Macular Pucker Surgery

Surgery for Macular Pucker.  Randall V. Wong, M.D., Retina Specialist, Fairfax, Virginia.Macular pucker surgery (removing an ERM) is my favorite surgery.  It’s elegant and usually involves healthy eyes.  It’s one of the few operations where we can get significant improvement, as long as we operate early enough.

Symptoms of Macular Pucker

Distortion and blurred vision are the two most common symptoms of an epiretinal membrane (ERM) or “macular pucker.”

Patients noticing a change in vision, either blurry, distorted, or both should consider surgery.  There is no other option.

Causes of ERM

An epiretinal membrane forms on the surface of the retina in response to some minor “trauma.”  In my experience, most patients have already had a PVD (posterior vitreous detachment) preceding the development of this proteinaceous membrane.

Sometimes the “trauma” can be cataract surgery.

The “membrane” really isn’t a true membrane.  Instead, it is simply a sheet of protein (a form of Collagen) which has been over produced by specialized cells (fibroblasts) which normally reside on the retina.

What Causes Distortion and Blurry Vision

The membrane contracts and wrinkles the underlying retina (hence the term “pucker”).  This puckering, or wrinkling, causes loss of vision and usually some distortion as the retina has been physically altered.

On the cellular level, the gentle pulling on the retina causes some macular edema which causes the blurred vision.

When You Need a Vitrectomy

I personally disagree that vision must drop below a certain level (e.g. 20/40) to consider surgery.  Noone can ever guarantee complete restoration of vision with ERM surgery, so the sooner you choose to operate, the better.

I prefer to operate as soon as you notice a change in your vision and we agree that ERM surgery is likely to help you.  At the very least, remove the ERM to prevent further vision loss.

An OCT (optical coherence tomography) should be obtained to demonstrate the changes in the macula, but is not absolutely necessary for surgery to be performed.

What Does this Mean?

Most patients with epiretinal membranes (ERM), macular pucker or cellophane maculopathy have healthy eyes.  The vision changes can be stopped and often improved.

The earlier the intervention, in skilled hands, the better the outcome, that is, operate as soon as you notice a change in your vision as no one should make guarantees about return of vision.  My goals for surgery are primarily to stop further vision loss and to give you the chance of improvement (no one should expect complete restoration of vision).

Item last:  There is a subset of ERM/Macular Pucker/Cellophane Maculopathy called vitreomacular adhesions (VMA) or vitreomacular traction (VMT).  Basically these refer to condition where the vitreous is tugging/pulling on the macula causing similar symptoms of ERM.

Randy

Randall V. Wong, M.D.
Retina Specialist
Fairfax, Virginia 
www.RetinaEyeDoctor.com

Comments

  1. JulieW says:

    Always enjoy reading your articles. You recommend early surgery to prevent further vision loss. Can the wrinkling of the retina be permanent?

  2. latifah khateeb says:

    i dint have a comment but do you know if there is anything to help people with stargards

  3. Joan crumrine says:

    I have macular degeneration also epiretinal membrane. Recently I have a distortion in vision, the doctor said it was the macular degeneration. I just wonder how he knew the difference.

  4. marian o neill says:

    Hi Randall
    I had surgery for a retinal detachment in Oct2011.
    I had a vitrectomy 6 weeks later for macular folds. My vision is reduced to HM only in my rt eye. Should I have waited 6months to see if the folds subsided and perhaps I would have been left with good enough vision in my rt eye.
    I have now developed sympathetic opthalmis in my left eye.
    I would appreciate your opinion.
    Marian

  5. Joan,

    Good question. I’d compare the two eyes, but you have a valid point, and I don’t have a great answer.

    Randy

  6. JulieW,

    Yes, but usually the retina flattens out (unwrinkles) yet some distortion remains.

    Randy

    Randall V. Wong, M.D.
    Retina Specialist
    Fairfax, Virginia
    http://www.RetinaEyeDoctor.com

  7. Latifa

    No. There is no known cure. Stem cells are a remote possibility in the future.

