BACKGROUND: Epiretinal membranes are a common disease that can either be idiopathic, meaning no cause can be detected this is usually caused by aging, or secondary which is caused by injury disease or surgery. Despite current treatment methods, there are still persistence of this disease in some rare cases. Methotrexate although traditionally used to treat cancer and rheumatoid arthritis has been being explored as a treatment option in the field of ophthalmology for use against proliferative and migrating cellular diseases coupled with inflammation. Methotrexate has been reported in a few ocular diseases to reduce or stop cell migration and proliferation due to this finding a case study was conducted with this recurrent ERM patient to test its effectiveness against this disease. PURPOSE: To investigate a potential new treatment method for recurrent epiretinal membranes. After a visually significant epiretinal membrane develops there would be an epiretinal membrane (ERM) peel performed. Traditionally if there is recurrence of epiretinal membranes post ERM peeling the patient will be treated with an internal limiting membrane (ILM) peel. For most cases, this will resolve the issue. In the rare instances where an ILM peel doesn’t resolve recurrence, like in this case, we sought to test whether a series of methotrexate injections could help prevent ERM re-proliferation. CASE REPORT: Reporting on a case of a 65-year-old woman with a recurrent recalcitrant epiretinal membrane. This membrane was treated with a pars plana vitrectomy and ERM peeling. The membrane grew back and was met with an ILM peel in hopes of resolution. With continuing recurrence, the patient was treated with another ERM and ILM peel and 12 weekly intravitreal methotrexate (MTX) injections. METHODS: A patient with persistent recurrent epiretinal membranes underwent three surgeries in an attempt to cure the ERM. At every clinical visit, best corrected distance visual acuity was assessed with a Snellen Vision Test and the retina was imaged using optical coherence tomography. Measurements were taken using the machines built in analysis technology to measure retinal thickness and retinal volume at each visit. These were graphed alongside visual acuity to determine complimenting trends. RESULTS: At the first visit the patient began treatment at a visual acuity of 20/200 and a central macular thickness of 676. Seven months after the final methotrexate injection the patient was at a visual acuity of 20/80 and a central macular thickness of 328. The overall results were that visual acuity and central macular thickness significantly improved without ERM recurrence at seven months after treatment. CONCLUSION: When an ERM is significantly impacting the patient’s visual acuity surgery is usually performed in the form of an ERM peel or ILM peel. Although treatment of recurrent epiretinal membranes is well maintained by these procedures there are a small percentage of cases where recurrence is still found post ILM surgery. This case represents the first documented use of MTX to treat recurrent ERM and it suggests great potential for its use in otherwise treatment resistant cases. More research is required to better understand the true potential of this treatment option as well as associated risks.

Idiopathic Epiretinal membrane is a proliferation of contractile cells on the surface of the retina that typically occurs after posterior vitreous detachment. Though many questions have been raised on the causes of this condition, a greater debate has been on the treatment of this pathology. The literature suggest the potential benefit in peeling ILM, due to its inherent proliferative characteristics, along with the ERM, during the surgery, however sufficient data has yet to been found. Due to the lack of consensus in treatment of iERM, this study set forth to provide some insight on the surgical outcomes of patients that undergo combined peeling as well attempting to contribute to a potential surgical protocol in treating iERM. This was a retrospective case series study looking at 140 eyes from 126 iERM patients that underwent ERM surgical treatment at Beth Israel Deaconess Medical Center between 1998 and 2015. Pre- and post- operative visual acuities, lens status (phakic, aphakic, pseudophakic), type (kenalog with or without ICG) and duration (0.5min, 1 min, 1.5 min) of the stains used in the procedure, and any prior or successive surgeries were recorded and analyzed. Overall, ERM surgeries demonstrated a significant (p<0.0001) improvement in visual acuity. Furthermore, the combined peel patients demonstrated a significantly (p<0.0467) greater mean change in logMAR score when compared to ERM-only peel procedures. In addition, the combined peel group showed a smaller rate of recurrence. Lastly, simultaneous cataract surgery and the use of ILM stains did not have an impact on the outcome of ERM surgery. The study found that combined (ERM and ILM) peeling along with simultaneous cataract surgery, if a cataract was present, along with the utilization of ILM stains is cost-effective, safe, and effective approach in treating iERM and decreasing its recurrence.