majority of epiretinal membranes remain relatively stable over time and do not require surgical intervention. 1 This conservative approach is appropriate because:

• Many ERMs cause minimal symptoms and maintain functional vision 1
• Spontaneous improvement is rare, but progression is not universal 1
• Surgery carries inherent risks that must be weighed against potential benefits 2, 3

Monitoring Strategy

Patients should be followed with:

• Spectral-domain optical coherence tomography (SD-OCT) as the gold standard for diagnosis and monitoring of ERM and associated retinal changes 1
• Regular monocular Amsler grid testing at home to detect progression 1
• Patient education about warning signs of worsening (increased metamorphopsia, vision decline) 1

Surgical Intervention: Vitrectomy

Vitrectomy surgery is indicated when patients develop functionally significant symptoms, specifically: 1

• Decreased visual acuity affecting daily activities
• Bothersome metamorphopsia (distorted vision)
• Double vision
• Difficulty using both eyes together (binocular dysfunction)

Expected Surgical Outcomes

The evidence strongly supports vitrectomy for symptomatic patients:

• Approximately 80% of patients improve by at least 2 lines of visual acuity following vitrectomy 1
• Metamorphopsia typically improves after membrane removal 1
• Both idiopathic and secondary ERMs respond well to surgery, though secondary ERMs may show greater improvement 2

Surgical Timing Considerations

The integrity of the photoreceptor layer on SD-OCT is a critical prognostic factor that should influence surgical timing: 4

• Surgery ideally should be performed while the photoreceptor inner segment/outer segment (IS/OS) junction remains intact 4
• If the IS/OS junction is already disrupted preoperatively, surgery should be scheduled as early as possible to prevent further deterioration 4

Surgical Complications to Discuss

Complications are relatively frequent but usually manageable: 2, 3

• Accelerated nuclear sclerosis (cataract progression) is the most common complication 2, 3
• Retinal breaks and retinal detachment can occur 2, 3
• Macular edema may develop postoperatively 2, 3
• Retinal pigment epitheliopathy 3
• Rarely: macular hole formation or hypotony 2

Only retinal detachments involving the macula significantly worsen the final visual prognosis 2, 3

Special Consideration: Concurrent Cataract

If cataract surgery is being considered in an eye with ERM:

• Cataract surgery alone in eyes with ERM yields less visual improvement (mean 0.27 logMAR gain, approximately 3 lines) compared to eyes without ERM (0.44 logMAR gain, approximately 4 lines) 5
• Risk of cystoid macular edema is significantly higher (8.6% vs 1.38% in eyes without ERM) 5
• Eyes with preoperative visual acuity of 20/40 or worse benefit more from cataract surgery than those with better baseline vision 5
• Approximately 6.5% of patients require subsequent ERM surgery after cataract extraction 5

Clinical Algorithm

For asymptomatic or minimally symptomatic patients:

• Observe with SD-OCT monitoring and Amsler grid testing 1

For symptomatic patients with functional impairment:

• Assess photoreceptor integrity on SD-OCT 4
• If IS/OS junction intact: offer vitrectomy with expectation of good visual recovery 4
• If IS/OS junction disrupted: recommend earlier surgery to maximize recovery potential 4

For patients with concurrent cataract:

• Consider combined vitrectomy and cataract surgery if both are symptomatic 5
• Counsel about higher CME risk and potentially limited visual gains if cataract surgery performed alone 5