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Epiretinal Membrane Formation Following Rhegmatogenous Retinal Detachment Repair: Optical Coherence Tomography Features and Surgical Outcomes

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Epiretinal Membrane Formation Following Rhegmatogenous Retinal Detachment Repair: Optical Coherence Tomography Features and Surgical Outcomes Epiretinal Membrane Formation Following Rhegmatogenous Retinal Detachment Repair: Optical Coherence Tomography Features and Surgical Outcomes M. Ali Khan, MD Retina Service, Wills Eye Hospital Assistant Professor, Kimmel Medical College Philadelphia, PA Retina Society Annual Meeting, 2020 Financial Disclosures • No relevant financial disclosures. • Consulting fees outside the submitted work: Allergan, Apellis Conclusions • Anatomic alteration due to epiretinal membrane (ERM) formation after RRD repair is commonly severe (Stage 4 OCT characteristics), and leads to significant worsening of logMAR visual acuity. • ERM removal with vitrectomy and membrane peeling resulted in a significant improvement in visual acuity in eyes with history of either macula on or macula off RRD. • Ectopic inner foveal layer (EIFL) thickness, IS/OS disruption, and microcytic changes were associated with visual acuity at 6 months post ERM peel using regression analysis. Confirmation of these associations in larger series is warranted. Epiretinal membrane after RRD Repair • Epiretinal membrane (ERM) formation after primary rhegmatogenous retinal detachment (RRD) repair is common, with estimates ranging from 4-13%.[1-4] • Several authors have described the utility of internal limiting membrane (ILM) peel during primary RRD repair to prevent later ERM formation.[5-9] • Preservation of IS/OS band on SD-OCT has been correlated to visual acuity improvement after membrane peel surgery.[10] • Macular status at time of RRD repair may determine visual potential. OCT Grading of ERM • Govetto et al. described a new, SD-OCT based grading scheme for ERM in 2017.[11,12] Insights Into Epiretinal Membranes: Presence of Ectopic Inner Foveal Layers and a New Optical Coherence Tomography Staging Scheme ANDREA GOVETTO, ROBERT A. LALANE, III, DAVID SARRAF, MARTA S. FIGUEROA, AND JEAN PIERRE HUBSCHMAN PURPOSE: To describe the presence of continuous PIRETINAL MEMBRANE (ERM) FORMATION IS A COM- ectopic inner foveal layers associated with epiretinal mon retinal condition characterized by fibrocellular • membranes (ERMs) and to present a new optical coher- E proliferation at the vitreoretinal interface, above the Utility ofence this tomography grading (OCT) staging system system of ERMs. in guidinginternal expectations limiting membrane, with a prevalence for thatidiopathic ranges epiretinal 1–3 DESIGN: Retrospective multicenter observational case between 2.2% and 28.9%, which increases with aging. [13] membrane,series. but has not been studiedERMs arein typically ERM idiopathic, following but can also be associated RRD repair. METHODS: Clinical charts and spectral-domain OCT with retinal vascular or inflammatory diseases, trauma, images of 194 eyes of 172 consecutive patients diagnosed tumors, intraocular surgery, or retinal detachment.4 The with ERMs were reviewed and analyzed. precise pathophysiology of this clinical entity is not RESULTS: The presence of continuous ectopic inner completely defined, although the proliferation of hyalo- foveal layers was identified in 63 out of 194 eyes cytes in the setting of anomalous posterior vitreous detach- (32.5%) and this morphology was significantly associated ment and vitreoschisis has been suggested as a possible with lower visual acuity. ERMs were divided into 4 mechanism in the early development of idiopathic ERMs.4 stages. Stage 1 (43 out of 194 eyes, 22.1%) ERMs were Various classification schemes have been proposed,5–7 mild and thin and a foveal depression was present. Stage including the original categorization by Gass, the most 2 (88 out of 194 eyes, 45.4%) ERMs were associated widely used.7 Owing to dramatic improvements in image with widening of the outer nuclear layer and loss of the resolution and data acquisition speed, spectral-domain foveal depression. Stage 3 (51 out of 194 eyes, 26.3%) optical coherence tomography (SDOCT) has driven a ERMs were associated with continuous ectopic inner transformative change in the study of ERMs, providing foveal layers crossing the entire foveal area. In stages 1, rapid cross-sectional imaging of the retina with near- 2, and 3 all retinal layers were clearly defined on OCT. histologic detail. OCT has become the gold standard in Stage 4 ERMs (12 out of 194 eyes, 6.2%) were thick the evaluation of ERMs, but despite its universal applica- and associated with continuous ectopic inner foveal tion, a globally accepted OCT-based classification system layers. In addition, retinal layers were disrupted. Visual is still lacking.8 acuity progressively declined from stage 1 through stage In recent years OCT studies of the foveal microstructure 4(P < .001). associated with ERMs have flourished in order to identify CONCLUSIONS: The presence of continuous ectopic in- the anatomic changes that may cause loss in visual acu- ner foveal layers in ERMs is a newly described OCT ity,9–17 including disruption