A Wrinkle in Your Retina (and Macula!)

You wouldn’t think twice about a wrinkle in your shirt: it’s nothing a quick touch-up with an iron won’t fix. A wrinkle in your retina, however, sounds a whole lot more serious.

Similarly, a puckered mouth is a pretty natural reaction to biting into a lemon—nothing much to worry about. But a puckered macula? That could be a big deal.

Both of these eye conditions are surprisingly common. What’s more, they’re also accurate descriptions of the retina’s change in shape in response to the same underlying condition. Whether your retina is wrinkling or your macula—the central part of the retina—is puckering, it’s an epiretinal membrane that’s the cause.

Just what is an epiretinal membrane? And where does it come from? How does it affect a patient’s visual acuity, and what can their eye doctor do to help? Are there common risk factors for it, and is it connected to other, more serious conditions like diabetic retinopathy or age-related macular degeneration (AMD)?

Let’s take a closer look at this retinal condition for a few answers.

Causes and Characteristics of an Epiretinal Membrane

The name game doesn’t stop with macular pucker or retinal wrinkle. Preretinal macular fibrosis, cellophane maculopathy, and surface-wrinkling retinopathy are just a few other common terms for epiretinal membrane¹. The many different names for this ailment hint at its causes and effects.

Like so many other eye conditions, an epiretinal membrane affects us as we get older.² When we are young, the vitreous gel that makes up most of the eye’s volume remains tightly pressed against the retina, contained by a thin, separating later called the internal limiting membrane.

As we age, that vitreous gel—and the internal limiting membrane along with it—shrinks away from the surface of the retina, in a process known as posterior vitreous detachment. When this vitreous detachment happens, it leaves behind small bunches of cells on the macula.³

These cells sometimes form a layer of scar tissue over the front of the retina, hence the term preretinal macular fibrosis. This transparent layer can pull tightly across the retina, much like cellophane food wrap forms a clear and stretchy film over a plate, just as the name cellophane maculopathy suggests.

From those two previous descriptions, the third—surface-wrinkling retinopathy—follows naturally. Along with the aforementioned macular pucker and retinal wrinkle, we get a pretty succinct description of what happens next. That stretchy layer of scar tissue, the epiretinal membrane, can tug on the retina, causing the retina to wrinkle, and sometimes its center—the macula—to pucker.

Symptoms of a Wrinkled Retina and Common Management Options

When this idiopathic condition occurs, patients sometimes experience no symptoms at all. Others, however, are not so lucky. Many patients with epiretinal membrane experience diminishment in their ability to discern fine details. Others have reported distortion resulting in curves to otherwise straight lines, or just generally blurry vision.

The majority of the time, symptoms of a wrinkled retina are not so severe that they interfere with a patient’s daily activities. The patients’ central vision remains mostly unimpacted by the condition, and most ophthalmologists are not overly eager to perform eye surgery when a patient can get by comfortably without a surgical procedure.

In some extreme cases, though, an epiretinal membrane can continue to tighten over time. As the membrane shrinks, it can cause such severe macular puckering that it causes blind spots, partial vision loss, and can lead to other comorbidities in the back of the eye. In such cases as these, an ophthalmologist may need to explore other options, specifically eye surgery.

Advanced Treatment of the Epiretinal Membrane

When this condition is severe enough that the patient experiences diminished visual acuity to the degree that it prevents them from actively engaging in daily activities, eye doctors use several different methods to diagnose the problem before exploring which surgical procedures to explore.

An optical coherence tomography (OCT) scan is commonly performed to discover the presence of the epiretinal membrane. This advanced and non-invasive photographic technique allows retina specialists to examine the layers of the retina, and can reveal the presence of this extra scar tissue buildup.

If the decision is made to perform eye surgery, the procedure begins with a vitrectomy. The eye’s vitreous gel is removed, and replaced with another material. Silicone oil, saline solution, or gas are all common choices in order to maintain the eye’s shape during the procedure, and limit potential side effects such as retinal detachment.

Following the initial vitrectomy surgery, the ophthalmologist will typically use a dye such as fluorescein in order to stain the epiretinal membrane. This makes it easier to identify during the subsequent procedure, the membrane peel.

During a membrane peel, the eye doctor uses microscopic tweezers to peel the layer of scar tissue away from the retina.⁴ This releases the tension on the retina, and alleviates the wrinkling of the retina.

Surgical procedures to treat a wrinkled retina do not typically take a lot of time to perform, and can often be done in under an hour at an eye institute or hospital.

Other Eye Conditions Associated with a Wrinkled Retina

Several comorbidities place a patient at a heightened risk for developing an epiretinal membrane. Patients who have floaters⁵—tiny deposits of ocular protein within the vitreous gel—are often at a heightened risk for the development of this layer of scar tissue.

Because of the greater separation of layers within the eye that take place during vitreous detachment, this condition also presents a higher change that a patient will develop an epiretinal membrane. The same is true for patients who have suffered a detached retina.

Uveitis⁶, or inflammation of the eye, is another common comorbidity associated with a wrinkled retina. Any condition which affects the tension of the various ocular layers can lead to an epiretinal membrane, and a higher risk is associated with any sort of eye surgery or eye injury as well. Because of this, a higher degree of susceptibility has been shown to exist among patients who also suffer from other conditions such as AMD and diabetic retinopathy.

Additionally, severe cases of an epiretinal membrane can lead to a problem worse than wrinkling of the retina. The stretching caused by the membrane, or occasionally the stress induced by a membrane peel, can lead to retinal tears or a macular hole. This additional injury often causes vision loss, and can be treated with a supplemental surgical procedure.

Smoothing Out the Wrinkles

While the thought of a wrinkle in your retina probably isn’t too pleasant, it’s important to remember that most of the time, these problems are not too serious. The majority of epiretinal membranes cause only very minor distortion in a person’s vision. Sometimes this doesn’t affect the central vision, and some people have a macular pucker without ever noticing it at all.

In the event that an epiretinal membrane does cause significant vision loss, it’s also good to bear in mind that it is among the most treatable of conditions in all of ophthalmology. It’s probably fair to say that nobody wants to hear that they have a wrinkled retina, but if they do, it’s good to know that their eye doctor has treatment options available.

References