When to Remove Macular Pucker

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When to Remove Macular Pucker

Most patients wait too long before considering removal of a macular pucker (epiretinal membrane). The decision should be made as soon as visual changes are noticed.

Surgery for Macular Pucker. Randall V. Wong, M.D., Retina Specialist, Fairfax, Virginia.There are two indications for removing an epiretinal membrane, or macular pucker.  An epiretinal membrane causes decreased vision and/or distortion.  When either the vision or the distortion is noticed, I recommend macular pucker surgery  The earlier the better.

Visual Acuity Not Good Enough

Too often, patients with an ERM/macular pucker are told their vision is “not bad enough.”

Patients with cataracts must wait until the vision is bad enough to qualify for cataract surgery.   If the vision fails to meet certain criteria (usually 20/40 or worse), insurance will not cover the surgery.

This same criteria does NOT hold for retinal surgery, but too many retinal surgeons apply the same visual criteria to make the decision to consider surgery.

I feel the macular pucker should be removed once you (the patient) are aware of  a difference in vision between the two eyes and your physician agrees the difference is due to the macular pucker.

Timing Macular Pucker Surgery

There is no guarantee how much your vision will improve with removal of the macular pucker.  Unlike a cataract where the timing of surgery is not very important, timing macular pucker surgery is more critical.  The better the vision at the time of surgery, the better the results.

For instance, if a patient develops a cataract, there is no impact on the visual prognosis depending upon the visual acuity at the time of cataract surgery.  In other words, it doesn’t matter if we perform cataract surgery at 20/40 versus, say, 20/80.  The visual improvement should be exactly the same.

This is not true of macular pucker surgery.  The worse the vision is at time of surgery, the worse the visual results.  Therefore, I advocate removal of the macular pucker as soon as possible.  The timing of surgery should not solely be based upon the visual acuity.

In addition, OCT measurements show protracted thickening of the macula for over a year.  It makes sense the remove the membrane to limit macular thickening.

Can’t Measure Distortion

While we measure vision with the eye chart, there is no way to measure distortion.  Distortion is often present with an epiretinal membrane.

The distortion is caused by physical wrinkling of the retinal surface and in my experience is almost always improved with timely surgery.

What Does this Mean?

Macular pucker surgery can be extremely successful, the earlier surgery is performed.  The decision to perform surgery  should include information about macular thickening and distortion and not just visual acuity.  Visual acuity, however, is the only variable that can be measured.

Whether you call it an epiretinal membrane or macular pucker, know that the sooner you choose to operate the more likely you’ll be happy with your results.

 

Comments
  • Theresa Gachter October 8, 2013 at 2:33 pm

    Thank you Doctor. I am still waiting on a miracle. Regards Theresa

  • Tom Lampos October 24, 2013 at 3:54 pm

    Dr Wong, I have been diagnosed with Pathologic Myopia. I have a Macular Pucker in my right eye which also had a giant retinal tear (11 to 3) that was repaired with laser surgery in 1997. Does the fact that I had a retinal tear make the macular pucker surgery more risky?
    I had cataract surgery in 2010 with a prescription lens that corrected my vision to 20/30 but now my vision is 20/100. I’m not sure if it is due to the pucker or my myopia. Also, I do notice a warping when I look at circular images. The left side of the image appears flat instead of curved (like people’s faces).

  • Shelley Liou October 31, 2013 at 10:38 pm

    Hi Dr. Wong,
    I was diagnosed with Macular Pucker in both eyes last month, left eye more serious than right. You suggested either Jetrea or surgery but I got cold feet at last minute. Both procedures will have many complications. I have macular retinoschisis in both eyes. Could that make my surgery more risky? Do you think Jetrea injection is an effective way to remove Macular Pucker?

  • geneva johnson November 21, 2013 at 5:51 pm

    Have an infection from retinal pucker removal surgery. Noticed terrible headaches w/ pain seemingly on one side inside head in back of left eyeball. Last one had nausiousness (sp). Doing eyedrops 2x per day. Most of my adult life involves hayfever, rhinitis, sinusitis, but had deviated septum fixed and now can take in twice as much oxygen which is wonderful. Am so worried about my problemchild left eyeball. Will it always be problematic…silly question. Is there material I can read to know what to expect? Thanks. gjohnson

  • carol December 21, 2013 at 12:14 pm

    Dr wong. after two failed retna attachments my husbands doctor finally put oil behind eye to hold retna. now after almost two years he sees a small bubble in the front of eye. He says if he starts getting pain to call and come in. meaning oil leaked. He made husband understand that there would be nothing more he could do? does that mean he could not replace the oil again. We live in Pa. we are away right now, and hope he does not get into trouble before we return. I hope you can give us some insight on what happens if there is leak, and if he will then just let the retna detach. thanks worried wife

  • carol December 23, 2013 at 3:49 pm

    Thanks for the responce. If its common for the oil to leak, does that mean it will happen repeatedly. and will have to go through many procedures to put oil back in? This has been a night mare for my poor husband. and he is such a trooper. He trys to live with vision in one eye like nothing happened. I read where you stated you put the oil in right away. we are not in virginia, and had no knowledge about this untill this doctor did the gas twice. By then it was way to late to have someone else do this. We live in Pa. and went to the northeastern eye in scranton. Not happy with this doctor at all. He will never have vision in that eye. all distorted, and we got many doctors stating it will not return.

