Scheie Eye Institute, University of Pennsylvania
Macular pucker (also known as an epiretinal membrane) is an eye condition that affects the central retina, or macula. As the name suggests, it is caused by distortion or “squeezing” of the macula. The condition is sometimes called “cellophane maculopathy,” because it can be caused by a thin, transparent layer of cellophane-like scar tissue tugging on the neurons of the macula.
While macular pucker is a different disease than age-related macular degeneration, the two diseases can have similar symptoms, such as wavy or distorted vision in the center of the visual field. Macular pucker usually causes only mild distortion of vision in one eye; however, less often it can affect both eyes and can cause significant loss of central vision.
The scar tissue is stimulated to grow by injury to the eye. The most common type of “injury” is the separation of the jelly (vitreous) in the center of the eye from the retina, which occurs in most people during the aging process. The vitreous is made of water and a network of tiny fibers. When these fibers separate from the retina, they tug on it and this can cause enough damage to stimulate growth of scar tissue. Alternatively, the scar tissue growth may be stimulated by inflammation in the eye, trauma, and perhaps, rarely, cataract surgery.
The macula is the area of the retina that is responsible for clear vision. As a person ages, the vitreous inside of the eye begins to shrink. When this occurs in the macular area, the retina initiates a healing response with a migration of cells found within the retina itself. These cells form a thin layer of scar tissue known as a macular pucker or epiretinal membrane.
Macular pucker can be diagnosed by an ophthalmologist performing a retinal examination following pupil dilating drops. Its progress can be followed over time by measuring visual acuity, checking for distorted vision while looking at a graph called an Amsler grid, or by special photographs. These can include color photographs of the retinas, and important cross-section photos of the retina taken by a process called optical coherence tomography (OCT). The OCT shows the extent of retinal scar formation and retinal distortion caused by traction from the scar tissue.
Since most patients have only mild symptoms, they can best benefit from new glasses, reading lamps, and perhaps magnifiers. For patients with more severe symptoms, medical or surgical treatment may be appropriate. A subgroup of patients with macular pucker that is caused by the vitreous tugging on the macula (vitreomacular traction) may benefit with a single injection into the eye of a medication called Jetrea. This drug is an enzyme that digests the tiny fibers in the vitreous, potentially releasing the traction.
For patients who would not benefit from Jetrea, surgery may be helpful. The outpatient surgery is done with local anesthesia and involves removing the vitreous (vitrectomy) and usually peeling off the cellophane-like scar tissue. This can help relieve the retinal traction, decreasing distortion of the vision, and improving visual acuity.
A related disease is the macular hole, which can result from traction on the retina, and can also require vitrectomy surgery to relieve the traction and close the hole. Another disease, retinal detachment, occurs when the retina separates from the back of the eye, usually caused by a tear in the peripheral retina resulting from the vitreous tugging on the retina as it separates. The symptoms of a retinal tear/detachment in one eye are:
Since a retinal tear is an emergency, patients with the symptoms of a retinal tear/detachment should call their ophthalmologist immediately to receive vision-protecting treatment if a tear or detachment is diagnosed.
A retinal detachment occurs when the retina's layers separate. Any portion of the retina that is detached cannot send visual signals to the brain. If left untreated, retinal detachment can cause devastating damage to an individual's vision. Retinal detachment is considered an ocular emergency that requires immediate medical attention.
Joshua Dunaief, MD, received his BA magna cum laude in Biology from Harvard (1987), MD/PhD from Columbia College of Physicians and Surgeons (1996), completed ophthalmology residency at the Wilmer Eye Institute, Johns Hopkins in 2000, and medical retina fellowship at Scheie Eye Institute, University of Pennsylvania in 2004.
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