    Randy

    Randall V. Wong, M.D.
    Retina Specialist
    Fairfax, Virginia
    http://www.RetinaEyeDoctor.com

  8. Dear Marian,

    Very complicated. Were the folds related to the retinal detachment?

    Stay close to your doctors and heed their advice with regard the sympathetic ophthalmia.

    Randy

    Randall V. Wong, M.D.
    Retina Specialist
    Fairfax, Virginia
    http://www.RetinaEyeDoctor.com

  9. Michael says:

    I’ve had three RD vitrectomies on my left eye since March. The second and third followed pvr development and redetachments. After the second surgery, I noticed that I had a small grey spot (I call it an asterisk) in the center of my field of vision, and a small bit of pinching of the image around that asterisk. I’m guessing I’ve developed a macular pucker, though maybe this is just something that’s a by product of the sugeries. I still have it after vitrectomy #3. I also have had periodic flashing just below the center of my field of vision since this third surgery (almost five weeks ago). It’s usually shaped like a small section of a circle. My doctors have looked and said there’s no sign of traction and I shouldn’t worry about it. Could it be related to the dot and distortion in my vision?

  10. Michael,

    I’ve found that whenever the macula is involved, there may be strange, unexplainable symptoms.

    I’d agree with your docs. Give it some time.

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

    http://www.TotalRetina.com
    http://www.RetinaEyeDoctor.com

  11. Dear Dr Wong,
    Thank you for offering your time to help many patients like us to have better appreciation of the problem we faces with our eyes. It helps to give us enough confident to take the next step.

    I am a male, age 53. I was diagnosed with Macular pucker 3 years ago on my right eyes. The eye specialist hastely and casually recommend me to have vitrectomy operation; informing me that the chances of suceess was 85%. I did not see eye-to-eye with his enthusiasm of the chance. I scan through the internet and found many cases of those who undergo the operation for macular pucker ended up having repeat operations. Some for further corrections and others for cataract operation soon after. Quire a few site advise to defer the operation until the condition reach a stage where it effects the patient’s sight significantly.

    So I bear with the condition for the last 3 years. Currently, I can still for distance viewing (slight distortion but acceptable) but for short distance viewing esp looking at displays (smartphones, computers, TV) I start seeing double vision, difficulty to focus esp after longer period of viewing these display. Also when I face against bright light background, I no longer can see clearly. The images are no longer sharp.

    My question: Is it better to proceed with the operation now or to continue to delay it. If so, can you recommend a good eye specialist in Malaysia (near Kuala Lumpur). Thanking you in advance. Do continue your great service to society.

    Best Regards,
    CK

  12. Dear CK,

    It is my practice to remove an ERM/macular pucker as SOON as the patient notices a change in vision.

    The reason is quite simple, no one can guarantee full restoration of vision after removal. Therefore, I recommend removal as soon as you notice the decreased vision.

    I would recommend Dr. Kenneth Fong

    Consultant Ophthalmologist and Vitreoretinal Surgeon
    Sunway Medical Centre,
    Petaling Jaya, Malaysia

    His website/address is here;

    http://www.eyeretina.my

    Good luck,

    Randy

    Randall V. Wong, M.D.
    Retina Specialist
    Fairfax, Virginia
    http://www.RetinaEyeDoctor.com

  13. Hello Dr. Wong,

    I had a vitrectomy to remove floaters in my right eye 3.5 months ago and it was very successful. Three months later I had a small retinal tear in the eye, and another vitrectomy and laser surgery was done (two weeks ago). However, this time, after the bubble dissolved, my vision is very wavy in the top half. The lines are completely distorted on the Amsler Grid.

    Could I have developed a macular pucker immediately after my surgery (does ERM form this quickly?), or do you think this is more than likely a case of swelling and maybe some fluid under the retina that will reabsorb? My surgeon thinks its the latter, but the vision hasn’t improved a bit in two weeks time.

    Finally, he says I have ERM in my other eye (vitrectomy 1 year ago), but I notice no wavy vision in that eye so he thinks nothing should be done until a problem occurs, so you agree?

