SURGICAL MANAGEMENT O F MACULAR PUCKER AFTER RETINAL REATTACHMENT SURGERY R O N A L D G. M I C H E L S , M.D.,
AND H O W A R D D. G I L B E R T ,
Baltimore,
Epiretinal membranes covering or dis torting the macula (macular pucker), or both, occasionally occur after otherwisesuccessful retinal reattachment surgery and may cause significant reduction of the postoperative visual acuity. 1 - 3 Re cent development of instrumentation and techniques for closed vitreous surgery through a pars plana approach provides a method to remove selected epiretinal membranes from the inner surface of the retina. 4-9 We report herein the surgical technique and our results in 13 consecu tive cases with macular pucker after otherwise-successful retinal reattachment surgery. M A T E R I A L AND M E T H O D S
M.D.
Maryland
the Ocutome system, 5 including a sepa rate infusion cannula secured to the sclera, an illumination source held in one hand, and various instruments including the Ocutome cutting probe and a hooked needle or vitreoretinal pick alternately held in the surgeon's other hand. The mechanical objectives of surgery are based on thorough preoperative eval uation of the vitreoretinal anatomy in each case. Usually a posterior vitreous separation is present, and the central por tion of the vitreous gel and the posterior vitreous surface are excised. All signifi cant intravitreal opacities are removed, and any vitreous sheets causing anteroposterior or tangential traction, or both,
The operation was performed using high magnification of the operating mi croscope equipped with motorized focus, zoom magnification, and remote control of two-dimensional movement in a hori zontal plane. Reflex-free intraocular illu mination was provided by an intraocular fiberoptic system. A bimanual technique was used, with instruments introduced through the pars plana in each of the two superior quadrants. The operation can be performed with a full-function vitrectomy probe (including infusion, suction, cutting, and illumination features on a single tip) combined with a hooked nee dle or special vitreoretinal pick (Fig. 1). Also, the operation can be performed with From The Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, Maryland (Dr. Michels); and the Department of Ophthalmology, University of Minnesota Medical School, Minneapolis, Minnesota (Dr. Gilbert). Reprint requests to Ronald G. Michels, M.D., Wilmer Institute, 116, Johns Hopkins Hospital, 600 N. Wolfe St., Baltimore, MD 21205.
Fig. 1 (Michels and Gilbert). Technique for sepa ration of epiretinal membranes. Vitrectomy instru ment or separate fiberoptic-light probe provides illu mination as epiretinal membrane is engaged with hooked needle or special vitreoretinal pick and elevated from underlying retina.
AMERICAN JOURNAL O F OPHTHALMOLOGY 88:92.5-929, 1979
925
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on the retina are divided. Care is taken to avoid damage to the lens and trauma to chorioretinal tissue elevated on a previ ous scleral buckle. If areas of preexisting retinal detachment are present, or if com plications such as intraocular hemor rhage, retinal tear formation, or retinal detachment occur during the operation, additional methods are used to manage these complications. 9 - 1 1 The epiretinal membrane causing the macular pucker is engaged with a hooked needle or special vitreoretinal pick 12 and gently separated from the inner surface of the retina. Excessive traction on the retina is carefully avoided, and various manipu lations may be required to aid in separat ing these tissues. These manipulations include the following: side-to-side move ments with a special vitreoretinal spatu la 12 to break delicate adhesions, use of special intraocular forceps or the tips of both intraocular instruments functioning like chopsticks to grasp a partially sepa rated epiretinal membrane, and use of the vitrectomy instrument or special intrao cular scissors to cut the membrane at points of firm adhesion to the underlying retina. Usually the epiretinal membrane can be completely separated by using only a hooked needle or vitreoretinal pick, although it may be necessary to engage the membrane sequentially from various directions. Visible extramacular epiretinal mem branes and posterior cortical vitreous that remain adherent to the retina may also be separated from the retina. This is done in a posterior-to-anterior direction, and these tissues are separated as far peripher ally as the equator when this can be done without excessive traction. The epiretinal tissue is then removed from the eye by us ing the vitrectomy instrument or special intraocular forceps, or the membrane is aspirated into the tip of a blunt needle introduced in place of the hooked needle. This tissue can be studied by histologic or eleetronmicroscopic methods, or both.
