Epiretinal Membrane (Macular Pucker)

What is Macular Pucker?

The eye is like a tiny camera, with lenses in front and film in the back. The film in the back of the eye is called the retina. The center part of the retina, which provides most of the reading and other sharp, central vision is called the macula.

The area in front of the retina is normally filled with a jelly-like material called vitreous. At birth, the vitreous is quite firm and has thin fibrous strands running through it and a clear fibrous skin on the back. As the vitreous ages, it becomes more liquid. Eventually, the fibrous skin peels partially or totally away from the retina. This process, called vitreous detachment, increases the number of floaters but does not usually cause damage to the retina.

Occasionally the vitreous can cause irritation to the macula, which can stimulates the formation of a thin sheet of scar tissue on the macular surface. This looks like cellophane and is sometimes called “cellophane maculopathy”. The scar tissue may thicken or contract over a period of time. This can distort or “pucker” the macula, causing significant visual distortion. This condition is called a macular pucker.

How is Macular Pucker Diagnosed?

Macular pucker causes fairly typical symptoms, although these symptoms are sometimes confused with macular degeneration, which is a totally different condition. It has a very typical appearance and is usually easy to diagnose with a dilated eye examination. Sometimes a special computerized picture test called a fluorescein angiography is performed to rule out other problems under the scar tissue, and to find inflammation sometimes associated with the pucker. This involves injection of a yellow dye into a small arm vein, which is then photographed as it flows through the circulation in the back of the eye. There are no X-rays, and the dye is generally very safe, with serious allergic complications being very unusual.

How is Macular Pucker Treated?

If the visual change is minor, and the patient is still able to function comfortably, then no intervention may be necessary. If the pucker is severe enough to prevent the patient from seeing and doing what they would like to, then the scar tissue can be surgically removed. This involves an operation called a vitrectomy. Tiny needle-sized openings are made in the white part of the eye. Tiny instruments, the size of hypodermic needles, are then used to gently peel the scar tissue away from the macular surface. The vitreous gel is removed to gain access to the macula. It is replaced with a clear fluid that the eye naturally replenishes continuously.

Vitrectomy surgery is usually done as an outpatient. The experience for the patient is similar to having cataract surgery. There may be some scratchy feeling on the day after surgery, but typically there is no severe pain. This surgery is usually done with a local anesthetic injection behind the eye. Complications, such as bleeding, infection, and retinal detachment are very unusual.

Visual recovery may take weeks to months, but the eye will feel relatively comfortable within days of the surgery. The patient can usually resume normal activities within one or two weeks after surgery.

Adapted from