What is an Epiretinal Membrane or Macular Pucker?

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What is an Epiretinal Membrane or Macular Pucker?

Epiretinal membrance, macular pucker, ERM, cellophane maculopathy,

Courtesy of JirehDesign.com (Mark Erickson)

An epiretinal membrane (ERM), or macular pucker, is a thin layer of tissue that grows on the surface of the macula.  It is found in normal, healthy eyes and may cause decreased vision and/or distortion.

Epiretinal membranes are not related to macular degeneration.

ERM = Macular Pucker = Cellophane Maculopathy = Wrinkle

Symptoms of an ERM

The most common symptoms of a “macular pucker” include decreased vision and/or distortion.  The protein sheet spreads across the macula and gently tugs and displaces the retinal tissue causing these symptoms.

The gentle tugging, on a microscopic level, disrupts the cellular interactions of the rods and cones causing the visual changes.  The membrane can cause the retina to “wrinkle” and hence the name “pucker” or “wrinkle.”

What Causes a Pucker?

Mild “trauma” or previous eye surgery causes the formation of the membrane.  In most cases, a PVD (posterior vitreous detachment) has occurred.  This mild stimulation excites/irritates special cells on the retina to produce a protein.  This protein is overproduced and forms a layer on the surface of the retina.

Not all patients will get an ERM.  Only patients with a genetic predisposition for “overproducing the protein” will develop epiretinal membranes.

Treatment for ERM Includes Surgery

The only known treatment for macular pucker is vitrectomy surgery.  The vitrectomy is the basic surgery of most retinal operations.  The vitreous is removed allowing access to the surface of the retina.

Forceps are then used to grasp the edge of the membrane and gently peel the membrane off the surface of the retina.

Warning:  this video demonstrating vitrectomy for epiretinal membrane is graphic!

I like to use either ICG dye or Brilliant Blue (another tissue dye) to stain the ERM prior to removal.  The stain allows me to see the tissue much easier.

What Does this Mean?

I recommend operating as soon as you are aware of symptoms.  The most common symptoms are distortion and decreased vision.

Unlike cataract surgery where the “severity” of the cataract does not correlate with the degree of visual improvement, no one can guarantee how much vision will return after successful ERM surgery… no one.

Therefore, I recommend removal as soon as you notice either slight blurring and/or distortion.  Some docs feel that vision must be reduced to a required level before considering surgery (e.g. 20/40 for cataracts), but since we can’t measure distortion, I feel this is not the best approach.

Occasionally, some patients have both cataracts and a macular pucker.  I will usually recommend cataract surgery before macular pucker surgery;  it will improve my view if I need to operate, the resultant vision after cataract surgery may be sufficient (we might avoid or delay ERM surgery) and cataract surgery prior to ERM surgery may decrease the chance of recurrence.

 

Comments
  • Mitchell Miller June 27, 2012 at 2:11 pm

    I had a macular pucker removed. My retina was torn in the process and my vision much worse off than it was with the pucker. A warning, along with this information, would be advised.

    • Randall V. Wong, M.D. July 10, 2012 at 5:45 am

      Dear Mitchell,

      A retinal tear is a possible complication of any surgery. Usually the tear is discovered during the surgery and treated, but a tear causing a retinal detachment after vitrectomy (say, for macular pucker) is possible.

      Was this how yours was discovered…after the operation?

      Randy

  • Ken July 5, 2012 at 8:16 am

    Another great article. Thanks

  • Tony Hart July 15, 2012 at 12:16 pm

    My ERM formed after I had a TPPV and scleral buckle to repair a detached retina, in April of 2011. My doc did not advise surgery for the ERM at that time, because he didn’t think the distortion was significant enough. I drive a commercial vehicle for a living, and my vision is barely 20/40 (the federal minimum standard) in the eye. My concern is that I may not see well enough this year to pass my D.O.T. physical, and therefore lose my career. Is it too late to consider surgery if my vision is indeed less than 20/40? Is it too late to get another opinion? My livelyhood may be in the balance. Thanks

    • Randall V. Wong, M.D. July 19, 2012 at 1:30 pm

      Dear Tony,

      Too many docs, not comfortable with ERM surgery wait too long before removing the pucker. If you have an ERM, it’s causing a decrease in vision and/or distortion that you notice…great reasons for getting it removed now!