NOVEMBER, 1979
We performed vitreous surgery to re move epiretinal membranes that were causing macular pucker and reduced vis ual acuity in 13 eyes after otherwisesuccessful retinal reattachment surgery. These patients included nine men and four women, and their ages ranged from 40 years to 76 years, with a median age of 63 years. One patient (Case 11) had diabe tes mellitus, with complications of proliferative diabetic retinopathy accounting for the previous combined traction and rhegmatogenous retinal detachment. Fur ther data regarding these eyes, and fea tures of the previous retinal detachments, are given in Table 1. The follow-up inter val ranged from six months to 24 months, with a median follow-up interval of ten months and a mean of 12 months. One patient (Case 9) died from a myocardial infarction six months after removal of the epiretinal membrane. RESULTS
The epiretinal membrane causing mac ular pucker was successfully removed in each case, resulting in partial visual im provement (Table 2, Fig. 2). In one eye (Case 1) a peripheral iatrogenic retinal break occurred during surgery, and this was successfully treated during the same operation. Peripheral rhegmatogenous retinal detachment, not involving the macula, occurred in two eyes (Cases 6 and 8) postoperatively. In each of these cases the retinal detachment was successfully treated by revision of the previous scleral buckle. In four eyes (Cases 1, 2, 3, and 6) progressive lens opacities occurred after the vitrectomy and ultimately reduced the visual acuity in two eyes. One eye (Case 6) underwent cataract extraction during the follow-up interval. Cystoid macular edema was present postoperatively in each of the 13 cases when studied by fundus biomicroscopy and fluorescein angiography. However, when preoperative fluorescein angiographic studies were available for com-
927
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TABLE 1 P A T I E N T S U N D E R G O I N G VITREOUS SURGERY F O R MACULAR P U C K E R * A F T E R PREVIOUS SURGERY F O R R E T I N A L R E A T T A C H M E N T
Preoperative Best Visual Acuity Postoperative No. of Macula Retinal Involved Before Last Visual Acuity After Retinal Case Age Status Reattachment by Retinal Retinal Operation Complications Reattachment Operation No. (yrs) of Lens Operations Detachment 1 2 3 4 5 6 7 8 9 10 11 12 13
66 65 63 76 56 66 47 47 72 40 50 44 58
Phakic Phakic Phakic Aphakic Aphakic Phakic Aphakic Phakic Aphakic Aphakic Aphakic Aphakic Phakic
1 1 1 1 2 1 1 1 1 3 1 1 2
Yes No Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes
6/60 (20/200) 6/6 (20/20) HM HM HM 6/30 (20/100) HM 6/15 (20/50) HM HM HM HM 6/30 (20/100)
None None Vitreous loss None None None None None None None None None None
6/24 (20/80) 6/6 (20/20) 6/18 (20/60) 6/120 (20/400) 6/120 (8/200) 6/12 (20/40) 6/12 (20/40) 6/12 (20/40) 6/15 (20/50) 6/21 (20/70) HM 6/24 (20/80) 6/120 (20/400)1
*HM designates hand motions. t Macular pucker present at time of second retinal reattachment operation.
