Epiretinal Membrane (Macular pucker)

  • Reference Number: HEY-961/2017
  • Departments: Ophthalmology Department

This leaflet has been produced to give you general information. Most of your questions should be answered by this leaflet. It is not intended to replace the discussion between you and the healthcare team, but may act as a starting point for discussion. If after reading it you have any concerns or require further explanation, please discuss this with a member of the healthcare team.

What is an epiretinal membrane or macular puker?

The inner lining of the back of the eye is called the retina this functions much like the film in a camera and transmits light signals to the brain. The most sensitive central part of the retina is called the macula. Epiretinal membrane is a very fine layer of scar tissue or membrane that has formed across the surface of the retina when the vitreous gel inside the eye has altered due to aging changes in the vitreous jelly and has caused an area of superficial irritation in the retina.

It is the healing response that has caused this fine membrane to develop, which in turn, has shrunk slightly causing a mechanical wrinkling and distortion if the retina.  In most patients there is very slow growth of this membrane which eventually stops growing.  These cells are usually clear and in many people do not produce any significant disturbance in vision. In some cases, over a period of time these cells may be more abundant and cause a thicker membrane to form, along with some contraction or pulling on the scar cells in this membrane takes place, giving the retina a wrinkled appearance. When this happens, this is when you notice that your central vision may become blurred with distortion in lines or letters. It is Important to realise that this condition is not the same as age related macular degeneration.

Do I need any treatment?

In many patient cases no treatment is required.  This is because the distortion in vision and reduced reading and distance vision is minimal, and in many cases you will adjust to the difference in vision. In some people the visual disturbances are very significant and the vision loss is marked making it difficult to carry out daily tasks such as reading and driving. In such cases then the Epiretinal membrane can be surgically removed. The aim of the surgery is to remove the membrane and reduce the effect of distortion. You will not necessarily get an improvement in reading and distance vision.

Following the operation it can take several months for the full effect to be determined. If you decide not have the operation you will not go blind, as only the central vision is affected by this condition. You need to have an annual eye check with your optician who can refer you back to us if your condition changes.

Surgery for epiretinal membrane

The surgical procedure

This involves making three small incisions about 1 mm in length, in the white of the eye, to enable fine instruments to enter the eye. The vitreous gel inside the eye is removed and is replaced with a salty fluid.  Some very fine forceps are then used to peel away the membrane from the surface of the retina.  At this point you will be asked to keep very still.

Once the main part of the operation is completed the retina lining of the eye is examined for any weak areas, as such you may need additional treatment such as a freezing treatment (cryotherapy) or laser to any weak areas in order to reduce the risk of a post operative complication called retinal detachment.

During the operation

During the operation you may be aware of pressure sensations around the eye, some shadows and lights inside the eye, this is quite normal as the retina is still functioning, the amount varies due to the intensity of the local anaesthetic. Following surgery you will need to use eye drops for up to six weeks while the eye heals. You will be advised on how and when to use the eye drops before leaving hospital. The drops are to prevent infection and to reduce inflammation around the eye.

In some exceptional cases, it may be necessary to fill the eye with a special gas, the gas bubble acts as an internal splint to support the retina after the operation while the eye heals. The gas is gradually absorbed by the body over several weeks. During this time you will not see as well as you might have expected. When the gas has been absorbed then your vision will gradually stabilise, this can take up to three months. If we have used a gas bubble in your eye you must not fly until the gas has disappeared completely; your doctor will be able to confirm this with you when you are seen in outpatients.  Gas can last from a week up to eight weeks, depending on the gas used.

If you need a general anaesthetic for another problem then it is essential that you inform the anaesthetist that you have gas inside the eye. It is essential that you must not lie on your back until all of the gas has been absorbed; this is to prevent the eye pressure going up and also to reduce the risk of developing a cataract. In some cases you may be asked to keep your head in a specific position to help the gas bubble to do its job.

Can there be any complications or risks?

This type of surgery has similar risks to other types of eye surgery such as:

  • Infection in the eye – This is called ‘Endophthalmitis’ and is very rare but can give rise to serious loss of sight.
  • Bleeding inside the eye.
  • Retinal detachment – This can happen at anytime following the surgery and will require further surgery to seal the retinal holes.
  • Cataract – Almost all patients develop a cataract (cloudy lens) more rapidly following this type of surgery. This is because the internal fluid has been disturbed but also because of the presence of the gas in the eye. In some cases a cataract may be removed at the same time to enable a clearer view for the vitrectomy surgery to be performed. Cataracts can also be removed in a separate operation.
  • High pressure inside the eye – You may need additional eye drops to control this for a period of time.
  • Inflammation inside the eye.
  • Bruising to the eyelids and eye – This settles after a few weeks.
  • Allergy to the medication used.