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第25171号 / 医博第5057号 / 新制||医||1071(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 花川 隆, 教授 林 康紀, 教授 高橋 淳 / 学位規則第4条第1項該当 / Doctor of Agricultural Science / Kyoto University / DFAM

Objetivos: Avaliar a função e estrutura da retina de pacientes com membrana epirretiniana (MER) ou buraco macular (BM) antes e após a cirurgia, e determinar suas relações e os valores preditivos para a acuidade visual após tratamento com vitrectomia associada a peeling da membrana limitante interna. Casuística e Métodos: Foram incluídos 51 olhos de 50 pacientes com indicação de tratamento cirúrgico de MER ou BM idiopáticos. Foi realizada avaliação oftalmológica completa, incluindo melhor acuidade visual corrigida (MAVC) no pré-operatório e nas semanas 1, 3, 8, 24 e 48 após a cirurgia, enquanto que eletrorretinografia multifocal (mfERG) e tomografia de coerência óptica (OCT) foram realizadas antes da cirurgia e dois e doze meses após o procedimento. Os resultados da mfERG serão apresentados na forma da razão entre os valores encontrados nos dois anéis centrais, normalizados pelas médias dos três anéis periféricos (denominada razão P1), para minimizar a variabilidade interpessoal desse teste e ressaltar as alterações encontradas nos anéis centrais. A OCT foi usada para calcular o quociente entre medidas da altura e base do BM (IBM). Resultados: Quarenta e cinco pacientes (46 olhos; n = 30 BM e 16 MER) completaram as 48 semanas de seguimento. No pré-operatório, a média ± SE da MAVC (logMAR) para os grupos BM e MER, respectivamente, foi: 0,93 ± 0,22 (20/170; ou 0,12 decimal) e 0,58 ± 0,11 (20/76; ou 0,26 decimal), com melhora significativa após 48 semanas de seguimento (média ± EP da diferença entre as acuidades visuais medidas em logMAR em 48 semanas e a basal) -0,25 ± 0,07 para o grupo BM e -0,29 ± 0,06 para o grupo MER. O mfERG mostrou-se alterado antes da cirurgia para BM, com melhora da razão P1 após a cirurgia. Para o BM, houve correlação entre a razão P1 no pré-operatório e o ganho da MAVC na semana 8 após a cirurgia (r = -0,42; p = 0,033), mas essa correlação não foi observada para o grupo MER. Também não houve correlação entre o IBM e a acuidade visual após a cirurgia. Conclusões: Os resultados indicam que pacientes com BM apresentando mfERG com baixa razão P1 têm menor probabilidade de ganho de visão após a cirurgia, mas essa afirmativa não é válida para a MER. / Purpose: To evaluate retinal structure and function in eyes with macular hole (MH) or epiretinal membrane (ERM) before and after pars-plana vitrectomy with internal limitant membrane (ILM) peeling, to determine function/structural interrelations and predictive values of postoperative visual acuity. Casuistic and Methods: Fifty-one eyes of 50 patients with idiopathic MH or ERM were included. Comprehensive ophthalmologic evaluation including best-corrected visual acuity (BCVA) was performe date baseline, 1, 3, 8, 24 e 48 weeks after surgery, while optical coherence tomography (OCT) and multifocal ERG was performed before and at 2 and 12 months after surgery. mfERG results are show using the ratio between the amplitude averages of the 2 central rings and the 3 peripheral rings (P1 ratio) and OCT was used to calculate the macular hole index (MHI) defined by the quotient between hole height/base. Results: Forty-five patients (46 eyes; n = 30 MH and 16 ERM) finished follow-up. Mean ± SE (logMAR) preoperative BCVA was 0.93 ± 0.22 and 0.58 ± 0.11 for MH and ERM respectively, and improved in -0.25 ± 0.07 logMAR for MH and -0.29 ± 0.06 logMAR for ERM. mfERG P1 ratio was reduced in BM, and increased significantly after surgery. There was significant correlation between preoperative P1 ratio and BCVA gainat week 8 for MH group (r = -0,42; p = 0,033), but not for ERM group. There was no correlation between preoperative MHI and postoperative BCVA. Conclusion: This data indicates that patients with MH and poor mfERG amplitudes have worse prognoses for BCVA improvement, but does not apply for ERM.