parison, the amount of cystoid macular edema seemed to be less postoperatively than it had been before removal of the epiretinal membranes. In one eye (Case 2) partial recurrence of
the epiretinal membrane developed dur ing the first six months after vitreous surgery. The recurrent membrane was thin and spared the center of the macula, giving the appearance of a pseudomacu-
TABLE 2 VISUAL R E S U L T S O F V I T R E O U S SURGERY F O R MACULAR P U C K E R
Case No. 1 2 3 4 5 6 7 8 9 10 11 12 13
Interval Between Retinal Surgery and Vitrectomy 7 5 5 6 6 5 34 6 8 5 1 17 3
mos mos mos mos mos mos mos mos yrs mos mo mos mos
Visual Acuity Before Vitrectomy
Visual Acuity After Vitrectomy
Follow-up After Vitrectomy (mos)
6/60 6/30 6/120 6/120 6/60 3/60 6/90 6/60 6/120 6/90 6/60 6/60 6/60
6/60 (20/200)* 6/15 (20/50)* 6/12 (20/40)1 6/21 (20/70) 6/24 (20/80) 6/15 (20/50) 6/18 (20/60) 6/9 (20/30) 6/60 (20/200)$ 6/15 (20/50) 6/21 (20/70) 6/21 (20/70) 6/12 (20/40)
22 16 24 14 9 20 14 10 6 9 6 6 6
(4/200) (20/100) (20/400) (20/400) (8/200) (2/200) (20/300) (7/200) (20/400) (20/300) (4/200) (6/200) (8/200)
*Increase in lenticular nuclear sclerosis after vitrectomy. {Visual acuity later reduced to 6/21 (20/70) by progressive lens opacities. $Patient died six months after vitreous surgery.
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Fig. 2 (Michels and Gilbert). Case 13. Left, Vertically-oriented epiretinal membrane eight months after retinal reattachment surgery. Right, Postoperative appearance after removal of epiretinal membrane. Macula has a nearly normal appearance.
lar hole. 13 The postoperative visual acuity remained unchanged at 6/15 (20/50). DISCUSSION
Epiretinal membranes causing macular pucker and reduced postoperative visual acuity are a recognized complication after otherwise successful retinal reattachment surgery. This complication occurs in about 7.5% of cases after retinal reattach ment operations, 3 and it may develop in the absence of preoperative involvement of the macula by the retinal detachment. The occurrence of macular pucker has been associated with such factors as a preoperative visual acuity of less than 6/15 (20/50), increasing patient age, mul tiple retinal reattachment operations, and vitreoretinal adhesions near the macula. 3 Also, presence of vitreous hemorrhage, vitreous loss during drainage of subretinal fluid,1 and use of diathermy to create a chorioretinal adhesion 2 have been associ ated with occurrence of macular pucker after reattachment surgery. The pathogenesis of these membranes remains un known, although recent studies suggest that cellular proliferation of both pig ment-epithelial and astroglial origin may be involved in epiretinal membranes com plicating rhegmatogenous retinal detach ment. 1 4 " 1 6
Untreated macular pucker after retinal reattachment surgery usually results in permanent reduction of visual acuity to less than 6/30 (20/100). 1 - 2 However, occa sionally the epiretinal membrane sponta neously separates from the retina, which suggests that a potential cleavage plane exists between the membrane and the underlying retina. This observation, to gether with Machemer's success in treat ing similar cases 17 and in dissecting epiretinal membranes in various other conditions, 6 - 8 provided the basis for at tempting surgical removal of the epireti nal tissue in our series. The early results of this series are en couraging. A technically successful result was achieved in each of the 13 cases, and visual acuity improved. However, the postoperative visual acuity did not im prove to better than 6/9 (20/30) in any case, and in two eyes final visual acuity was 6/60 (20/200). Also, an iatrogenic retinal tear occurred during surgery in one eye, and in two eyes a recurrent retinal detachment occurred postoperatively and required further retinal sur gery. In four eyes, progressive lens opaci ties occurred several months after the vitreous surgery. Therefore, the surgical treatment of macular pucker has provided a means to achieve only a partial restora-