      The reason for not waiting and operating early is that noone guarantee how much vision you’ll get back after the operation, so, why wait?

      My criteria for operating are decreased vision/distortion noticed by the patient….I don’t rely on the eye chart.

      Find another doc.

      Randy

  • annonymous July 29, 2012 at 6:09 pm

    What is the approximate cost of EMR surgery for a patient who does not have medical insurance or has a plan that does not cover it. After a PVD, I was diagnosed with some wrinkling; which seems to be getting worse. I have not been to a retina specialist yet. I am uninsured and concerned about cost should I eventually need EMR surgery. Thank you very much for your very informative website.

    • Randall V. Wong, M.D. August 17, 2012 at 11:42 am

      Dear Annonymous,

      I will have Chrissy email you.

      Thank you very much for your comments.

      Randy

  • Dalene August 17, 2012 at 11:54 am

    Hi Dr. Wong,

    I was most recently diagnosed with macular dystrophy in which my ophthamologist feels is genetically linked. I have visual distortion in my left eye, which I have had for a year and read on your website about metamorphopsia and the causes and that most have a treatment. This is very intriguing for me since I was told the only treatment is nutritional supplementation. Therefore, I have been lumped into the melting pot of everyone else who has macular degeneration even though I do not have the disease. I am 41 years old and feel I am too young for this and would like your medical opinion. I did have a fluorescein angiogram performed, which didn’t show anything significant and an OCT, which only showed foveal hypoplasia. My doctor also stated I have a grainy pattern bilaterally. Any advice would be greatly appreciated.

    Sincerely,
    Dalene

    • Randall V. Wong, M.D. August 28, 2012 at 7:46 am

      Dalene,

      I agree with you. You’ve been shoved into “macular degeneration” but you don’t seem to fit the profile.

      I am curious about your vision. Do you know the measurement?

      Also, there is no evidence whatsoever that nutritional supplements improve anyone’s vision.

      Look forward to hearing back from you.

      r

  • Ken E August 18, 2012 at 9:34 am

    Doctor Wong,

    My surgeon has all but assured me that having a “core” FOV will result in macula pucker. This upsets me. What are your thoughts?

  • Brenda Peffley September 19, 2012 at 1:54 pm

    my Problem begain in 2010 I had A detached retina they did Surgery and put The retina Back and put in the silcone Oil very little vision returned 6 months later The oil was removed he said there was now a Macula hole.he Had put A bubble to Close It…But It Didn’t Close…And The retina Come loose Again..so we Go Back To surgery to repair The retina this Time I got The Gas Bubble but Still didn’t Work…Many surgery not much success This last one he Did The Surgery put The oil Back was in for my check Up..it been 4 months that he put the oil back in…Now He tells me He Going To leave The oil in unless it Causes other Problem..two Other Times He put The oil in he Said It Could only stay 6 months..Now I don’t know why it can Stay Now And Not Before…Can You Give me more Information about This…Brenda

    • Randall V. Wong, M.D. September 26, 2012 at 9:58 am

      Brenda,

      Usually oil can stay in the eye for an undetermined time. There is no hard and fast rule about 6 months. As I’ve written before, silicone oil may be viewed as toxic to the eye when, in fact, the “toxicity” is not from the oil but from multiple retinal detachment surgeries.

      Unfortunately, your case is not terribly unique and highlights the difficulties of retinal surgery.

      I love to use silicone oil earlier than later as it usually stops the vicious cycle of repetitive operations.

      r

  • JulieW November 26, 2012 at 9:12 pm

    Last year (13 months ago) I had a vitretomy for traction retinal detachment and ERM
    ( i am Type 1 diabetic with PDR). Removal of the ERM caused a 2nd area to detach. I quickly developed a cataract. (my ophthalmologist is in no hurry to do the surgery–even though my vision was 20/150 in Aug).