  • Kathy January 13, 2014 at 5:38 pm

    Dr. Wong. I have an ERM or Macular Pucker caused by an acute PVD (started on Nov. 9, 2013). My Opthomalogist, a Wills Eye Dr, recommends waiting until my vision gets worse, which may not happen. He seems to think either it may stay as it is or the ERM could fall off by itself. He and his assistant opthomologist had both stated weeks ago that my vision would be likely to get worse, and would hopefully improve a bit once my vitreous was totally detached. I now have 20/25 vision in that eye, and see the world about 20% larger than in my right eye. There is some distortion that I can notice in straight lines or grids, and shadowing in various places as well. I also see colors with a slightly grey tinge in that eye. My doctor said that while the surgery is usually quite successful, there are risks, and it would be difficult for me to find a doctor who would take those risks on me when my vision is still so good.

    Do you think that my vision will deteriorate in the eye with the ERM? Also, I know that I am more likely than most to end up with an acute PVD in the other eye in the next year or two. Is there a big chance that that eye will also end up with an ERM?

    • Randall V. Wong, M.D. January 21, 2014 at 4:58 pm

      Kathy,

      You’ve read this article. It has been my experience that the ERM should be removed as soon as the patient notices a difference in vision; either from distortion, blurry vision or both.

      No one can (or rather should) guarantee and degree of improvement with ERM removal. Full restoration may be unlikely no matter when the ERM is removed (as compared to cataract surgery). Therefore, I recommend removal as soon as possible.

      The chance of spontaneous separation of the ERM from the retinal surface is probably less than 5% – it has been 1 or 2 times in my practice of 22 years that I can remember.

      You are right, if you are prone to ERM in one eye, you are likely to get one in the other. I think it’s due to over zealous gliocytes (protein producing cells resident to your retina) producing too much protein.

      Best of luck!

      Randy

      Randall V. Wong, M.D.
      Retina Specialist
      Northern Virginia
      Fairfax, VA. 22030

      http://www.vitrectomyforfloaters.com

  • Dorothy Jones January 28, 2014 at 4:04 pm

    Hi, Dr. Wong. I’ve been following your writings for awhile; I just wish I had discovered your posts sooner. I had cataract surgery in January 2012. In October 2012, I had a retina detachment. It was treated, and I retained 20/20 vision in the eye. About six weeks later, I noticed a distortion in the eye and immediately headed to my optometrist. He said he didn’t know what it was and sent me to another specialist. I asked to be referred back to the retina specialist, as it was so close to the to the retina surgery. Even though he didn’t know what it was, he assured me it wasn’t the retina. I found that interesting. Anyway, seven weeks went by before they diagnosed a retinal pucker and operated. The surgery seemed to go well, the vision was good, but three days later I developed scar tissue, and in one hour I was blind in that eye. The retinal specialist operated again and used silicon oil to arrest the scarring. That was in January 2013. I still have the silicon oil in the eye and the vision is poor. My new optometrist has now identified a membrane growing over the implant and felt that it could be removed by laser. That renewed my hope for better vision. The vision is like I’m looking through a dark curtain. The retina surgeon said to leave it alone. I realize you can’t diagnose without seeing the patient. I’m looking for answers and would like a second opinion. In your opinion, is a second opinion warranted? I would have no problem travelling to see you if you think you can help me. You only have one pair of eyes.

    Your advice to have the macular pucker taken care of asap is right on. I wish I had had that knowledge when it was happening to me. The surgery wouldn’t have been so tramatic, and I don’t believe I would have had the scarring.

    Thank you, Dr. Wong, for the time you devote to answering questions and helping patients to understand.

    I look forward to your comments.

  • John Williams April 12, 2014 at 5:28 pm

    Hi Dr. Wong,

    This is a great website and a valuable public service. Thank you. You are a treasure.

    Three questions:

    1. Which symptoms (if any) of my macular pucker (see ‘details’ below) are most likely to be reduced by successful surgery. Since my pucker is three years old, I know good overall results are unlikely. (I just found you today.)

    2. At this point (3 years in) would surgery prevent further deterioration of my eyesight. My annual checkups (by a retina specialist ophthalmologist) show the pucker is pretty stable.

    3. With the surgery, would I be risking a bigger size discrepancy (see ‘details’ below) between my eyes than I already have?

    The details:

    My right eye has a macular pucker that causes things to look about 10% bigger/closer than they appear in my (good) left eye. It also causes some central vision blurring; a vertical ‘speed bump’ in the middle of horizontal lines and a slight bending outward of the peripheral lines on an Amsler grid.