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tion of visual function and is associated with a notable risk of complications in volving the lens or retina, or both. Addi tionally, the epiretinal membrane possi bly may recur postoperatively in some cases, and this has been noted after re moval of epiretinal membranes in other conditions, including proliferative dia betic retinopathy (S. Charles, personal communication, 1978) and after penetrat ing ocular injuries (C. P. Wilkinson, per sonal communication, 1978). Despite these limitations, the use of vitrectomy methods in treatment of macu lar pucker after retinal reattachment sur gery is likely to become more frequent as the instrumentation is further improved, surgical techniques are refined, and expe rience is accumulated regarding the re sults that can be achieved and the risks involved. Small-diameter instruments seem to reduce the likelihood of intraoperative complications, and development of new vitreoretinal picks has improved the safety with which these epiretinal membranes can be engaged and separat ed. Extramacular epiretinal membranes causing visual loss by distortion of the macula seem to have an especially favor able prognosis. Also, surgical removal of epiretinal membranes provides material that can be analyzed to determine the cellular origin of the epiretinal tissue. SUMMARY
We used vitrectomy techniques to re move epiretinal membranes that caused reduced visual acuity in 13 consecutive eyes with macular pucker after otherwise successful retinal reattachment surgery. A technically successful result with vis ual improvement was achieved in each case. An iatrogenic retinal tear (success fully repaired) occurred in one eye, and recurrent retinal detachment requiring an additional operation occurred postoper atively in two eyes. Despite such risks, and that the best postoperative visual
929
acuity achieved was 6/9 (20/30), the use of vitrectomy methods in removal of epi retinal membranes in selected cases of macular pucker can provide significant improvement in vision. REFERENCES 1. Tanenbaum, H. L., Schepens, C. L., Elzeneiny, I., and Freeman, H. M.: Macular pucker fol lowing retinal detachment surgery. Arch. Ophthalmol. 83:286, 1970. 2. Hagler, W. S., and Aturaliya, U.: Macular puckers after retinal detachment surgery. Br. J. Ophthalmol. 55:451, 1971. 3. Lobes, L. A., Jr., and Burton, T. C : The inci dence of macular pucker after retinal reattachment surgery. Am. J. Ophthalmol. 85:72, 1978. 4. Machemer, R., Parel, J. M., and Buettner, H.: A new concept for vitreous surgery. 1. Instrumenta tion. Am. J. Ophthalmol. 73.1, 1972. 5. O'Malley, C , and Heintz, R. M., Sr.: Vitrec tomy with an alternative instrument system. Ann. Ophthalmol. 7:585, 1975. 6. Machemer, R.: A new concept for vitreous surgery. 7. Two-instrument techniques in pars plana vitrectomy. Arch. Ophthalmol. 92:407, 1974. 7. Machemer, R.: Vitrectomy in diabetic retino pathy. Removal of preretinal proliferations. Trans. Am. Acad. Ophthalmol. Otolaryngol. 79:OP-394, 1975. 8. Machemer, R., and Laqua, H.: A logical ap proach to the treatment of massive periretinal prolif eration. Ophthalmology 85:584, 1978. 9. Michels, R. G.: Vitrectomy techniques in reti nal reattachment surgery. Ophthalmology In press. 10. Charles, S., White, J., Dennison, D., and Eichenbaum, D.: Bimanual, bipolar intraocular dia thermy. Am. J. Ophthalmol. 81:101, 1976. 11. Charles, S.: Fluid-gas exchange in the vitre ous cavity. The Ocutome Newsletter. 2:1, 1977. 12. Michels, R. G., Rice, T. A., and Ober, R.: Vitreoretinal dissection instruments. Am. J. Oph thalmol. 87:836, 1979. 13. Allen, A. W., Jr., and Gass, J. D. M.: Contrac tion of a perifoveal epiretinal membrane simulating a macular hole. Am. J. Ophthalmol. 82:684, 1976. 14. Laqua, H., and Machemer, R.: Clinicalpathological correlation in massive periretinal pro liferation. Am.J. Ophthalmol. 80:913, 1975. 15. Van Horn, D. L., Aaberg, T. M., Machemer, R., and Fenzl, R.: d i a l cell proliferation in human retinal detachment with massive periretinal prolif eration. Am. J. Ophthalmol. 84:383, 1977. 16. Machemer, R., Van Horn, D., and Aaberg, T. M.: Pigment epithelial proliferation in human retinal detachment with massive periretinal prolif eration. Am. J. Ophthalmol. 85:181, 1978. 17. Machemer, R.: Die chirurgische Entfernung von epiretinalen Makulamembranen (macular puckers). Klin. Monatsbl. Augenheilkd. 173:36, 1978.