of the inner segment finding associated with significant vision loss and is an ellipsoid zone and photoreceptor outer segments.9–12 essential element of a novel OCT-based grading scheme More recently attention has shifted to the study of the of ERMs that may influence visual prognosis. (Am J inner retinal anatomy. In this regard, various reports have Ophthalmol 2017;175:99–113. Ó 2016 Elsevier Inc. shown a significant association of the thickness of the All rights reserved.) inner retinal layers with vision loss in eyes with ERM.13–17 This study performed an in-depth SDOCT analysis of the development and evolution of ERMs and identified novel morphologic features that impacted visual acuity prognosis and were critical in the development of a new Supplemental Material available at AJO.com. Accepted for publication Dec 7, 2016. OCT-based staging system. From the Retina Division (A.G., R.A.L., J.P.H.) and Retinal Disorders and Ophthalmic Genetics Division (D.S.), Stein Eye Institute, University of California Los Angeles, Los Angeles, California; Greater Los Angeles VA Healthcare Center, Los Angeles, California (D.S.); and Retina Division, Ophthalmology Department, Ramon y Cajal University METHODS Hospital, Madrid, Spain (M.S.F.). Inquiries to Andrea Govetto, Retina Division, Stein Eye Institute, University of California Los Angeles, 100 Stein Plaza, Los Angeles, CA A RETROSPECTIVE, OBSERVATIONAL, AND CONSECUTIVE 90095-7002; e-mail: [email protected] chart review of patients diagnosed with ERM and seen by 0002-9394/$36.00 © 2016 ELSEVIER INC.ALL RIGHTS RESERVED. 99 http://dx.doi.org/10.1016/j.ajo.2016.12.006 ECTOPIC INNER FOVEAL LAYERS GOVETTO ET AL 349 over a macular area of either 15 · 10° with 97 B-scan each spaced 31 mm apart or 15 · 5° with 131 B-scan spaced 11 mm apart. On SD-OCT, all retinal layers were identified according to the IN • OCT Consensus.20 Ectopic inner foveal layers were identified with SD-OCT and were defined according to Govetto et al19: presence of continuous hyporeflective and hyperreflective bands Fig. 2. Manual measurement of the thickness of the EIFLs with the caliper function. A straight vertical line is traced from the outer margin extending from the inner nuclear layer and inner plex- of the inner nuclear layer to the inner margin of the ILM. iform layer across the foveal region and visible in all SD-OCT scans centered in the fovea, as illustrated in With SD-OCT, ERMs were defined as single, Figure 1. irregular, and hyperreflective lines above the ILM, The thickness of the EIFL in the central foveal often associated with underlying retinal wrinkling and region was measured manually with the “caliper” with the presence of hyporeflective spaces between the function of the Heidelberg Spectralis, adjusted to an ERM and ILM. All ERMs were classified according to aspect ratio of 1:1 mm, by tracing a vertical line from the 4-grade staging system by Govetto et al,19 as illus- the outer margin of the inner nuclear layer to the inner trated in Figure 1. 19 margin of the ILM (Figure 2). Mean central foveal Cystoid macular edema (CME) was defined with thickness (CFT) values were obtained automatically SD-OCT as the presence of multiple hyporeflective by the Heidelberg software. intraretinal cystoid spaces. The presence of a discon- tinuous ellipsoid band in the foveal region was considered a sign of ellipsoid zone disruption, whereas • Stagethe appearance 1: Mild ERM of with a roundish preservation or diffuse of foveal hyperre flective depression.area between the ellipsoid zone and the interdigitation zone in the central fovea was defined as the Tsunoda or “cotton ball” sign, representing tractional elevation of the photoreceptors.20,21 All SD-OCT images were quantitatively and qual- • Stageitatively 2: Foveal evaluated depression by three is lost, independent but all retinal and masked layersobservers are easily (A.G., identified. F.J.R., and M.S.F.), and disagree- ments were resolved with the intervention of a fourth observer (D.S. or J.P.H.). Surgical Procedures • Stage 3: Presence of ectopic inner foveal layers (EIFL,All white patients arrows) underwent across the a foveal standard, floor. 3-portFoveal 23-gauge depressionPPV with is lost, ERM but andall retinal ILM layers peeling remain performed identifiable. by 3 vitreoretinal surgeons (J.P.H., F.J.R., and M.S.F.) with the Constellation vision system (Alcon, Fort wort, TX). Combined phacoemulsification and intraocular • Stagelens 4: implantation Severe alteration procedures in anatomy were with performed foveal at the disorganization.discretion of the EIFL surgeon. (white arrows) is present. RetinalCore layers vitrectomy are not identifiable. was performed in all cases, and after the creation of posterior vitreous detachment, Grieshaber ILM forceps (Alcon) were used to peel Image source: Govetto A, Lalane RA, Sarraf D, Figueroa MS, Hubschman JP. Insights Into Epiretinal Membranes: Presence of bothEctopic Inner ERM Foveal Layers and and a New ILM Optical Coherence up to Tomography the Staging vascular Scheme. Am J Ophthalmol arcades.. 2017;175:99-113. Fig. 1. SD-OCT staging scheme of ERMs. Stage 1. Mild ERM with Depending on surgeons’ preferences, in some cases, few anatomical modifications.
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