Epiretinal membrane or macular pucker is a disease of the eye in response to changes in the

vitreous humor The vitreous body (''vitreous'' meaning "glass-like"; , ) is the clear gel that fills the space between the lens and the retina of the eyeball (the vitreous chamber) in humans and other vertebrates. It is often referred to as the vitreous humor ...

or more rarely,

diabetes Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level ( hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ...

. Sometimes, as a result of immune system response to protect the retina, cells converge in the

macula The macula (/ˈmakjʊlə/) or macula lutea is an oval-shaped pigmented area in the center of the retina of the human eye and in other animals. The macula in humans has a diameter of around and is subdivided into the umbo, foveola, foveal av ...

r area as the vitreous ages and pulls away in

posterior vitreous detachment A posterior vitreous detachment (PVD) is a condition of the eye in which the vitreous membrane separates from the retina. It refers to the separation of the posterior hyaloid membrane from the retina anywhere posterior to the vitreous base (a 3� ...

(PVD). PVD can create minor damage to the retina, stimulating exudate, inflammation, and

leucocyte White blood cells, also called leukocytes or leucocytes, are the cells of the immune system that are involved in protecting the body against both infectious disease and foreign invaders. All white blood cells are produced and derived from multi ...

response. These cells can form a transparent layer gradually and, like all scar tissue, tighten to create tension on the retina which may bulge and pucker, or even cause swelling or macular edema. Often this results in distortions of vision that are clearly visible as bowing and blurring when looking at lines on chart paper (or an Amsler grid) within the macular area, or central 1.0 degree of visual arc. Usually it occurs in one eye first, and may cause binocular

diplopia Diplopia is the simultaneous perception of two images of a single object that may be displaced horizontally or vertically in relation to each other. Also called double vision, it is a loss of visual focus under regular conditions, and is often v ...

or double vision if the image from one eye is too different from the image of the other eye. The distortions can make objects look different in size (usually larger =

macropsia Macropsia is a neurological condition affecting human visual perception, in which objects within an affected section of the visual field appear larger than normal, causing the person to feel smaller than they actually are. Macropsia, along with its ...

), especially in the central portion of the visual field, creating a localized or field dependent

aniseikonia Aniseikonia is an ocular condition where there is a significant difference in the perceived size of images. It can occur as an overall difference between the two eyes, or as a difference in a particular meridian. If the ocular image size in both e ...

that cannot be fully corrected optically with glasses. Partial correction often improves the binocular vision considerably though. In the young (under 50 years of age), these cells occasionally pull free and disintegrate on their own; but in the majority of those affected (over 60 years of age) the condition is permanent. The underlying photoreceptor cells, rod cells and

cone cells Cone cells, or cones, are photoreceptor cells in the retinas of vertebrate eyes including the human eye. They respond differently to light of different wavelengths, and the combination of their responses is responsible for color vision. Cone ...

, are usually not damaged unless the membrane becomes quite thick and hard; so usually there is no

macular degeneration Macular degeneration, also known as age-related macular degeneration (AMD or ARMD), is a medical condition which may result in blurred or no vision in the center of the visual field. Early on there are often no symptoms. Over time, however, so ...

Cause

The source of the cells in epiretinal membranes (ERM) has been found to comprise glial cells, retinal pigment epithelial (RPE) cells, macrophages, fibrocytes, and collagen cells. These cells are found in varying proportions. Those from retinal breaks, previous retinal detachments, or cryopexy are composed mainly of dispersed RPE cells, while cells of glial origin predominate in idiopathic pathology. Laminocytes are the fundamental cell type in idiopathic ERMs. These cells are frequently found in small and dispersed numbers in eyes containing a PVD. The presence of retinal pigment cells invariably indicates proliferative retinopathy and is only seen in association with a retinal detachment or tear. The incidence of associated PVD range from 75 to 93%, and PVD is present in virtually all eyes with retinal breaks or retinal detachments and subsequent ERM formation. PVD can lead to retinal breaks that may liberate RPE cells that initiate membrane formation. Small breaks in the internal limiting membrane (ILM) after PVD also may provide retinal astrocytes access to the vitreous cavity, where they may subsequently proliferate. Many ERM also have ILM fragments that may be peeled separately. Finally, vitreous hemorrhage, inflammation, or both associated with a PVD also may stimulate ERM formation. Both sexes appear to be affected equally frequently.

Diagnosis

Epiretinal membrane is typically diagnosed by appearance with

optical coherence tomography Optical coherence tomography (OCT) is an imaging technique that uses low-coherence light to capture micrometer-resolution, two- and three-dimensional images from within optical scattering media (e.g., biological tissue). It is used for medica ...

(OCT) of the macula. Features include a thickening of the nerve fiber layer, a serrated appearance to the surface of the retina just beneath a thickened layer of glial tissue at the retinal-vitreous interface.

