Epi-macular Membrane Associated Macular Edema: OCT-based Morphology; Management with Kenacort and/or Avastin, or with Priming Kenacort, Vitrectomy and ILM Peeling

Hsiao-Ming Chao

Purpose: Epi-macular membrane (EMM) associated macular edema (ME) is vision-threatening. The investigation and management is mandatory.

Methods: Visual acuity and results of microperimetry (MP-1), standard electroretinogram (sERG) and optical coherence tomography (OCT) assessment of macular volume were evaluated (n=7; mean age ± SD, 76.30 ± 7.5 years) preoperatively (baseline) and postoperatively (at a monthly base during the following 6 months). Enrolled patients were respectively classified into three or two groups according to associated macular edema pattern or treatment mode.

Results: As shown by OCT, foveal depression was absent in all the cases of EMM (figures 2 and 4). ME was further classified into 3 morphological categories: wedge-shaped intraretinal edema (WRE; group A; n=4), cyst-like ME (CME: single or multiple cysts; group B; n=4), and retinal edema subsensory retinal edema or diffuse retinal edema (SRE/DRE; group C; n=6 or n=4). As compared to the age-matched normal eyes (group D; n=6 or n=4), more than 50 % reduction in visual acuity was seen in patients of groups A, B and C. Those eyes of group 1 patients (n=4) who were irreluctant or inappropriate to receive vitreoretinal surgery were selected to receive dose(s) of intravitreous injection (i.v.i.) of kenacort and/or avastin. Others who received vitrectomy (VT) and EMM peeling were defined as group 2.

Results: Cases of EMM with none CME (n=2: one wedged-shaped and one subsensory retinal edema) or CME (n=3) were respectively slightly and obviously efficiently treated by intravitreous injection (i.v.i.) of kenacort, but not avastin (figure 2). CME was relieved as shown by the OCT and visual functions (BCVA, sERG, MP-1) were consequently improved (figure 3). Repeated injection was given and effective on the recurrent CME. Three eyes with a BCVA worse than 0.3 respectively received i.v.i. kenacort 1 week before peeling, an artificial posterior vitreous detachment was created after VT and then, with the aid of indocyanine green (ICG) staining, EMM/ILM was peeled. As compared to the pre-operative levels, defined visual functions of these eyes tend to be improved after the EMM peeling.

Conclusion: Angiography, OCT and visual acuity should be performed before consideration of kenacort injection in CME associated EMM patients who refused an invasive vitreoretinal surgery. Moreover, alleviation of edema and visual function improvement was obvious with kenacort, but not with avastin. Priming kenacort injection one week before VT plus EMM peeling might have an additive effect in treating EMM associated ME. The preliminary findings need further investigations.