  14. Eric,

    So you detached?

    The distortion can be from either macular edema or an ERM. They can sometimes form quickly.

    The macular edema means that you had a retinal detachment involving your macula.

    Is this true?

    Randy
    Randall V. Wong, M.D.
    Retina Specialist
    Fairfax, Virginia 22031
    http://www.TotalRetina.com

  15. Mary Ann says:

    Dr. Randy,
    Thanks for the information you sent about the epiretinal membrane. It is helpful to have something to refer to. This is a new experience for me. It is always a bit of a shock to have to consider a surgery and having something to refer to helps acclimate me to the realization that surgery is needed and not so intimidating.
    –Mary Ann.

  16. Mary Ann,

    Glad this was helpful. Apologize for such a delay in responding.

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

    http://www.TotalRetina.com

  17. I had surgery for a cataract and macular pucker of my right eye on 7/9/13. Since then, when viewing eye charts to test vision, the letters will be blurry, but then suddenly come into focus. I asked my surgeon about this but he acted like my surgery had gone great and I was recovering wonderfully and did not address my question. While my vision is much improved, it is still difficult to read road signs while driving since it is unpredictable when it will be blurry and when it will be clear. Is this something you have experienced with your patients? Will it improve with time?

  18. I had macular pucker surgery 1 week ago. Things went smoothly I was in and out of the hospital within a couple of hours and had patch removed the next morning. I must admit I was worried about doing it but am glad I did. Now let’s hope my vision/distortions improve over the coming weeks/months. I would advise anyone who needs to do this should get it done!

  19. Phil,

    Very hopeful that you’ll improve due to the fact that you episodes of really clear vision.

    I wonder if you’ve developed/have a cataract?

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

    http://www.TotalRetina.com

  20. I am scheduled for victrectomy; now doctor says two years before see difference and need glasses after surgery this concerns me. Any comments?

  21. Di Welsch,
    I don’t think the vitrectomy will cause you to need glasses. Perhaps I don’t understand your question.

    Randy

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

    TotalRetina.com

  22. Hello Dr. Wong,
    I am a 46 year old male who was recently diagnosed with a macular pucker in my left eye. My visual acuity has declined and there is significant blurriness. I have many questions pertaining to alternative therapies as well as possible post operative scenarios. I have looked at ayurvedic approaches and there is one hospital that I was referred to in India. Can this type of condition be reversed? Can the fibrosis breakup naturally and the eye return to normal? If this is possible, how long might that take? Is there anything I could be doing to improve my odds? The thing that is most scary, of course, is the potential to lose significant vision in the eye permanently. I have looked all over the Net for solid stories about success, but a lot of these seem to be hidden. How successful are these surgeries? Does everyone experience some type of loss or distortion? Thank you for your time and effort and any solace or hope you might bring. Oh, also if the acuity is lost in the eye are contact lenses prohibited? Is there a source that I might not have found that might answer many of these questions for me?

    sincerly,
    Rich

  23. Richard,

    I can not address other therapies, I simply don’t know enough about them.

    ERM surgery, in my experience, is exceptionally successful. With the right surgeon, the ERM should be removed as early as possible. In my experience and opinion, waiting too long decreases your visual prognosis, that is, you may not get all your vision back.

    I doubt you’ll find much on the Internet. Not really an acute problem, perhaps?

    All the best.

    Randy

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

    http://www.vitrectomyforfloaters.com

  24. Kathy White says:

    Hello Dr. Wong, 2 years ago I was diagnosed with a macular pucker. My eye Dr. said it was not bad enough for surgery and we would watch it. Last year, he said the same thing. This year I decided to go to a Retinal specialist, Dr. Bucher. He said I should have surgery now. If I wait, it could possibly advance to a macular hole. My surgery is scheduled for April 2nd. Now I have so many questions. I started searching the web, without much luck…..until I found your website! Thank you so much! All of my questions were addressed and you thoroughly answered them to my satisfaction. You sound like a very compassionate Dr. Thank You, Kathy

  25. Kathy,

    !!!!!

