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 Table of Contents    
CLINICAL IMAGE
Year : 2020  |  Volume : 13  |  Issue : 1  |  Page : 49-50  

Gradual resolution of foveal herniation after epiretinal membrane peeling


Vitreoretinal Services, Aravind Eye Hospital, Puducherry, India

Date of Submission02-Jun-2018
Date of Decision26-Oct-2019
Date of Acceptance25-Nov-2019
Date of Web Publication17-Feb-2020

Correspondence Address:
Dr. V G Madanagopalan
Aravind Eye Hospital, Thavalakuppam, Puducherry - 605 007
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ojo.OJO_104_2018

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   Abstract 


We demonstrate the gradual resolution of foveal herniation with optical coherence tomography (OCT) images after epiretinal membrane (ERM) removal. A young male presented with diminished vision in the left eye (OS). Examination of OS revealed an ERM and thickening of the foveal region. OCT delineated the ERM clearly. It also showed a central defect in the ERM through which the inner retinal layers had prolapsed into the vitreous cavity leading to foveal herniation. The patient underwent vitrectomy and surgical removal of the ERM. After removing the source of macular traction, over a period of 4 months, gradual reduction in height of the elevated central foveal tissue was observed. At 6 months, the foveal bulge had reduced remarkably and remained stable. The resolution of foveal herniation after ERM removal is a slow process. The OCT images convey that it may take few months for the foveal bulge to decrease in height. When the outer retinal layers are normal, visual recovery, though delayed, is appreciable.

Keywords: Epiretinal membrane, foveal herniation, macular surgery, optical coherence tomography


How to cite this article:
Madanagopalan V G, Nagesha C K, Velis G, Sindal MD. Gradual resolution of foveal herniation after epiretinal membrane peeling. Oman J Ophthalmol 2020;13:49-50

How to cite this URL:
Madanagopalan V G, Nagesha C K, Velis G, Sindal MD. Gradual resolution of foveal herniation after epiretinal membrane peeling. Oman J Ophthalmol [serial online] 2020 [cited 2020 Jul 6];13:49-50. Available from: http://www.ojoonline.org/text.asp?2020/13/1/49/278544




   Introduction Top


Epiretinal membranes (ERMs) in young patients tend to be thicker and taut.[1] Surgical removal of these membranes over the macula is warranted when they cause retinal distortion. In few eyes with an ERM, the foveal tissue is seen to bulge through a central defect in the ERM. This has been termed foveal herniation.[2] This article reports a case of foveal herniation where surgical ERM removal was followed by a gradual resolution of herniation, flattening of the foveal contour, and appreciable visual recovery over a period of 6 months.


   Case Report Top


A 24-year-old male presented with diminished vision in the left eye (OS) for 5 years. He gave a history of trauma around OS 10 years ago. Visual acuity in the right eye (OD) was 20/20 and in OS was 20/200. Ocular examination revealed clear cornea and lens in both eyes. Intraocular pressure measured by applanation tonometry was 14 mm Hg in both eyes. Examination of the fundus revealed normal disc, vessels, and macula in OD. In OS, macula showed an ERM with concomitant dragging of retinal vessels. The fovea appeared to protrude into the vitreous through a defect in the ERM. There was no clinical evidence of uveitis, peripheral vascular lesions, or retinal breaks. OD was clinically normal. Spectral-domain optical coherence tomography (SD-OCT) using the Spectralis (Heidelberg Engineering, Heidelberg, Germany) through the macula in OS showed a taut ERM with the thickened inner retina. A central defect measuring 1018 μ was noted in the ERM. The thickened inner retinal layers at the fovea herniated into the vitreous through this central defect, resulting in a foveal height of 876 μ. The outer retinal layers presented a normal configuration without ragged borders [Figure 1].
Figure 1: Preoperative macular scan showing fibrotic preretinal membrane, that is, discontinuous at the fovea (arrows). Diffuse thickening of the inner retina is observed. Herniation of the foveal portion of inner retinal layers through the central defect into the vitreous cavity to form a foveal bulge can be made out (arrowhead)

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The patient underwent 25-G pars plana vitrectomy. The posterior vitreous was detached with the aid of triamcinolone acetonide. After using trypan blue, the ERM was peeled. Brilliant blue–green dye was used to stain the internal limiting membrane (ILM) and to remove it. One month after surgery, SD-OCT showed partial resolution of foveal herniation and reorganization of inner retinal layers [Figure 2]. The foveal height was 744 μ. The patient was seen at monthly intervals, and the foveal bulge gradually decreased and stabilized over 4 months. At 6 months, the foveal bulge showed remarkable resolution and reduced to 423 μ. Visual acuity had improved to 20/60 [Figure 3].
Figure 2: One month after the surgical removal of the epiretinal membrane, spectral domain optical coherence tomography shows progressive reduction in height of the foveal bulge and resolution of inner retinal thickening. A retinal scar secondary to instrument touch and laser retinopexy can be seen superonasal to the fovea (arrow)

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Figure 3: Six months after surgery, the foveal bulge and central retinal thickness had remarkably reduced (arrowhead)

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   Discussion Top


ERMs in young patients are rare but tend to cause significant visual impairment.[1] Foveal herniation results from the circumferential contraction of the ERM in a centripetal manner. Subsequently, the macular tissue is dragged toward the center of the ERM. As there is a central defect in the ERM, the inner retinal layers prolapse through this defect into the vitreous, and hence, the term foveal herniation.[2],[3] Surgically removed ERM has been shown to demonstrate myofibroblasts, myoblastic differentiation of retinal pigment epithelial cells, fibrous astrocytes, and smooth muscle actin.[3],[4]

The removal of ERM along with ILM has been shown to result in improvement of vision and resolution of retinal distortion with the least recurrence.[1],[2] Francis et al. evaluated the surgical outcomes in six eyes with ERM and foveal herniation. They concluded that the removal of ERM results in improved retinal thickness and visual outcomes.[3] Our patient showed a typical presentation with premacular fibrosis sparing fovea. As the herniated inner retina was held in this position by a thick membrane for a considerable length of time, the bulge was tenacious. Surgical removal of ERM relieved the centripetal force and allowed the retinal tissue to slowly fall back to its original position over many months, thereby decreasing the thickness of the central herniated foveal tissue. The outer retinal layers were not disturbed by the dynamic pathology at the retinal surface, and therefore, visual recovery was good after the removal of the ERM.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Fang X, Chen Z, Weng Y, Shu Z, Ni H, Jiang J, et al. Surgical outcome after removal of idiopathic macular epiretinal membrane in young patients. Eye (Lond) 2008;22:1430-5.  Back to cited text no. 1
    
2.
Ozdemir H, Karacorlu M. Epiretinal membrane with Foveal herniation. Retina 2017;37:e71-2.  Back to cited text no. 2
    
3.
Francis JH, Rao S, Milman T, Hu DN, Gentile RC. Epiretinal membranes with foveal herniation: clinicopathological characteristics, optical coherence tomography and surgical outcomes Invest Ophthalmol Vis Sci 2011;52:4490.  Back to cited text no. 3
    
4.
Smiddy WE, Maguire AM, Green WR, Michels RG, de la Cruz Z, Enger C, et al. Idiopathic epiretinal membranes. Ultrastructural characteristics and clinicopathologic correlation. Ophthalmology 1989;96:811-20.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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