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Epiretinal Membrane ⁣

An avascular fibrocellular membrane that proliferates on the inner surface of the⁣

retina and produces visual impairment⁣

Causes:⁣

Idiopathic ERMs is the most common presentation. ⁣

Secondary ERMs: retinal vascular diseases including diabetic retinopathy, retinal vein occlusion, ocular inflammatory disease, trauma, intraocular surgery, intraocular tumors, and retinal tear or detachment.⁣

Symptoms: Gradual painless loss of vision, Metamorphopsia, Micropsia⁣

Pathology: Fibrous proliferative membrane like structure consisting of cells interspersed with an extracellular matrix.⁣

Fundus examination: ⁣

Thin sheen like membrane to a thick opaque membrane, associated with vascular tortuosity, straightening and dragging of vessel toward the fovea. ⁣

Associated intraretinal hemorrhage, cystic changes in macula, cotton wool spots, macular edema, macular hole or pseudohole. ⁣




Gass classification of ERM :⁣

Grade 0 – Cellophane maculopathy⁣

● Completely translucent membrane barely visible clinically. There is no foveal distortion and retinal traction ⁣

Grade 1 – Crippled cellophane maculopathy⁣

● Contraction of ERM⁣

● Membrane causes an irregular wrinkling of inner retinal surface.⁣

● If wrinkling is severe enough, para macular vessels may be pulled towards the fovea⁣

in a corkscrew formation (seen on FFA) ⁣

Grade 2 – Macular pucker⁣

● Membrane is thick and opaque.⁣

● Full thickness puckering of macula may be present along with edema, small⁣

hemorrhages, cotton wool spots and sometimes localized RD⁣

● Severe visual loss⁣

Cause of vision loss in ERM:⁣

● Contraction of ERM causes elevation of macula⁣

● Retinal distortion and traction⁣

● Macular edema⁣

Investigations :⁣

● Amsler grid⁣

● FFA - can show retinal vascular tortuosity, straightening and leakage, as well as⁣

CME, also helps in excluding the other retinal pathologies that may cause ERM formation ⁣

● OCT- To see CME,VMT,Localizing the edge and thickest part of ERM and to⁣

differentiate lamellar macular hole from pseudohole⁣

● Multifocal ERG⁣

Management :⁣

● ERM removal with/without ILM peeling


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CMV Retinitis⁣


Necrotizing full thickness retinitis due to CMV, most common in HIV patients with CD4 count <50⁣

Other causes- leukemia, lymphoma, on immunosuppressants, organ⁣

transplant recipients⁣




Pathogenesis:

CMV reaches the retina hematogenously and infects the vascular endothelium & spreads to retinal cells⁣

Symptoms:

Asymptomatic, photopsia, visual loss, floaters, scotomas⁣

Signs:⁣

AC & vitreous reaction minimal⁣

Irregular border of solitary yellow white active retinitis, small white satellite lesions⁣

Centrifugal spread with central clearing⁣

Prominent vasculitis resulting in ischemia and hemorrhages- Pizza pie/cottage cheese & ketchup appearance⁣

Brushfire pattern of spread along vessels -Frosted branch appearance-⁣

active border advances by 25-300 um/wk⁣

ON involvement- concurrent CNS infection⁣

RRD -1/3 patients when >25% of retina is involved⁣

Types:⁣

Fulminant-hemorrhagic necrosis on white/yellow cloudy retinal lesions, centered around vasculature⁣

Granular-retinal periphery, with minimal necrosis/hemorrhage/vascular sheathing⁣

Perivascular- Frosted branch angitis- white lesions around vessels⁣

Zones:⁣

1- 1DD (1500um) around disc & 2DD (3000um) around fovea:immediately sight threatening ⁣

2- Anterior to zone 1 & posterior to vortex vein ampullae⁣

3- Peripheral to Zone 2⁣

Visual loss:⁣

Macula/ON involvement⁣

Immune recovery uveitis-Rejuvenated immune response against residual viral antigen following immune constitution with HAART⁣

Signs: Vitritis, Optic disc edema, CME, ERM, Cataract, Anterior uveitis etc.⁣

RD⁣

Diagnosis:

Clinical

PCR -aqueous/vitreous⁣

DD: HIV Retinopathy, ARN, Toxo, Syphilis, TB, Behçet’s⁣

CWS: Lesions condense, fade & disappear over 4-6 wks ⁣

CMV Retinitis: Lesions advance, at about 1/2DD in 2-3 wks⁣

Rx:⁣

HAART in AIDS patients ⁣

IV ganciclovir 5-7 mg/kg/day in 2 divided doses for 2 weeks -induction dose⁣

Maintenance dose -OD till complete resolution of lesions & improvement of immune status⁣

Oral valganciclovir 900mg BD as induction dose for 21 days, 900mg OD as maintenance dose⁣

Other options: IV foscarnet/cidofovir, Intraocular ganciclovir device, Intravitreal ganciclovir, Oral leflunomide ⁣


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Image from Rajan Eye Care Hospital⁣


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CONTACT

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