AND H O W A R D D. G I L B E R T ,
Baltimore,
Epiretinal membranes covering or dis torting the macula (macular pucker), or both, occasionally occur after otherwisesuccessful retinal reattachment surgery and may cause significant reduction of the postoperative visual acuity. 1 - 3 Re cent development of instrumentation and techniques for closed vitreous surgery through a pars plana approach provides a method to remove selected epiretinal membranes from the inner surface of the retina. 4-9 We report herein the surgical technique and our results in 13 consecu tive cases with macular pucker after otherwise-successful retinal reattachment surgery. M A T E R I A L AND M E T H O D S
M.D.
Maryland
the Ocutome system, 5 including a sepa rate infusion cannula secured to the sclera, an illumination source held in one hand, and various instruments including the Ocutome cutting probe and a hooked needle or vitreoretinal pick alternately held in the surgeon's other hand. The mechanical objectives of surgery are based on thorough preoperative eval uation of the vitreoretinal anatomy in each case. Usually a posterior vitreous separation is present, and the central por tion of the vitreous gel and the posterior vitreous surface are excised. All signifi cant intravitreal opacities are removed, and any vitreous sheets causing anteroposterior or tangential traction, or both,
The operation was performed using high magnification of the operating mi croscope equipped with motorized focus, zoom magnification, and remote control of two-dimensional movement in a hori zontal plane. Reflex-free intraocular illu mination was provided by an intraocular fiberoptic system. A bimanual technique was used, with instruments introduced through the pars plana in each of the two superior quadrants. The operation can be performed with a full-function vitrectomy probe (including infusion, suction, cutting, and illumination features on a single tip) combined with a hooked nee dle or special vitreoretinal pick (Fig. 1). Also, the operation can be performed with From The Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, Maryland (Dr. Michels); and the Department of Ophthalmology, University of Minnesota Medical School, Minneapolis, Minnesota (Dr. Gilbert). Reprint requests to Ronald G. Michels, M.D., Wilmer Institute, 116, Johns Hopkins Hospital, 600 N. Wolfe St., Baltimore, MD 21205.
Fig. 1 (Michels and Gilbert). Technique for sepa ration of epiretinal membranes. Vitrectomy instru ment or separate fiberoptic-light probe provides illu mination as epiretinal membrane is engaged with hooked needle or special vitreoretinal pick and elevated from underlying retina.
AMERICAN JOURNAL O F OPHTHALMOLOGY 88:92.5-929, 1979
925
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AMERICAN JOURNAL OF OPHTHALMOLOGY
on the retina are divided. Care is taken to avoid damage to the lens and trauma to chorioretinal tissue elevated on a previ ous scleral buckle. If areas of preexisting retinal detachment are present, or if com plications such as intraocular hemor rhage, retinal tear formation, or retinal detachment occur during the operation, additional methods are used to manage these complications. 9 - 1 1 The epiretinal membrane causing the macular pucker is engaged with a hooked needle or special vitreoretinal pick 12 and gently separated from the inner surface of the retina. Excessive traction on the retina is carefully avoided, and various manipu lations may be required to aid in separat ing these tissues. These manipulations include the following: side-to-side move ments with a special vitreoretinal spatu la 12 to break delicate adhesions, use of special intraocular forceps or the tips of both intraocular instruments functioning like chopsticks to grasp a partially sepa rated epiretinal membrane, and use of the vitrectomy instrument or special intrao cular scissors to cut the membrane at points of firm adhesion to the underlying retina. Usually the epiretinal membrane can be completely separated by using only a hooked needle or vitreoretinal pick, although it may be necessary to engage the membrane sequentially from various directions. Visible extramacular epiretinal mem branes and posterior cortical vitreous that remain adherent to the retina may also be separated from the retina. This is done in a posterior-to-anterior direction, and these tissues are separated as far peripher ally as the equator when this can be done without excessive traction. The epiretinal tissue is then removed from the eye by us ing the vitrectomy instrument or special intraocular forceps, or the membrane is aspirated into the tip of a blunt needle introduced in place of the hooked needle. This tissue can be studied by histologic or eleetronmicroscopic methods, or both.