Objetivos: Avaliar a função e estrutura da retina de pacientes com membrana epirretiniana (MER) ou buraco macular (BM) antes e após a cirurgia, e determinar suas relações e os valores preditivos para a acuidade visual após tratamento com vitrectomia associada a peeling da membrana limitante interna. Casuística e Métodos: Foram incluídos 51 olhos de 50 pacientes com indicação de tratamento cirúrgico de MER ou BM idiopáticos. Foi realizada avaliação oftalmológica completa, incluindo melhor acuidade visual corrigida (MAVC) no pré-operatório e nas semanas 1, 3, 8, 24 e 48 após a cirurgia, enquanto que eletrorretinografia multifocal (mfERG) e tomografia de coerência óptica (OCT) foram realizadas antes da cirurgia e dois e doze meses após o procedimento. Os resultados da mfERG serão apresentados na forma da razão entre os valores encontrados nos dois anéis centrais, normalizados pelas médias dos três anéis periféricos (denominada razão P1), para minimizar a variabilidade interpessoal desse teste e ressaltar as alterações encontradas nos anéis centrais. A OCT foi usada para calcular o quociente entre medidas da altura e base do BM (IBM). Resultados: Quarenta e cinco pacientes (46 olhos; n = 30 BM e 16 MER) completaram as 48 semanas de seguimento. No pré-operatório, a média ± SE da MAVC (logMAR) para os grupos BM e MER, respectivamente, foi: 0,93 ± 0,22 (20/170; ou 0,12 decimal) e 0,58 ± 0,11 (20/76; ou 0,26 decimal), com melhora significativa após 48 semanas de seguimento (média ± EP da diferença entre as acuidades visuais medidas em logMAR em 48 semanas e a basal) -0,25 ± 0,07 para o grupo BM e -0,29 ± 0,06 para o grupo MER. O mfERG mostrou-se alterado antes da cirurgia para BM, com melhora da razão P1 após a cirurgia. Para o BM, houve correlação entre a razão P1 no pré-operatório e o ganho da MAVC na semana 8 após a cirurgia (r = -0,42; p = 0,033), mas essa correlação não foi observada para o grupo MER. Também não houve correlação entre o IBM e a acuidade visual após a cirurgia. Conclusões: Os resultados indicam que pacientes com BM apresentando mfERG com baixa razão P1 têm menor probabilidade de ganho de visão após a cirurgia, mas essa afirmativa não é válida para a MER. / Purpose: To evaluate retinal structure and function in eyes with macular hole (MH) or epiretinal membrane (ERM) before and after pars-plana vitrectomy with internal limitant membrane (ILM) peeling, to determine function/structural interrelations and predictive values of postoperative visual acuity. Casuistic and Methods: Fifty-one eyes of 50 patients with idiopathic MH or ERM were included. Comprehensive ophthalmologic evaluation including best-corrected visual acuity (BCVA) was performe date baseline, 1, 3, 8, 24 e 48 weeks after surgery, while optical coherence tomography (OCT) and multifocal ERG was performed before and at 2 and 12 months after surgery. mfERG results are show using the ratio between the amplitude averages of the 2 central rings and the 3 peripheral rings (P1 ratio) and OCT was used to calculate the macular hole index (MHI) defined by the quotient between hole height/base. Results: Forty-five patients (46 eyes; n = 30 MH and 16 ERM) finished follow-up. Mean ± SE (logMAR) preoperative BCVA was 0.93 ± 0.22 and 0.58 ± 0.11 for MH and ERM respectively, and improved in -0.25 ± 0.07 logMAR for MH and -0.29 ± 0.06 logMAR for ERM. mfERG P1 ratio was reduced in BM, and increased significantly after surgery. There was significant correlation between preoperative P1 ratio and BCVA gainat week 8 for MH group (r = -0,42; p = 0,033), but not for ERM group. There was no correlation between preoperative MHI and postoperative BCVA. Conclusion: This data indicates that patients with MH and poor mfERG amplitudes have worse prognoses for BCVA improvement, but does not apply for ERM.