Prevention

There is no good evidence for any preventive actions, since it appears this is a natural response to aging changes in the vitreous. It has been estimated that

Posterior vitreous detachment A posterior vitreous detachment (PVD) is a condition of the eye in which the vitreous membrane separates from the retina. It refers to the separation of the posterior hyaloid membrane from the retina anywhere posterior to the vitreous base (a 3� ...

(PVD) occurs in over 75 percent of the population over age 65, that PVD is essentially a harmless condition (although with some disturbing symptoms), and that it does not normally threaten sight. However, since epiretinal membrane appears to be a protective response to PVD, where

inflammation Inflammation (from la, inflammatio) is part of the complex biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants, and is a protective response involving immune cells, blood vessels, and molec ...

, exudative fluid, and scar tissue is formed, it is possible that NSAIDs may reduce the inflammation response. Usually there are flashing light experiences and the emergence of

floater Floaters or eye floaters are sometimes visible deposits (e.g., the shadows of tiny structures of protein or other cell debris projected onto the retina) within the eye's vitreous humour ("the vitreous"), which is normally transparent, or betwe ...

s in the eye that herald changes in the

vitreous Vitreous may refer to: Materials * Glass, an amorphous solid material ** Vitreous enamel, a material made by fusing powdered glass to a substrate by firing * Vitreous lustre, a glassy luster or sheen on a mineral surface Biology * Vitreous bod ...

before the epiretinal membrane forms.

Treatment

Surgeons can remove or peel the membrane through the

sclera The sclera, also known as the white of the eye or, in older literature, as the tunica albuginea oculi, is the opaque, fibrous, protective, outer layer of the human eye containing mainly collagen and some crucial elastic fiber. In humans, and so ...

and improve vision by 2 or more Snellen lines. Usually the vitreous is replaced at the same time with clear (BSS) fluid, in a

vitrectomy Vitrectomy is a surgery to remove some or all of the vitreous humor from the eye. Anterior vitrectomy entails removing small portions of the vitreous humor from the front structures of the eye—often because these are tangled in an intraocular ...

. Surgery is not usually recommended unless the distortions are severe enough to interfere with daily living, since there are the usual hazards of surgery, infections, and a possibility of

retinal detachment Retinal detachment is a disorder of the eye in which the retina peels away from its underlying layer of support tissue. Initial detachment may be localized, but without rapid treatment the entire retina may detach, leading to vision loss and blin ...

. More common complications are high intraocular pressure, bleeding in the eye, and

cataract A cataract is a cloudy area in the lens of the eye that leads to a decrease in vision. Cataracts often develop slowly and can affect one or both eyes. Symptoms may include faded colors, blurry or double vision, halos around light, trouble ...

s, which are the most frequent complication of vitrectomy surgery. Many patients will develop a cataract within the first few years after surgery. In fact, the visual distortions and

created by cataracts may sometimes be confused with epiretinal membrane.

Epidemiology

This ocular pathology was first described by Iwanoff in 1865, and it has been shown to occur in about 7% of the population. It can occur more frequently in the older population with postmortem studies showing it in 2% of those aged 50 years and 20% in those aged 75 years.

Culture

In 1996,

Spalding Gray Spalding Gray (June 5, 1941 – January 11, 2004) was an American actor, novelist, playwright, screenwriter and performance artist. He is best known for the autobiographical monologues that he wrote and performed for the theater in the 1980s a ...

(June 5, 1941 – ca. January 10, 2004), an

American American(s) may refer to: * American, something of, from, or related to the United States of America, commonly known as the "United States" or "America" ** Americans, citizens and nationals of the United States of America ** American ancestry, pe ...

actor An actor or actress is a person who portrays a character in a performance. The actor performs "in the flesh" in the traditional medium of the theatre or in modern media such as film, radio, and television. The analogous Greek term is (), lit ...

screenwriter A screenplay writer (also called screenwriter, scriptwriter, scribe or scenarist) is a writer who practices the craft of screenwriting, writing screenplays on which mass media, such as films, television programs and video games, are based. ...

and

playwright A playwright or dramatist is a person who writes plays. Etymology The word "play" is from Middle English pleye, from Old English plæġ, pleġa, plæġa ("play, exercise; sport, game; drama, applause"). The word "wright" is an archaic English ...

, released ''

Gray's Anatomy ''Gray's Anatomy'' is a reference book of human anatomy written by Henry Gray, illustrated by Henry Vandyke Carter, and first published in London in 1858. It has gone through multiple revised editions and the current edition, the 42nd (Octo ...

'', a film monologue describing his experiences dealing with a macular pucker and his decision to undergo surgery. In the 2011 film '' Paul'', Ruth had Epiretinal membrane complicated by macular edema in her left vitreous cavity.

References

Additional references

* * * * *

External links

Macular Pucker
Resource Guide from the National Eye Institute (NEI). {{Eye pathology Disorders of choroid and retina