    Now- 3 months later my vision is 20/400. Just went to my retinal surgeon, who said I should have the surgery, BUT I will be having a hysterectomy in January, so will need to recover from that before I have the cataract done. I have another ERM, and will probably need to have that removed too.

    My questions:
    -How long do you have to wait btwn cataract and ERM surgery?
    -The vitreous was removed with the vitrectomy a year ago. Is an “air bubble” required again? Will I need to be face-down for a period of time after ERM surgery?
    -Am I at higher risk for another retinal detachment?
    -My good eye(NPDR) has slight traction and ERM but no visual distortion or change in visual acuity. Any odds you can give me on needing surgery in the future?
    -If ERM affects visual acuity, how can an ophthalmologist determine the correct cataract lense to use?

    Thank you so much for any info you can give me.

    • Randall V. Wong, M.D. December 3, 2012 at 9:41 pm

      Dear JulieW,

      I don’t consider patients who develop traction retinal detachments as a simple “ERM.” They are somewhat more complex and more difficult to operate.

      But,

      1. I’d operate within 2-6 weeks of cataract surgery. Your surgeon will have a clear view, and there is always the “notion” that other eye surgery may hasten the “pulling” of the epiretinal tissue on the surface of your retina.

      2. I use a bubble if a tear was created during surgery. The only reason gas/bubble is needed to prevent a retinal detachment when a tear is caused. The membranes on the surface of the retina from proliferative diabetic retinopathy are not as easy to remove as those with a simple “ERM.”

      Often, and this is surgeon and patient dependent, holes or tears are created during the surgery to remove the epiretinal tissue.

      The short answer? If no tears develop…you shouldn’t need gas.

      3. Are you at risk for another retinal detachment? Tough for me to say, but based upon your history…yes.

      4. Odds on needing surgery…depends upon if you can get the PDR to stabilize..AND, how far away the ERM is from the macula.

      5. Can’t.

      Hang in there!

      r

  • JulieW November 28, 2012 at 3:36 pm

    Another question pertaining to my previous post. I have the option of having my hysterectomy using DaVinci (robot). However, I would have to be in deep trendelenberg (feet up/HOB down) t/o the surgery. Would this put any added strain on eye conditions (PDR, NPDR, previous retinal detachment, ERM, traction)?

    I just want to make sure I make the right choice. Thanks

  • Tom Lampos December 28, 2012 at 11:59 am

    I had a giant retinal tear in my right eye (11 – 3) in 1997 that was repaired with laser surgery. About two years ago, I noticed distortion in the eye that my ophthalmologist concluded is a macular pucker caused by the retinal tear trauma. He recommended the new drug Ocriplasmin to fix the pucker.
    Do you think Ocriplasmin is a good solution to repair the macular pucker? What is the success rate and risks?

    • Randall V. Wong, M.D. January 2, 2013 at 9:27 am

      Dear Tom,

      If you read the article on Ocriplasmin consider ERM as part of the VMT group…only 26% of patients got resolution (ERM may be considered an extreme subset of vitreo-macular traction, VMT, where an actual membrane is causing traction on the macula).

      Let’s assume you are good candidate for surgery, that is, on examination I can see your ERM. There is a 99% chance of removing the ERM with surgery.

      The chance of infection of other intra-ocular injections (e.g. steroids, Ozurdex, anti-VEGF) is about 1/2000 whereas the chance of infection for vitrectomy (i.e. surgery) is about 1/10,000.

      Ergo, at this point, pending other data, I don’t think Ocriplasmin is worth consideration.

      I would encourage removing the ERM as soon as possible if you are aware it is disturbing your vision.