NOVEMBER, 1979
We performed vitreous surgery to re move epiretinal membranes that were causing macular pucker and reduced vis ual acuity in 13 eyes after otherwisesuccessful retinal reattachment surgery. These patients included nine men and four women, and their ages ranged from 40 years to 76 years, with a median age of 63 years. One patient (Case 11) had diabe tes mellitus, with complications of proliferative diabetic retinopathy accounting for the previous combined traction and rhegmatogenous retinal detachment. Fur ther data regarding these eyes, and fea tures of the previous retinal detachments, are given in Table 1. The follow-up inter val ranged from six months to 24 months, with a median follow-up interval of ten months and a mean of 12 months. One patient (Case 9) died from a myocardial infarction six months after removal of the epiretinal membrane. RESULTS
The epiretinal membrane causing mac ular pucker was successfully removed in each case, resulting in partial visual im provement (Table 2, Fig. 2). In one eye (Case 1) a peripheral iatrogenic retinal break occurred during surgery, and this was successfully treated during the same operation. Peripheral rhegmatogenous retinal detachment, not involving the macula, occurred in two eyes (Cases 6 and 8) postoperatively. In each of these cases the retinal detachment was successfully treated by revision of the previous scleral buckle. In four eyes (Cases 1, 2, 3, and 6) progressive lens opacities occurred after the vitrectomy and ultimately reduced the visual acuity in two eyes. One eye (Case 6) underwent cataract extraction during the follow-up interval. Cystoid macular edema was present postoperatively in each of the 13 cases when studied by fundus biomicroscopy and fluorescein angiography. However, when preoperative fluorescein angiographic studies were available for com-
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VOL. 88, NO. 5
TABLE 1 P A T I E N T S U N D E R G O I N G VITREOUS SURGERY F O R MACULAR P U C K E R * A F T E R PREVIOUS SURGERY F O R R E T I N A L R E A T T A C H M E N T
Preoperative Best Visual Acuity Postoperative No. of Macula Retinal Involved Before Last Visual Acuity After Retinal Case Age Status Reattachment by Retinal Retinal Operation Complications Reattachment Operation No. (yrs) of Lens Operations Detachment 1 2 3 4 5 6 7 8 9 10 11 12 13
66 65 63 76 56 66 47 47 72 40 50 44 58
Phakic Phakic Phakic Aphakic Aphakic Phakic Aphakic Phakic Aphakic Aphakic Aphakic Aphakic Phakic
1 1 1 1 2 1 1 1 1 3 1 1 2
Yes No Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes
6/60 (20/200) 6/6 (20/20) HM HM HM 6/30 (20/100) HM 6/15 (20/50) HM HM HM HM 6/30 (20/100)
None None Vitreous loss None None None None None None None None None None
6/24 (20/80) 6/6 (20/20) 6/18 (20/60) 6/120 (20/400) 6/120 (8/200) 6/12 (20/40) 6/12 (20/40) 6/12 (20/40) 6/15 (20/50) 6/21 (20/70) HM 6/24 (20/80) 6/120 (20/400)1
*HM designates hand motions. t Macular pucker present at time of second retinal reattachment operation.
