New Framework for Deciding When to Operate on Patients With Epiretinal Membranes

At the American Academy of Ophthalmology (AAO) meeting, Yasha S. Modi, MD, of New York University (NYU) Langone Health in New York City, gave a presentation focused on the decision-making process for surgical treatment of epiretinal membranes.

MedPage Today brought together three expert leaders in the field: Moderator Peter K. Kaiser, MD, of the Cleveland Clinic, is joined by Modi and Arshad Khanani, MD, of the University of Nevada in Reno, for a virtual roundtable discussion. This second of four exclusive episodes focuses on Modi’s talk and what factors can help guide how to choose which patients to operate on.

Click here to watch the other videos from this AAO roundtable series.

Following is a transcript of their remarks:

Kaiser: Yasha, at AAO you presented a very nice paper on sort of choosing patients to operate on who have epiretinal membranes. Why don’t you go through some of your data and some of the learnings that you gave at AAO?

Modi: Yeah. I think it’s not so much data, but it’s sort of a framework of how to think about this problem. And I remember very much in fellowship we used oftentimes visual acuity as a threshold, but what we’ve learned from OCT [optical coherence tomography]-based classifications of epiretinal membrane, specifically Andrea Govetto and David Sarraf’s classification, looking at OCT, if you go from sort of stage 1 where you have preservation of the foveal pit, to stage 2 where we lose that, to stage 3 where we develop what’s called ectopic inner foveal layers, and to stage 4 where we lose the sort of continuity of those layers, almost sort of thinking about it as an inner retinal problem where maybe the outer retina gets affected in later stages.

What we learn is that by the time you get to stage 3, you have irrevocable vision loss, but that may be at the level of 20/40, 20/30 vision, ones where in the past we would’ve oftentimes not operated on them. And so I think that probably using metamorphopsia and having studies target more functional assays when considering using epiretinal membrane surgery are going to be really important. And there’s a protocol in DRCR [Diabetic Retinopathy Clinical Research] right now called Protocol AM, and this is looking at early versus delayed epiretinal membrane surgery. And not only are they using vision, but they’re also doing a host of functional testing to see should we operate on these patients immediately or should we delay the surgeries potentially without having adverse consequence.

Kaiser: I think this is a big issue, right? We see patients with epiretinal membranes every day, and the decision whether to operate or not is myriad. And I really congratulate the DRCR for taking the bulls by the horn.

In your practice Arshad, what are some of the things that you do to kind of decide if you’re going to operate on a patient with an epiretinal membrane? Do you use this criteria that David Sarraf wrote about?

Khanani: So I don’t specifically use the criteria, but I am looking at structural endpoints that Yasha presented. So Yasha, congrats on an excellent talk, and I think this is very useful, right? Because we all have patients who have good visual acuity … but either they have symptoms or they have changes that you cannot account for unless you look at their structure on OCT and you realize that they’re actually changes that are very relevant. So I’ve been a big believer in early intervention for symptomatic patients. Now, one question I have for you, Yasha, is that you see those changes that you’re describing, but patient is asymptomatic. What do you do then?

Modi: Yeah, I think you nailed it, right? Symptoms have to be the driver. It’s a really tall order to operate on somebody who’s otherwise asymptomatic. And so sometimes we see patients who are stage 3. Clearly, they should have some level of visual compromise when you look at their anatomy, but it sort of highlights the fact that everybody has a different visual demand. And actually, I credit one of my partners, Peter Weseley at NYU, and he always talks to me, he’s like, the question that I always ask patients is, is the binocular vision affected? And while we didn’t talk about this at academy, if somebody’s perceiving the deficit with both eyes open, those are individuals who are likely to derive sometimes the best benefit.

Kaiser: Yeah, it’s sort of like the first question I ask a patient who walks in my door from a surgical candidate, what brings you in? And if they say, I have no idea. I was sent in by my optometrist or my general ophthalmologist, then I know they’re really not a great surgical candidate just yet. They have no idea why they’re there.

Modi: That’s a great point.