      Randy

  • Amboy J January 27, 2013 at 2:03 pm

    Dr Wong-
    I recently had Macular Pucker surgery with a virectromy (to remove scar tissue from a previous retinal detachment surgery). I was told that I would not need any sedation other than being unconscious for the 5 minutes to numb up my eye, as I would not see or feel anything. However, I saw the entire surgery and felt some pain…it was very frightening and traumatic, especially not being sedated at all. The surgical team seemed surprised that I saw anything and said to try not to look at it, but that was impossible. When I saw my surgeon later, he said it was very unusual that I saw anything. Just wondering if you have ever heard of patients seeing the surgery during this procedure, or is the eye supposed to be blinded by the local anesthetic?

    • Randall V. Wong, M.D. February 2, 2013 at 5:03 am

      Dear Amboy,

      I would guess that about 50% of my patients “see” something of the operation. Not that unusual.

      Randy

  • Krish May 8, 2013 at 12:27 pm

    Dear Dr Wong,

    I have been seeing floaters in my right eye for the last ten months plus. I got my eye checked and found that you vision was – 0.72 in lt eye and -1.00 in rt eye. in March 13 I realized the vision in my rt eye has deteriorated and it was 6/60. i was referred to retina specialist. I have been diagnosed with a horse shoe retina tear in both eyes. I was given a emergency laser bandage on both eyes for this. I have also been diagnosed with ERP in my rt eye. I was also told both my eyes are asymmetric. I have not been treated for ERP. I have been told I will have to undergo surgery on a later dated. But my vision in rt eye has deteriorated further and also the floaters have increased. I have not had any trauma, nor sugar, nor BP. I am in my early thirties.

    I would like to know what is the chances of my vision recovery and also is it ok for delaying the surgery.

    Regards

  • Suzie May 15, 2013 at 5:02 am

    I have been diagnosed with ERM. About four months ago went to see my eye doctor since it was time for my yearly check up and was having problems seeing. It was noted them my vision had decreased in my right eye and the I had a wrinkle in the eye. I was told we would watch it and was given new glasses. I went back in two weeks saying cant read the road sign was given different glasses. I am 51 years old and see better to read without my glasses but am noticing I am having a problem with reading some print. Yesterday went to see another eye doctor that noticed my vision in approx two months has changed again in my right eye. I was told my vision is 20/30 in that eye. The EMR was noted and pictures were taken. I was told surgery was an option. How ere was also told this might correct itself. Was told they do not rush to do surgery since it is a difficult surgery. I was also told that my left eye also has some retinal changes noted. Not sure what to do. I have an appointment in two months. CONCERENED

  • Suzie May 15, 2013 at 6:54 am

    Also wanted to add it feels like someone has taken my glasses and put finger prints all over them and I can not see through them. I have been wearing glasses for 46 years.

  • Lynne July 14, 2013 at 7:51 pm

    Thank you for providing this information for us.

    I was just diagnosed with Epiretinal Membrane in my right eye. I am 60 years old, female and have Ankylosing Spondilitis with a history of recurring iritis in both eyes which started when I was 18. I am very near sighted and have worn corrective lenses since I was a child. I now wear progressive lenses.

    My vision in my right eye is foggy and I am seeing more floaters than before, but it is still tested well with my glasses – at about 20/25. My ophthalmologist said that surgery is difficult and very high risk and was not an option until my vision got much worse and that I would get used to the fogginess and floaters. But you recommend surgery as soon as possible after diagnosis. Would you recommend surgery even though my vision is still good? Do progressive lenses make the distortion worse?

  • Judy K. July 26, 2013 at 3:15 pm

    I have just been told I have macular pucker, I had been seeing flashes of light fly across the top of my eye right to left. I had also noted I have trouble reading size 12 font and smaller. My dr. told me the problem. I am now set up to see Dr. Shaw. I could not explain what this all meant until I looked it up and your site caught my eye first. I know what happened to me or at least I think I know. Late in last year I had rolled over in bed to turn my alarm clock off but my hand went between the dresser and night stand and no way could I stop my self from rolling on off the bed and first the corner of my eye hit the corner of the night stand. Within seconds my whole body was resting on my hands and knees on the floor. I woke my husband because my face was burning with pain esp my cheek bone and the corner of the eye just above that. Our bed was very high up off the floor. The bottom mattress was removed. Then in the end of March I was going to heat a pad in the microwave to put on my calf and foot that was in a hard cramp. 1:30 am. I never touched the key pad I passed out and found myself flat on my back and later found I had a broken heel and torn myniska in the knee. results of my hitting the floor. Now this eye problem shows up but after reading your article I believe my eye problem comes from those two falls I took. So I can deal with it now.
    I see Dr. Shaw in first week of Sept. Your comments can ease our anxiety. thank you for taking the time to inform us older folks. sincerely,Judy