Concerns following discharge

If you experience any of the following problems after you have gone home following your operation you should contact the ward immediately:

  • Excessive pain
  • Loss of vision
  • Increasing redness of the eye
  • Dirty discharge from the eye

How do I prepare for the operation?

Please read the information leaflet.  Share the information it contains with your partner and family (if you wish) so that they can be of help and support.  There may be information they need to know, especially if they are taking care of you following this examination.

Anaesthetic

This is major eye surgery. It is normally carried out under a local anaesthetic but in exceptional circumstances a general anaesthetic is offered.

Pre operative assessment

Before the surgery you will need to attend for a pre-operative assessment  at this visit you will be asked questions about your general health, some blood tests will be taken and a recording heartbeat (sometimes referred to as an Electrocardiogram – ECG) are performed to ensure your general health is good enough to undergo the surgery. Measurements will be made of your eye’s length and curvature, this is required for planning the local anaesthetic. At this visit you will be given a suitable date for your operation.

Medication

We need to know what tablets and medicines you are currently taking also if you are hypersensitive to any substances.  At the pre operative assessment you will be advised on what pre-operative preparations you need to make such as altering medications.

What will happen?

The operation is carried out as a day case.  You will need to be at the eye hospital for 7.30 am on the day of surgery and you should expect to be there for most of the day. The following morning you will need to attend the ward for a quick eye check, if you are travelling from a long distance then it is possible to stay overnight.

  • Due to space restrictions if you want to bring anyone with you we request that only one person accompanies you. They will be requested to come back to collect you later in the day.
  • Please bring a clean dressing gown and pair of slippers with you along with overnight clothing and toiletries.
  • If you use a hearing aid bring it along with you.
  • Take your usual medications unless you have been advised to stop them prior to surgery.
  • Also bring any medications that you may need to take whilst you are in hospital including inhalers and sprays.
  • Please do not wear any make up, nail varnish or jewellry other than a wedding ring, as you will need to remove it before your operation.
  • It is advisable not to bring valuables or money to the hospital. The Trust will not accept responsibility for loss or theft.
  • Please eat and drink normally before coming in to hospital unless you have been advised not to do so.
  • On arrival to the ward a nurse will meet you and confirm the information that you gave at your pre assessment visit.
  • Eye drops to dilate the pupil of the eye you are having operated on are instilled.
  • You will be asked to get changed into a hospital gown, your dressing gown and your slippers.
  • Patients are offered drinks and light snacks free of charge.
  • Visitors are asked to use the dining facilities in the main hospital or Women’s’ and Childrens Hospital. A drinks machine is available on the ground floor.
  • During your stay several checks are made. These checks are to ensure the correct patient receives the correct procedure on the correct eye. These may seem tedious but are in the interests of your safety.

What happens afterwards?

After care

You will be told at this time when you need to come for a check up, how to look after your eye and told when to use the eye drops you need, to help the eye to heal.

Important points to follow

Please remember the following points:

  • You do not need to keep the eye covered once the anaesthetic has worn off.
  • You should avoid heavy lifting and straining for the first week.
  • You should avoid getting shampoo and soap into your eye for four weeks.
  • You should avoid swimming for 12 weeks.
  • You must not drive until you reach the minimum legal standard of vision.
  • You should not drive until the anaesthetic has completely worn off and there is no double vision.
  • It is normal for the eye to appear red and feel gritty this is due to the membrane covering the white of the eye being sutured after the operation, some of these effects last for up to four weeks. The stitches are dissolvable but take several weeks to completely dissolve.                   

Follow up appointments

If for any reason you are unable to attend for your appointments or need further advice please contact the Eye Clinic on (01482) 816658 or Ward 35 on (01482) 604346.

Should you require further advice on the issues contained in this leaflet, please do not hesitate to contact the Ophthalmology Department (01482) 608788

General Advice and Consent

Most of your questions should have been answered by this leaflet, but remember that this is only a starting point for discussion with the healthcare team.

Consent to treatment

Before any doctor, nurse or therapist examines or treats you, they must seek your consent or permission. In order to make a decision, you need to have information from health professionals about the treatment or investigation which is being offered to you. You should always ask them more questions if you do not understand or if you want more information.

The information you receive should be about your condition, the alternatives available to you, and whether it carries risks as well as the benefits. What is important is that your consent is genuine or valid. That means:

  • you must be able to give your consent
  • you must be given enough information to enable you to make a decision
  • you must be acting under your own free will and not under the strong influence of another person

Information about you

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