First Author: H.M.Chao TAIWAN
Co Author(s): J.H. Liu 0 0 0 0 0 0 0 0 0
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Macular pucker (MP) associated with opaque membrane or macular edema (ME) is vision-threatening. The investigation and management is mandatory.
Ophthalmology, Cheng-Hsin General Hospital
Results of visual acuity, microperimetry (MP-1), standard electroretinogram (sERG) and optical coherence tomography (OCT) of central retinal thickness (CRT) and macular volume (MV) were evaluated (mean age SD, 76.30 7.5 years) preoperatively (baseline) and postoperatively (generally at a monthly base). Enrolled patients whose pucker was peeled were classified into three groups based on the OCT pucker patterns, namely MP with mushroom umbrella (MU; n=6) epimacular membrane (EMM), volcano or tsunami-like shape (VT; n=3) EMM and MP with cyst-like macular edema (CME or ME; n=4). Furthermore, intravitreous injection (i.v.i.) of kenacort (IVIK), avastin (IVIA), lucentis (IVIL), avastin plus kenacort (IVIA+IVIK) or lucentis plus ozurdex (IVIL+IVIO), subconjunctival injection of kenacort (SCIK) as well as injection of IVIA plus SCIK were administered to others (7 eyes out of 6 patients) to alleviate their many episodes of pucker associated macular edema without membrane removal or after EMM peeling. The number of episodes of macular edema cured by a single injection was counted at various groups. The pre-injection and post-injection central retinal thickness and best corrected visual acuity (logMAR) were recorded.
MPMU patients whose EMMs (n=6) were peeled (Figure 1) had significant postoperative improvement in terms of BCVA (LogMAR), CRT and MV (Figure 2). In particular, their postoperative improved BCVAs (LogMAR) were significantly different from those of either group of MPVT (n=3) or group of MPME (n=4). In contrast, after EMM peeling for patients in groups of MPVT and MPME, there was a significant reduction in MV, but only a trend of reduction in CRT. On the other hand, numerous episodes of CME which was dried by a single intravitreous injection (i.v.i.) of kenacort [n=20; CME which recurred (n=5) was dried in a patient with EMM peeling]. Moreover, there was a significant postoperative reduction in CRT and a trend of postoperative improvement in BCVA (LogMAR; Figures 3 and 4). In Fig 4D, as compared to those cases with no CME (NME; n=6), the MP cases with CME (ME; n=4) had significantly higher levels of MCP-1, an inflammatory biomarker. This pioneering finding relevantly explains why CME was dried by a single anti-inflammatory agent kenacort injection which was given to the MP patient. Other single agent (n=5) or combined agents (n=3) were injected and also treated effectively the CME (Fig 4A~4C).
Macular pucker peeling could be cautiously and selectively performed on those patients of MPMU (n=6) in terms of significant postoperative improvement in BCVA as well as significant postoperative reduction in CRT and MV. Furthermore, MV might be more sensitive in detecting macular edema change than CRT. What is more, inflammation might play a role in MPME patients with a higher MCP-1 levels. Therefore, alleviation of edema and vision improvement was respectively significantly and obvious after i.v.i. kenacort was given to MP patients with CME.