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Epiretinal Membrane (Macular Pucker, Surface-Wrinkling Retinopathy, Cellophane Maculopathy)

ROUTINE — Retina

Symptoms

metamorphopsia (distorted vision) is the most common volunteered symptom

often asymptomatic; detected on routine examination

decreased central visual acuity

incidence increases with age; ~20% bilateral (often asymmetric)

Clinical Findings

Clinical spectrum

  • cellophane maculopathy: fine glistening membrane on the retinal surface
  • macular pucker: thick gray-white membrane with prominent contraction
  • retinal folds radiating from the membrane
  • macular vessel displacement, straightening, or tortuosity drawn toward the membrane
  • advanced: macular edema, intraretinal cystoid spaces, or macular detachment

OCT diagnostics

  • thin hyperreflective line along the ilm with focal "saw-tooth" adhesions
  • retinal thickening and loss of foveal contour
  • ectopic inner foveal layers (eifl) in advanced disease

Govetto OCT staging

  • stage 1: foveal pit preserved
  • stage 2: pit lost; no eifl
  • stage 3: eifl present
  • stage 4: disorganized inner retina (worst prognosis)

Pseudohole VS ftmh

  • ring-shaped erm condensation may simulate a full-thickness hole (ftmh)
  • watzke-allen sign: slit beam is distorted but not broken (true ftmh is broken)

Etiology

Idiopathic

  • ~95% of cases; typically associated with age-related pvd

Secondary causes

  • post-injury: retinal cryotherapy, photocoagulation, or prior retinal breaks/detachment
  • surgical/traumatic: prior intraocular surgery or vitreous hemorrhage
  • vascular: diabetic retinopathy or retinal vein occlusion
  • inflammatory: uveitis

Pediatric

  • rare; occurs in young children without obvious underlying cause

Red Flags

rapid decline in visual acuity or progressive metamorphopsia

erm associated with a lamellar macular hole

bilateral erm in a young patient (requires exclusion of inflammation)

recurrent erm after previous retinal surgery

Investigations

Clinical exam

  • dilated fundus exam with slit lamp biomicroscopy (60/90-d or contact lens)
  • thorough peripheral retinal exam to rule out breaks

Imaging

  • oct: gold standard for staging, measuring eifl, and monitoring thickening
  • octa: optional to rule out concurrent vascular pathology

Treatment

Observation

  • first-line for asymptomatic patients with good vision
  • serial oct monitoring every 6 months

Surgical intervention

  • pars plana vitrectomy (ppv) with membrane and ilm peel
  • indicated for significant metamorphopsia or progressive vision loss
  • ilm peel is performed to reduce recurrence risk to ~1%
  • manage underlying causes (e.g., uveitis) before surgical intervention

Differential Diagnosis

  • diabetic macular edema
  • full-thickness macular hole (ftmh)
  • cystoid macular edema (cme)
  • vitreomacular traction (vmt) syndrome
  • neovascular amd

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