    The 10% difference causes me to have a moderate case of double vision – with or without glasses. This affects my computer work, reading, driving and TV watching. I still have passable monocular use of the affected eye at distance (wearing my astigmatism correcting glasses or contact lens). I can see well enough to drive with that eye but road signs are hard to read until I get close to them.

    I first noticed the double vision when I got a new pair of distance glasses. But, over the last year or so, as I pay more attention to my vision, I can tell I have double vision even without glasses, at middle distances and beyond. Close in, for computer work, my left eye dominates and I can generally ignore the right eye.

    The pucker was diagnosed by a local ophthalmologist immediately after it occurred and is being measured/photographed/monitored, annually, by a retina specialist ophthalmologist.

    • Randall V. Wong, M.D. April 20, 2014 at 9:38 am

      John,

      Three answers :). Thanks for the compliments.

      1. Hmmm – likely to be improvement in distortion and less blurry. Double vision can be from so many causes, if due to the macular pucker, should decrease, but I’d have to examine you.

      2. If it’s stable, but bothering you, I don’t understand the hesitation to remove. Highly likely you’d get some improvement. Again, I can’t examine you so I’m just basing this on your account.

      3. No I think it should reduce, assuming it’s due to the ERM.

      Best of luck!

      Randy

  • John Williams April 25, 2014 at 11:08 pm

    Dr. Wong,

    Thanks for your reply.

    I guess I’m one of those patients who is in a kind of gray area.

    The argument for surgery is the possible, modest improvement in one or more symptoms. I would like even modest improvement. But, if my symptoms are not going to get worse, I know I can live with them.

    The arguments against surgery are: possible complications; possible worsening of my eyesight and the near certainty of needing cataract surgery much sooner than otherwise needed. Even a successful, complication free surgery that produced modest improvement might not be enough to significantly change my perception of the problem. And, if I had the bad luck to be in the small percentage of patients who experience complications that further damaged my sight, I would be regretting it for the rest of my life.

    I guess if I could be convinced that there was no possibility of even a slightly negative outcome, I would have the surgery.

  • keith u gordon November 9, 2019 at 7:46 pm

    I have had a pucker removed after having shots for over a year. I changed doctors and he told me about the pucker which he removed. I have ARMD in that eye which has not gotten any worse since pucker was removed. However since I was first diagnosed, my eye has been more and more sensitive to light. As soon as I wake and go into the light I go into a brain fog which lasts until dark. I don’t have dementia. But this fog is very disturbing, Have you heard of this and if so can anything be done to correct it? I am very sensitive to a lot of medicines.

    • Randall Wong, M.D. December 16, 2019 at 9:15 pm

      Keith,

      This does not sound usual to me. I’d ask you to consult with your doctors.

      Randy

  • Cheryl January 21, 2020 at 8:20 pm

    Dr. Wong, I was examined for my
    Eyes on June 11 2019. It was a regular eye exam. I read the snell chart well in both eyes. . The prescription was given. I was told I have 20/ 20 in left eye. After wearing the prescribe glasses by the doctor the right eye gave me a problem. I went to the optermolgist and it was not clear to proceed with surgery on my part due to the diagnosis of a macular hole that startled me yo accept this reading. IN ADDITION THE OPTERMOLGIST STATEDCIT THAT SYSTOMS WAS MILD AND I NEED TO COME BACK FOR A FOLLOW UP. I read that a bad prescription given by the eye doctor, can cause an macular hole? Is it ok if this is a macular hole or pucker is safe to proceed wth surgery due to the time period lasped, what kind of surgery can be done? or is it
    another way of treatment other than surgery? In wearing this eyeglass prescription when I take off the eyeglasses I have bluriness in the 20/20 eye.

    I had a second opinion also of a ERM . I GO BACK ON THE 23 OF JANUARY TO GET ANOTHER UPDATE ON THE THIS MACULAR PUCKER.
    Thank you

    • Randall Wong, M.D. April 1, 2020 at 10:41 pm

      All the best and good luck! No other option than surgery.

      Randy

  • Ginny Rowland January 24, 2020 at 11:11 pm

    My opthalmologist told me 5 years ago that I had macular pucker in the right eye, but that there was no reason to do anything about it as it was not affecting my vision. The vision in that eye deteriorated in the last two years and he recommended cataract surgery, and placed a multi focal Toric IOL My vision post cataract surgery is dramatically worse. Images are about 25% larger, blurry and wavy. He is referring me to a retina specialist. Three questions. Was a multi focal lens an appropriate choice? Could I expect any improvement in my vision if the pucker was removed after having it for at least 5 years? If a multifocal lens is part of the problem, would it be wise to change out the lens for a different type?

    • Randall Wong, M.D. April 1, 2020 at 10:47 pm

      I can’t formulate an opinion as I can’t examine you. I apologize.

      Randy

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