No description available.

Objetivo: Estudar e comparar a acuidade visual, metamorfopsia, espessura foveal, camada limitante externa e zona elipsoide por meio da Tomografia de Coerência Óptica (OCT), e a taxa de recorrência dos pacientes operados de remoção de membrana epirretiniana, com e sem a retirada da membrana limitante interna. Métodos: Pacientes com MER operados por um único cirurgião e randomizados, aleatoriamente, em dois grupos. Todos os pacientes tiveram a retirada da membrana epirretiniana: 35 pacientes do Grupo 01, sem a adicional retirada de membrana limitante interna, e 28 pacientes do Grupo 02, com a retirada dessa membrana. Os pacientes foram seguidos e avaliados no primeiro, terceiro e sexto mês. Resultados: Setenta pacientes operados no total, sendo sete excluídos por perda de seguimento. Os pacientes de ambos os grupos evoluíram com melhora gradativa da visão ao longo do tempo. No Grupo 01, a média de acuidade visual inicial foi 0,60 logMAR (±0,3 desvio padrão - DP), no primeiro mês foi 0,49 logMAR (±0,26 DP), no terceiro mês, 0,39 logMAR (±0,30 DP) e no sexto mês, 0,27 logMAR (±0,25 DP). No Grupo 02, a média de acuidade visual inicial foi 0,63 logMAR (±0,25 DP), no primeiro mês foi 0,44 logMAR (±0,26 DP), no terceiro mês, 0,41 logMAR (±0,35 DP), e no sexto mês, 0,43 logMAR (0,44 DP). Não houve diferença estatisticamente significante quanto à melhora da acuidade visual entre os dois grupos. Não foi encontrada diferença estatisticamente significante em relação às alterações na OCT entre os grupos. O Grupo 02 apresentou maior taxa de recidiva (17%) quando comparada com o Grupo 01 (3,6%), embora esta diferença não foi estatisticamente significante (p=0,09). Conclusão: Ambos os grupos apresentaram melhora funcional e anatômica semelhantes, mas o grupo no qual não se removeu a membrana limitante interna mostrou uma possível tendência à maior taxa de recidiva / Objective: To study and compare the visual acuity, metamorphosis, foveal thickness, the outer limiting layer and the ellipsoid zone, studied by Optic Coherence Tomography (OCT), and the recurrence rate of patients undergoing removal of epiretinal membrane with and without the removal of the internal limiting membrane. Methods: Seventy patients undergoing removal of epiretinal membrane, by a single surgeon and randomly assigned into two groups. Group 1, without additional removal of internal limiting membrane, 35 patients, and group 2 with the removal of the internal limiting membrane, 28 patients. Both groups were followed and evaluated in the first, third and sixth month. Results: Patients of both groups developed with a gradual improvement of vision over time. In group 1, the mean initial visual acuity was 0.60 logMAR (±0.3 standard deviation - SD), the average visual acuity of the first month was 0.49 logMAR (±0.26 SD), in the third month 0.39 logMAR (±0.30 DP), and in the sixth month logMAR 0.27 (±0.25 SD). In group 2, the mean initial visual acuity was 0.63 logMAR (±0.25 SD), average visual acuity of the first month was 0.44 (±0.26 DP) logMAR, in the third month 0.41 logMAR (±0.35 DP), and in the sixth month 0.43 logMAR (±0.44 DP). There was no statistical difference in improvement in visual acuity between the two groups, there was no statistically significant differences related to tomographic alterations between the groups, but the group 2 showed a higher relapse rate (17%) compared to the group 1 (3.6%). Although the difference is not statistically significant (p=0.09). Conclusion: Both groups showed similar functional and anatomical improvement, but the group which the internal limiting membrane was not removed showed a higher recurrence rate