    Great for you. Thanks for the compliments. Best of luck with your surgery!

    Randy

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

    http://www.vitrectomyforfloaters.com

  26. Dr Wong:
    I had an uneventful IOL implant in august 2013. Because the doctor found a minor ERM in the other eye he wanted to wait a year before considering IOL in other eye; also my vision in the non operated eye was decent. Guess he was weighing the risk. My circumstance is complicated by a split image problem; I need a significant prism correction to partially address this diplopia issue. But the acuity difference compromises my vision. My wife gets frustrated when I close one eye to get a better image. Wouldn’t chancing surgery in the ERM eye be worth the risk since I’m increasing closing the bad eye. Value your input.

  27. Jim,

    Have no idea why you shouldn’t consider removal of the cataract with close follow up to monitor the ERM.

    Makes sense to me.

    R

  28. I am 52 years old, had macular pucker surgery 5/12/14 for my right eye. I had bleeding after the surgery which caused high pressure and severe pain. The doc. surgically removed the blood a week later. Two week after that, my retina detached in the operated eye. A different doc reattached the retina with laser and put silicone oil in. It’s been 2 and ½ weeks since the retinal detachment surgery and I have been noticing wavy/distorted vision. My questions are,
    1. What might have caused the bleeding after the macular pucker surgery? My doc was not sure.
    2. Is it a common practice to remove the blood if high pressure and severe pain are present?
    3. What cause the wavy and distorted vision after retinal detachment surgery? Will they go away?
    Thank you for your help.

  29. Alan,

    1. Have no idea, but could be;

    a. Retinal tear caused by the vitrectomy
    b. If 25 gauge, sometimes blood from the outside of the eye seeps into the eye…did you have 25 gauge vitrectomy?

    2. It can be effectuve,

    3. Don’t know. So many reasons or causes, but I can’t examine you.

    r

  30. Dr. Wong,
    Thanks for your response and all you do for patients like us.
    I have another question. Because my doctor plans to leave the silicone oil in my operated eye for another two-three months and I’d like to see better during this time, is it advisable for me to get a prescription lenses? I know it’s most likely temporary, but as of now, my old lenses no longer works and makes my vision worse, and I’d like to have a roughly functioning eye when I drive, read, watch TV, etc., instead of patching it up. I asked my doctor this question, he doesn’t object and says “I can do anything that makes me feel better,” but I like to see how you feel. Thanks a lot.
    BTW, I went to your Facebook page and liked it. Very impressive work, Dr. Wong.

  31. Dear Alan,

    Thanks for the nice comments.

    Unlikely you can get glasses that will help you see through the oil. The index of refraction of oil is too different than water. Glasses will be too thick on one eye compared to the other….and that’s assuming your vision isn’t blurred from the detached retina.

    Randy

  32. Arlene Miller says:

    I had macular pucker surgery a little over 14 months ago. I had a slight cataract in that eye at the time and was told I would likely need cataract surgery some time after the retinal surgery. My doctor apparently did not use state of the art technique. I had sutures and asked him about that later. He said,”Well that/s fine. They disappear.” Meanwhile, it took weeks and weeks for me to heal. My eye was very, very red and sore for a long time. At first, when I asked the doctor said I would be able to wear eye make up in a week. Ha! Now, I still have a little distortion, but who can tell. I have gray patches in my field of vision that I did not have before the surgery. All I had was distortion and wavy lines He had said I would see some improvement unless something went wrong. Nothing apparently went wrong, but in addition to the gray patches, my distance vision is getting worse and worse…..could be the healing, could be the cataract. No one seems to care. They tell me to go the optometrist and get glasses. I have since then seen the doctor’s associate and the cataract surgeon. Neither had any satisfactory answers. I am thinking of suing for ruining my eye.

  33. Arlene,

    Sutures or no sutures – should not affect your results from ERM surgery.

    Doesn’t sound like your doc is able to explain things well to you.

    Best of luck. If I had the ability to examine you, I’d be more helpful.

    Randy

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