parison, the amount of cystoid macular edema seemed to be less postoperatively than it had been before removal of the epiretinal membranes. In one eye (Case 2) partial recurrence of
the epiretinal membrane developed dur ing the first six months after vitreous surgery. The recurrent membrane was thin and spared the center of the macula, giving the appearance of a pseudomacu-
TABLE 2 VISUAL R E S U L T S O F V I T R E O U S SURGERY F O R MACULAR P U C K E R
Case No. 1 2 3 4 5 6 7 8 9 10 11 12 13
Interval Between Retinal Surgery and Vitrectomy 7 5 5 6 6 5 34 6 8 5 1 17 3
mos mos mos mos mos mos mos mos yrs mos mo mos mos
Visual Acuity Before Vitrectomy
Visual Acuity After Vitrectomy
Follow-up After Vitrectomy (mos)
6/60 6/30 6/120 6/120 6/60 3/60 6/90 6/60 6/120 6/90 6/60 6/60 6/60
6/60 (20/200)* 6/15 (20/50)* 6/12 (20/40)1 6/21 (20/70) 6/24 (20/80) 6/15 (20/50) 6/18 (20/60) 6/9 (20/30) 6/60 (20/200)$ 6/15 (20/50) 6/21 (20/70) 6/21 (20/70) 6/12 (20/40)
22 16 24 14 9 20 14 10 6 9 6 6 6
(4/200) (20/100) (20/400) (20/400) (8/200) (2/200) (20/300) (7/200) (20/400) (20/300) (4/200) (6/200) (8/200)
*Increase in lenticular nuclear sclerosis after vitrectomy. {Visual acuity later reduced to 6/21 (20/70) by progressive lens opacities. $Patient died six months after vitreous surgery.
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Fig. 2 (Michels and Gilbert). Case 13. Left, Vertically-oriented epiretinal membrane eight months after retinal reattachment surgery. Right, Postoperative appearance after removal of epiretinal membrane. Macula has a nearly normal appearance.
lar hole. 13 The postoperative visual acuity remained unchanged at 6/15 (20/50). DISCUSSION
Epiretinal membranes causing macular pucker and reduced postoperative visual acuity are a recognized complication after otherwise successful retinal reattachment surgery. This complication occurs in about 7.5% of cases after retinal reattach ment operations, 3 and it may develop in the absence of preoperative involvement of the macula by the retinal detachment. The occurrence of macular pucker has been associated with such factors as a preoperative visual acuity of less than 6/15 (20/50), increasing patient age, mul tiple retinal reattachment operations, and vitreoretinal adhesions near the macula. 3 Also, presence of vitreous hemorrhage, vitreous loss during drainage of subretinal fluid,1 and use of diathermy to create a chorioretinal adhesion 2 have been associ ated with occurrence of macular pucker after reattachment surgery. The pathogenesis of these membranes remains un known, although recent studies suggest that cellular proliferation of both pig ment-epithelial and astroglial origin may be involved in epiretinal membranes com plicating rhegmatogenous retinal detach ment. 1 4 " 1 6
Untreated macular pucker after retinal reattachment surgery usually results in permanent reduction of visual acuity to less than 6/30 (20/100). 1 - 2 However, occa sionally the epiretinal membrane sponta neously separates from the retina, which suggests that a potential cleavage plane exists between the membrane and the underlying retina. This observation, to gether with Machemer's success in treat ing similar cases 17 and in dissecting epiretinal membranes in various other conditions, 6 - 8 provided the basis for at tempting surgical removal of the epireti nal tissue in our series. The early results of this series are en couraging. A technically successful result was achieved in each of the 13 cases, and visual acuity improved. However, the postoperative visual acuity did not im prove to better than 6/9 (20/30) in any case, and in two eyes final visual acuity was 6/60 (20/200). Also, an iatrogenic retinal tear occurred during surgery in one eye, and in two eyes a recurrent retinal detachment occurred postoperatively and required further retinal sur gery. In four eyes, progressive lens opaci ties occurred several months after the vitreous surgery. Therefore, the surgical treatment of macular pucker has provided a means to achieve only a partial restora-