Objetivo: Estudar e comparar a acuidade visual, metamorfopsia, espessura foveal, camada limitante externa e zona elipsoide por meio da Tomografia de Coerência Óptica (OCT), e a taxa de recorrência dos pacientes operados de remoção de membrana epirretiniana, com e sem a retirada da membrana limitante interna. Métodos: Pacientes com MER operados por um único cirurgião e randomizados, aleatoriamente, em dois grupos. Todos os pacientes tiveram a retirada da membrana epirretiniana: 35 pacientes do Grupo 01, sem a adicional retirada de membrana limitante interna, e 28 pacientes do Grupo 02, com a retirada dessa membrana. Os pacientes foram seguidos e avaliados no primeiro, terceiro e sexto mês. Resultados: Setenta pacientes operados no total, sendo sete excluídos por perda de seguimento. Os pacientes de ambos os grupos evoluíram com melhora gradativa da visão ao longo do tempo. No Grupo 01, a média de acuidade visual inicial foi 0,60 logMAR (±0,3 desvio padrão - DP), no primeiro mês foi 0,49 logMAR (±0,26 DP), no terceiro mês, 0,39 logMAR (±0,30 DP) e no sexto mês, 0,27 logMAR (±0,25 DP). No Grupo 02, a média de acuidade visual inicial foi 0,63 logMAR (±0,25 DP), no primeiro mês foi 0,44 logMAR (±0,26 DP), no terceiro mês, 0,41 logMAR (±0,35 DP), e no sexto mês, 0,43 logMAR (0,44 DP). Não houve diferença estatisticamente significante quanto à melhora da acuidade visual entre os dois grupos. Não foi encontrada diferença estatisticamente significante em relação às alterações na OCT entre os grupos. O Grupo 02 apresentou maior taxa de recidiva (17%) quando comparada com o Grupo 01 (3,6%), embora esta diferença não foi estatisticamente significante (p=0,09). Conclusão: Ambos os grupos apresentaram melhora funcional e anatômica semelhantes, mas o grupo no qual não se removeu a membrana limitante interna mostrou uma possível tendência à maior taxa de recidiva / Objective: To study and compare the visual acuity, metamorphosis, foveal thickness, the outer limiting layer and the ellipsoid zone, studied by Optic Coherence Tomography (OCT), and the recurrence rate of patients undergoing removal of epiretinal membrane with and without the removal of the internal limiting membrane. Methods: Seventy patients undergoing removal of epiretinal membrane, by a single surgeon and randomly assigned into two groups. Group 1, without additional removal of internal limiting membrane, 35 patients, and group 2 with the removal of the internal limiting membrane, 28 patients. Both groups were followed and evaluated in the first, third and sixth month. Results: Patients of both groups developed with a gradual improvement of vision over time. In group 1, the mean initial visual acuity was 0.60 logMAR (±0.3 standard deviation - SD), the average visual acuity of the first month was 0.49 logMAR (±0.26 SD), in the third month 0.39 logMAR (±0.30 DP), and in the sixth month logMAR 0.27 (±0.25 SD). In group 2, the mean initial visual acuity was 0.63 logMAR (±0.25 SD), average visual acuity of the first month was 0.44 (±0.26 DP) logMAR, in the third month 0.41 logMAR (±0.35 DP), and in the sixth month 0.43 logMAR (±0.44 DP). There was no statistical difference in improvement in visual acuity between the two groups, there was no statistically significant differences related to tomographic alterations between the groups, but the group 2 showed a higher relapse rate (17%) compared to the group 1 (3.6%). Although the difference is not statistically significant (p=0.09). Conclusion: Both groups showed similar functional and anatomical improvement, but the group which the internal limiting membrane was not removed showed a higher recurrence rate