Spark ImageWise 3 – Retina

Epiretinal Membrane with Vitreomacular Traction

Dr Shashank Somani, Dr Sarang Lambat, Dr Prabhat Nangia, Dr Vinay Nangia 
Suraj eye institute, 559, New Colony, Nagpur.

Case Description
A male, 77 years of age, came for a routine ophthalmic examination. He had a history of ischaemic heart disease 5 years back. His best corrected visual acuity was 6/6p, N6 in right eye (OD) and 6/9, N6 in left eye (OS). Anterior segment examination showed presence of pseudophakia in both eyes (OU). Intraocular pressure recorded by Goldmann applanation tonometer was 12 mmHg in OD and 14 mmHg in OS. 

Figure 1 shows colour fundus photograph of right eye centred at the macula. It shows clear media with  oval disc, well defined margins, a vertical cup to disc ratio of 0.5:1 and healthy neuro retinal rim. Blood vessels shows normal dichotomous branching with tortousity at the posterior pole. Foveal reflex was absent with a visible sheen more in the superior part of the macula suggestive of an epiretinal membrane (ERM) (green arrow). Retina was attached throughout.

Figure 2 shows colour fundus photograph of left eye centred at the macula. It shows clear media with  oval disc, well defined margins, a vertical cup to disc ratio of 0.5:1 and healthy neuro retinal rim. Blood vessels shows normal dichotomous branching with mild tortousity at the posterior pole. Foveal reflex was absent with a minimal sheen seen in the superior part of the macula suggestive of an epiretinal membrane (ERM) (green arrow). Retina was attached throughout. 
Figure 3a shows an infra-red image and SD-OCT horizontal line scan passing thorough the fovea of RE.  The epiretinal membrane is visible on the infrared image (Green arrow). The OCT scan (Fig 3b) shows a a parafoveal hyper reflective membrane on the surface of retina suggestive of an  ERM. (Yellow arrow)
Figure 4a shows oblique line scan along 10 – 4’o clock hour passing through fovea of right eye, Fig 4b shows a thin hyper-reflective membrane in the vitreous phase, attached to the fovea, showing a point of attachment along the slope of the foveal pit suggestive of vitreomacular Traction (VMT) (Red arrow) The posterior hyaloid phase is seen (Blue arrow), along with patchy hyper reflective membrane (ERM) on the surface of retina extending beyond fovea. (Yellow arrow)
Figure 5a shows vertical line scan passing thorough the fovea of left eye. In Figure 5b there is presence of  a foveal retinal tag that is lifted up and attached to the convexity of the posterior hyaloid face. causing distortion of the foveal contour leading to formation of an impending macular hole. (Pink arrow)
Figure 6a shows oblique line scan along 11-5’ o clock hour passing through fovea of left eye. It shows presence of VMT with a defect in the inner layers of retina suggestive of lamellar macular hole. (Red arrow)(Figure 6b)
Figure 7a shows oblique line scan along 8 – 2’o clock thorough the fovea of left eye. It shows presence of VMT with distortion of the foveal contour and formation of a foveal cyst. (Cyan arrow)(Figure 7b)

Discussion 

The colour Fundus appearance of the RE shows an easily  visible epiretinal membrane. There is also a small patch of epiretinal membrane visible in the left eye along the superotemporal arcade.  However the  vitreomacular traction is more prominent in the left eye.  The OCT of the left eye showed vitreomacular traction which  has  lead to the development of a lamellar macular hole. The OCT of the right eye showed minimal vitreomacular traction which may resolve on its own and does not need an active intervention at present. There is a possibility however that should the epiretinal membrane severity increases in the RE with a resultant decrease in vision, further surgical management may need to be considered. The patient underwent pars plana vitrectomy for the LE and the traction was released.

This case demonstrates the importance of doing OCT star scan in patients of vitreomacular traction as the characteristics of  the traction can be missed in a single line scan. Though the single line scans generally have a very high resolution the importance of these scans is lost if they do not pass through the area of interest. This may happen in the patients where the pathology involves the fovea as these patients may have difficulty in focussing the internal target of the OCT machine. One may also consider the possibility of using a dense scan that helps us to assess the macula in greater details and could help to avoid the chances of missing a clinically important  pathological finding.  

ReadWise 

Readwise 

  1. Kumar N, Al Kandari J, Al Sabti K, Wani VB. Partial-thickness macular hole in vitreomacular traction syndrome: a case report and review of the literature. J Med Case Rep. 2010 Jan 13;4:7. doi: 10.1186/1752-1947-4-7. 
  2. Alfredo García-Layana, José García-Arumí, José M. Ruiz-Moreno, Lluís Arias-Barquet, Francisco Cabrera-López, Marta S. Figueroa, “A Review of Current Management of Vitreomacular Traction and Macular Hole”, Journal of Ophthalmology, vol. 2015, Article ID 809640, 14 pages, 2015. https://doi.org/10.1155/2015/809640

Correspondence 
Dr. Sarang Lambat
MS, FRF
Consultant
Vitreoretinal services
Suraj Eye Institute
Nagpur
Email –education@surajeye.org

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