RETINA - VITREOUS-MACULA INTERFACE RETINOPATHIES

Question 1

what is an ERM?

Answer 1

is a fibrocellular tissue (glial tissue) found on the inner surface of the retina (ILM layer).

Question 2

Pathophysiology of ERM?

Answer 2

ERMs result from glial cell proliferation on the internal limiting membrane (ILM) –> glial cells get into ILM via small hole caused by vitreoretinal traction.

Question 3

what can cause an ERM?

Answer 3

• idiopathic
• PVD
• retinal breaks
• trauma
• introcular surgeries

Question 4

what are symptoms of ERM?

Answer 4

• asymptomatic or mild VA reduction (blurry vision).

Question 5

Signs of an ERM?

Answer 5

• mild ERM - fline, glistering membrane near the fovea
• Advance ERM - thick, gray-white membranes (near the fovea) with retinal folds (macular pucker).
• Easy to visualize w/ OCT - appears on the very top layer and will appear messy with plications

Question 6

tx for ERM?

Answer 6

• mild (VA 20/40) - monitor
• advance/symptomatic (VA 20/50 or worse) - vitrectomy w/ membrane peel or Jetrea injections.
• F/U – PRN

Question 7

what is a macular hole?

Answer 7

full thickness retinal defect at the fovea (only RPE remains intact)

Question 8

what gender and age is more at risk for macular hole?

Answer 8

woman over the age of 60.

Question 9

what causes macular holes?

Answer 9

• idiopathic (83%)
• trauma (5-15%)
• ERM
• CME
• VMT

“ EVICT” the macula

Question 10

symptoms for macular hole?

Answer 10

• blurry vision (20/40 - HM) depending on the stage.
• possible central scotoma
• metamorphopsia

Question 11

what are the signs for each stage of macular hole?

Answer 11

• Stage 1 - impending hole with loss of the foveal depression (detachment) & yellow spot or yellow ring.
• Stage 2 - small, full thickness hole with a pseudo-operculum, only attached to one side.
• Stage 3 - large, full thickness hole with the pseudo-operculum completely separating (operculum).
  
  • Positive Watzke -Allen.
• Stage 4 - stage 3 plus a PVD.
  
  • At stage 4 a round, red, well-delineated spot on the macula can be seen on fundus photo.
    - Klein tags on macula

Question 12

what will be the results of a watzke allen sign on pt with full thickness macular hole?

Answer 12

(+) - patient reports complete break in the beam.

Question 13

tx for macular hole?

Answer 13

• no tx for stage 1 b/c 50% will regress.
• stage 2-4 can be tx with vitrectomy & membrane peel - best result if done within 6 months of onset.
• VMT can be tx with Jetrea injections or victrectomy.
• F/U – high myopes 2x/year
• F/U – PRN for s/s of RD.

Question 14

what will be the results of a watzke allen sign on pt with full pseudo macular hole?

Answer 14

Patients with pseudo-holes and ERMs may report that the line is distorted but it should remain intact.

Question 15

what kind of light is best used to see macular pucker under slit lamp?

Answer 15

blue-green filter

Question 16

what is VMT?

Answer 16

vitreous traction on the macula

Question 17

what conditions cause fibrovascular VMT?

Answer 17

DR.VOS

Question 18

how to tx VMT?

Answer 18

• vitrectomy w/ membrane peel.
• new tx: Ocriplasmin - its a new vitreolysis agent. It contains an enzyme that targets fibronectin and laminin – leads to liquefaction of the vitreous with the goal of inducing complete vitreous detachment.