  • Zubair ahmed August 3, 2013 at 6:15 am

    I have been advised erm surgery for removal of the membrane in my right eye.Please let me know how long the surgery takes and how long before I can return to work. Also if I decide to go ahead with the surgery then what is the time from booking an appointment to a surgery date. I live in India and therefore what would you advise.

  • Judy Kelley October 3, 2013 at 7:56 am

    I am so glad I found your site. I couldn’t wrap my mind around what this Macular Pucker was. I started the research and found the possible cause of my situation. I had (don’t laugh -oh go ahead I still do.) rolled over to turn alarm clock off and kept on going-my hand missed the table and I kept rolling my cheek and corner of eye hit the night table though and we had a high bed. (no longer though). Then a few mo. later I simply passed out cold and hit the floor. No warning and had never had any warning. I woke up flat on my back with my husband standing over me. I guess these happenings would fall into the catagory of sharp blow to the head.

    I had surgery Sept 24,2013 And as far as I can tell things seem to doing fine. I see my dr Shah in about 4 hours from now. It was a relative painless surgery. I would see bright orange shapes and lots of other shapes n sizes and colors float around in my vision. Just all kind of movement in my vision when I closed my eyes. The bubble was entertaining though. mine just got smaller then was gone in about 5days.

    The main purpose of this comment is to say thank you once I had knowledge I was ok with the surgery to follow. I do not know what website you ask for. This old lady can get around but isn’t always understanding how or why smile

  • Pam Olano March 25, 2014 at 4:43 pm

    70 yr old female. Have blurry, cloudy vision in left eye since i had accident (severe concussion/brain damage/broken nose & eyebrow bone) in 1979. Basically i have lived “one-eyed” for 35 yrs. At that time, retina specialist told me to go home & be grateful I had a great right eye! Surgery wasn’t recommended. Recently a retina specialist diagnosed me w/retinal pucker & highly recommended surgery.

    My question: what are your thoughts about success of surgery, given i’ve had condition for over 30 yrs? I was told i’d have to do face-down recovery for 7 days. My quality of life would certainly improve w/the benefit of 2 good eyes & i’m willing to tough out the face-down part; i just want to ascertain what my chances for success are
    Thanx for this informative blog.
    Pam

    • Randall V. Wong, M.D. April 1, 2014 at 10:52 am

      Pam,

      Regardless of age, you might consider macular pucker removal if everything else is normal. Obviously, I can’t tell over the Internet.

      Straightforward macular pucker surgery should not require gas. Don’t know why your surgeon would recommend otherwise unless you’ve got a macular hole or retinal detachment.

      If you have just a macular pucker, in my opinion, your resultant vision is related to your pre-operative vision, that is, how bad is your vision now?

      I recommend removing the ERM as early as possible, but that doesn’t mean you won’t do swimmingly!!!

      Randy

      Randall Wong, M.D.
      Retina Specialist
      Fairfax, Virginia 22030

      http://www.VitrectomyForFloaters.com

  • Pam Olano April 3, 2014 at 3:31 pm

    Thanx for ur response, Dr. Wong. I’m in good health & my eyesight was excellent before my accident & the resultant scar tiissue/retinal pucker. I have 0 eyesight in that left eye, so any improvement will be fab. I’m going for it!!
    Again, thanx for this unformative site & ur expertise.
    Pam

  • madalena vieira May 29, 2014 at 10:49 pm

    Dr Wong
    I have Lupus and because of the medication I have to have my eyes checked. I have something going on on my left eye and no eye Dr understands what it is. Sometimes I have a white or black shadow that comes on my eye and blinds me partially and very rarely totaly. It can last for close to a minute or can go longer and the it starts disappear by itself. I wonder if you have any clue of what it could be. They did tests and they still dont understand what it is and it happens only in my left eye.