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tion of visual function and is associated with a notable risk of complications in volving the lens or retina, or both. Addi tionally, the epiretinal membrane possi bly may recur postoperatively in some cases, and this has been noted after re moval of epiretinal membranes in other conditions, including proliferative dia betic retinopathy (S. Charles, personal communication, 1978) and after penetrat ing ocular injuries (C. P. Wilkinson, per sonal communication, 1978). Despite these limitations, the use of vitrectomy methods in treatment of macu lar pucker after retinal reattachment sur gery is likely to become more frequent as the instrumentation is further improved, surgical techniques are refined, and expe rience is accumulated regarding the re sults that can be achieved and the risks involved. Small-diameter instruments seem to reduce the likelihood of intraoperative complications, and development of new vitreoretinal picks has improved the safety with which these epiretinal membranes can be engaged and separat ed. Extramacular epiretinal membranes causing visual loss by distortion of the macula seem to have an especially favor able prognosis. Also, surgical removal of epiretinal membranes provides material that can be analyzed to determine the cellular origin of the epiretinal tissue. SUMMARY
We used vitrectomy techniques to re move epiretinal membranes that caused reduced visual acuity in 13 consecutive eyes with macular pucker after otherwise successful retinal reattachment surgery. A technically successful result with vis ual improvement was achieved in each case. An iatrogenic retinal tear (success fully repaired) occurred in one eye, and recurrent retinal detachment requiring an additional operation occurred postoper atively in two eyes. Despite such risks, and that the best postoperative visual
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acuity achieved was 6/9 (20/30), the use of vitrectomy methods in removal of epi retinal membranes in selected cases of macular pucker can provide significant improvement in vision. REFERENCES 1. Tanenbaum, H. L., Schepens, C. L., Elzeneiny, I., and Freeman, H. M.: Macular pucker fol lowing retinal detachment surgery. Arch. Ophthalmol. 83:286, 1970. 2. Hagler, W. S., and Aturaliya, U.: Macular puckers after retinal detachment surgery. Br. J. Ophthalmol. 55:451, 1971. 3. Lobes, L. A., Jr., and Burton, T. C : The inci dence of macular pucker after retinal reattachment surgery. Am. J. Ophthalmol. 85:72, 1978. 4. Machemer, R., Parel, J. M., and Buettner, H.: A new concept for vitreous surgery. 1. Instrumenta tion. Am. J. Ophthalmol. 73.1, 1972. 5. O'Malley, C , and Heintz, R. M., Sr.: Vitrec tomy with an alternative instrument system. Ann. Ophthalmol. 7:585, 1975. 6. Machemer, R.: A new concept for vitreous surgery. 7. Two-instrument techniques in pars plana vitrectomy. Arch. Ophthalmol. 92:407, 1974. 7. Machemer, R.: Vitrectomy in diabetic retino pathy. Removal of preretinal proliferations. Trans. Am. Acad. Ophthalmol. Otolaryngol. 79:OP-394, 1975. 8. Machemer, R., and Laqua, H.: A logical ap proach to the treatment of massive periretinal prolif eration. Ophthalmology 85:584, 1978. 9. Michels, R. G.: Vitrectomy techniques in reti nal reattachment surgery. Ophthalmology In press. 10. Charles, S., White, J., Dennison, D., and Eichenbaum, D.: Bimanual, bipolar intraocular dia thermy. Am. J. Ophthalmol. 81:101, 1976. 11. Charles, S.: Fluid-gas exchange in the vitre ous cavity. The Ocutome Newsletter. 2:1, 1977. 12. Michels, R. G., Rice, T. A., and Ober, R.: Vitreoretinal dissection instruments. Am. J. Oph thalmol. 87:836, 1979. 13. Allen, A. W., Jr., and Gass, J. D. M.: Contrac tion of a perifoveal epiretinal membrane simulating a macular hole. Am. J. Ophthalmol. 82:684, 1976. 14. Laqua, H., and Machemer, R.: Clinicalpathological correlation in massive periretinal pro liferation. Am.J. Ophthalmol. 80:913, 1975. 15. Van Horn, D. L., Aaberg, T. M., Machemer, R., and Fenzl, R.: d i a l cell proliferation in human retinal detachment with massive periretinal prolif eration. Am. J. Ophthalmol. 84:383, 1977. 16. Machemer, R., Van Horn, D., and Aaberg, T. M.: Pigment epithelial proliferation in human retinal detachment with massive periretinal prolif eration. Am. J. Ophthalmol. 85:181, 1978. 17. Machemer, R.: Die chirurgische Entfernung von epiretinalen Makulamembranen (macular puckers). Klin. Monatsbl. Augenheilkd. 173:36, 1978.
