Home Conditions | Epiretinal membrane (macular pucker)

Epiretinal membrane (macular pucker)

Optical coherence tomography angiography machine that detects epiretinal membrane or macular pucker

Epiretinal membrane (ERM) refers to a thin, semi-opaque layer of fibrous tissue that forms over the macula, an important part of the retina that’s responsible for processing sharp details and colors. 

This eye condition, also known as cellophane maculopathy or macular pucker, differs greatly from macular degeneration and macular holes. In this case, the ERM that covers the macula becomes cellophane-like scar tissue, making it difficult to see through. 

The ERM can also shrink and pull on the macula, causing it to wrinkle or pucker. With macular puckering, central vision can be distorted (metamorphopsia) — that is, straight lines may look wavy, flat objects may appear round or shapes may seem smaller than normal (micropsia) or larger than normal (macropsia). 

Daily activities, such as driving, reading and identifying small details, may be affected due to this lack of visual clarity. At this point, epiretinal membrane surgery (vitrectomy) is recommended to stop the progression of the condition. This procedure also includes an epiretinal membrane peel (membranectomy).

Macular pucker, also known as epiretinal membrane, is a thin, film-like tissue that can form over the macula and cause distorted, blurry vision. [Image credit: Macular pucker. Permission granted by  © 2022 American Academy of Ophthalmology]

What causes an epiretinal membrane?

According to the National Institutes of Health, the exact cause of an epiretinal membrane is unknown, and you can develop an ERM even if you don't have any history of eye problems or any of the risk factors listed below.

Other underlying factors that may contribute to ERMs include:

  • Posterior vitreous detachment, a very common condition associated with ERMs

  • Aging, especially people age 50 and older

  • Previous eye surgeries, including procedures for cataracts or retinal detachments or tears

  • Head or eye injury or trauma 

  • Inflammation inside the eye (uveitis

  • Diabetes or diabetic retinopathy

  • An existing ERM in the other eye

The majority of people with an ERM show no signs or symptoms (asymptomatic), so having an annual eye exam is essential for detection and monitoring as ERMs slowly get worse over time. 

Signs and symptoms of an epiretinal membrane

Any of the following signs or symptoms related to a decrease in visual acuity (visual sharpness) — including blurry vision and double vision — need to be reported to your eye doctor:

  • Distortion – A straight line appears crooked or bent.

  • Difficulty reading – The letters of reading material seem unusually small or large.

  • Blurriness – The features of a person's face aren't sharp or easily distinguishable.

  • Double vision (diplopia) – A single object looks like two objects.

It’s important that you visit an eye doctor if you notice any signs and symptoms associated with an ERM — or if symptoms persist, worsen or change. 

An epiretinal membrane can happen to anyone but is more commonly found in the older population, specifically 2% in those over age 50 and 20% over age 75. Most of the time, it presents in one (unilateral) eye or both (bilateral) eyes; however, having an ERM in one eye can increase the likelihood of getting it in your other eye

Epiretinal membrane surgery

There's nothing you can do to prevent or cure an ERM, and when the membrane interferes with your vision in a negative way, surgery may be advised by your eye doctor. A vitrectomy improves vision in 80-90% of people and is done in conjunction with an epiretinal membrane peel. 

During surgery, tiny cuts are made in the eyeball, and the transparent gel-like fluid at the back of the eyeball (vitreous humor) is removed and replaced with saline. Using miniature forceps, the surgeon peels off the ERM from the macula. An air or gas bubble may be inserted to encourage healing. Afterward, the macula becomes smoother and relaxes to lie back into position and the small incisions can be sutured — incisions may also close on their own.

As with all medical procedures, there may be complications postoperatively. With vitrectomy and ERM peeling, some may include:

Typically, recovery after this outpatient surgery is slow, but you should find improvements in vision within three to six months. Reoccurrence of ERMs may happen in a small percentage of people.

Only surgical treatment can improve vision and remove distortions caused by epiretinal membranes. Nonsurgical treatments can’t help — not even glasses, eye drops, medications or vitamins. 

Most people who have an ERM don't need treatment, especially if the condition is mild and doesn't progress. Early intervention is always recommended and treatment for an ERM can happen at any age. 

If you have an ERM in only one eye, you may not opt for surgery, instead relying on your other eye to see. If untreated, though, an ERM can progress to the point where your everyday activities and quality of life are affected. Then, you may want to talk to your eye doctor about surgery. 

Your eye doctor can diagnose epiretinal membranes

You can go for years and years without even noticing that you have an epiretinal membrane as it may not hinder your lifestyle. It may not be until you visit your eye doctor for your annual exam that you find out you have one.

Your eye doctor may give you one (or more) of the following tests, ranging from simple to comprehensive, to diagnose or to measure the severity or monitor the progression of an ERM:

  • Dilated eye exam – After dilating your pupils, the doctor uses a slit lamp with a highly magnified lens to look at the back of the eye for the presence of an ERM. 

  • Amsler grid – This chart, comprising a grid with a dot at the center, may indicate metamorphopsia if you're seeing distorted or blurry lines.

  • Optical coherence tomography (OCT) – Using light waves, this machine takes cross-sectional images of your retina's tissue layers for further evaluation.

  • Fluorescein angiography – After injecting a fluorescent dye into your bloodstream, an ophthalmic photographer takes photos to assess blood flow as the dye travels through the retina's blood vessels. 

If a year or more has passed since your last exam, it's time to schedule an appointment with an eye doctor near you.

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