    Thanks
    Madalena

    • Randall V. Wong, M.D. June 9, 2014 at 11:23 pm

      Madalena,

      Does not sound as if related to lupus or lupus treatment. I wonder if someone my consider migraine?

      R

  • Matthew Rowley July 3, 2014 at 11:13 am

    I have recently been to see a specialist at my local hospital and have a epiretinal membrane in my left eye which they tell me is from birth. I have blurred vision from the eye and it constantly waters which i assume is from straining vision. They told me that i could go for surgery but my vision mite not improve. I am now 29, so would surgery not be advisable?

    • Randall V. Wong, M.D. July 12, 2014 at 2:46 pm

      Matthew,

      I’ve never heard of a true ERM from birth. There are other types of membranes which occur congenitally, I wonder if you have another condition?

      Randy

  • Michelle Kirrane August 18, 2014 at 4:07 am

    Hello Dr Wong

    I am 35 years old, last year I was told I had ERM a year later there has been no change and I don’t yet notice a change to my vision. I was told for someone who is 60 that it might not get as bad as it can get for 10-15 years, in your experience because I am younger would the progression be slower? It is in both of my eyes, I was born with poor eyesight currently +10 the only trauma I can think of in both eyes is that I had a dettol (cleaning like substance) like substance in my eyes from cleaning my contact lenses in it – could this be the reason or could it just be something congenital?

    Many thanks
    Michelle

    • Randall V. Wong, M.D. August 25, 2014 at 12:35 pm

      Michelle,

      Most likely this is genetic (that is, you are prone to getting these). Doubt it has anything to do with your contact lens routines.

      ERM’s progress at different rates in different people. My opinion is that an ERM which hasn’t changed, will likely stay stable.

      I would get examined at least 1x a year or more if your doctor suggests.

      r

  • Scott C. August 20, 2014 at 1:33 pm

    I have been diagnosed with ERM in the lower right quadrant of my right eye. How many ERM procedures have you performed? I live in Texas and would like to find the most experienced surgeon regarding this procedure. How can I find out who has the most experience with ERM surgeries?

    • Randall V. Wong, M.D. August 25, 2014 at 12:29 pm

      Scott,

      I’ve been in practice for 23 years. For about 5-6 years, I was one of the busiest vitreo-retinal surgeons in the state of Maryland.

      Other than telling you I’ve got tremendous experience and have probably performed 1000’s of ERM removal – there is no way for you, the patient, to verify this (or maybe anyone for that matter!).

      The ERM surgery on YouTube took less than 15 minutes – it may give you an idea of technical skill – but not everyone has a YouTube. It’s one of the challenges of a patient.

      If I can help, please let me know.

      Randy

  • ann July 4, 2018 at 3:36 am

    I am 15 months post ERM surgery. My doctor did the cataract at the same time. I now have distortion which I did not notice prior to the surgery. I noticed blurry vision reading street signs but no the wavy vision I have now. Can the surgery itself cause distortion?
    My CMT before surgery was 378.

    • Randall Wong, M.D. September 23, 2018 at 11:03 am

      It’s possible if there were a complication where the instruments damaged the retina, but usually not. Randy

  • Karen September 25, 2018 at 6:36 pm

    I was diagnosed with epiretinal membrane two years ago. Acuity is holding stable at 20/40, however, distortion is most bothersome and causing some binocular diplopia. Would surgery at this point help with the distortion and double vision or is it too late to see much improvement?

    • Randall Wong, M.D. October 7, 2018 at 3:00 pm

      It is my opinion that ERMs should be removed as soon as the patient is aware of a change in vision. Given 20/40, I don’t think too late at all, but choose someone comfortable operating at this time (level of vision). Randy

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