Epiretinal Membrane: Symptoms, OCT Diagnosis and Treatment

Author: Dr Val Phua
Estimated reading time: 20 minutes

An epiretinal membrane is a thin layer of fibrocellular tissue that develops on the inner surface of the retina, usually over the macula.

The macula is the central part of the retina responsible for:

• Reading
• Recognising faces
• Driving
• Colour perception
• Fine visual detail
• Seeing objects directly in front of you

An epiretinal membrane may remain thin and cause no noticeable symptoms. If it thickens or contracts, however, it can pull on the macula and distort its normal structure.

This may cause:

• Blurred central vision
• Straight lines appearing bent or wavy
• Words looking compressed or stretched
• Objects appearing larger or smaller in one eye
• Double or overlapping images from one eye
• Difficulty reading
• Reduced contrast
• Unequal image quality between the eyes

An epiretinal membrane is also called:

• Macular pucker
• Cellophane maculopathy
• Preretinal macular fibrosis
• Epimacular membrane

Epiretinal membranes become more common with age. Population studies have reported prevalence estimates approaching 9% in some older adult populations, although the measured frequency varies according to ethnicity, age and whether retinal photography or OCT is used.

Many patients require only observation.

When distortion, reduced vision or binocular imbalance significantly affects daily life, the membrane can be removed during vitrectomy surgery. Current guidance emphasises that the decision to operate should be based on symptoms, functional impairment, OCT findings, visual potential and the patient’s priorities—not retinal thickness or eye-chart vision alone.

The Quick Answer

What Is an Epiretinal Membrane?

An epiretinal membrane is a thin sheet of tissue that forms on the surface of the macula.

It may initially be transparent and loosely attached. As it contracts, it can:

• Wrinkle the retina
• Flatten the normal foveal depression
• Thicken the macula
• Shift retinal tissue
• Distort the arrangement of retinal layers
• Affect the photoreceptors responsible for fine vision

The condition is usually idiopathic, meaning that no specific underlying eye disease is identified. Secondary epiretinal membranes may occur after retinal tears, retinal detachment, inflammation, vascular disease, trauma or eye surgery.

Is an Epiretinal Membrane Dangerous?

Most epiretinal membranes do not cause complete blindness or an ophthalmic emergency.

They primarily affect central image quality rather than peripheral vision.

However, a significant membrane may progressively interfere with:

• Reading
• Driving
• Facial recognition
• Fine work
• Depth perception
• Binocular visual comfort

A sudden shower of floaters, flashes, a curtain or rapid loss of vision is not typical of uncomplicated epiretinal membrane and requires urgent retinal assessment.

Does Every Epiretinal Membrane Need Surgery?

No.

Observation is often appropriate when:

• Vision remains good.
• Distortion is mild.
• Daily activities are not significantly affected.
• OCT findings are stable.
• The patient is comfortable with the current vision.
• Another eye condition limits the expected benefit of surgery.

In a long-term study of eyes with good visual acuity, only about one in five progressed to surgery over four years.

Can Eyedrops Remove an Epiretinal Membrane?

No.

Eyedrops, supplements, glasses and laser treatment cannot dissolve or peel away an established membrane.

Glasses may improve blur caused by an accompanying refractive error, but they cannot remove retinal distortion caused by traction.

The only treatment that physically removes the membrane is vitrectomy with membrane peeling.

Does Surgery Restore Completely Normal Vision?

Not always.

Surgery frequently improves:

• Visual acuity
• Distortion
• Reading ability
• Binocular comfort
• Vision-related quality of life

However, the retina may not return completely to its original microscopic structure. Some residual blur, waviness, altered image size or reduced contrast may remain, particularly when the membrane has been present for a long time or has caused advanced retinal-layer changes.

Understanding the Macula

The Retina

The retina is a thin layer of light-sensitive nerve tissue lining the inside of the back of the eye.

It converts light into electrical signals that travel through the optic nerve to the brain.

The Macula

The macula is the specialised central region of the retina.

It provides the detailed vision needed for:

• Reading
• Recognising facial features
• Driving
• Using a phone
• Sewing
• Drawing
• Seeing fine textures
• Distinguishing colours

The Fovea

The fovea is the central depression within the macula.

In a healthy eye, the arrangement of the retinal layers around the fovea is highly organised to provide sharp central vision.

An epiretinal membrane may flatten or eliminate this depression and pull inner retinal tissue across the foveal centre.

The Internal Limiting Membrane

The internal limiting membrane, or ILM, is the innermost microscopic boundary of the retina.

An epiretinal membrane grows immediately above it.

During surgery, the surgeon may remove both:

• The epiretinal membrane
• A surrounding area of ILM

ILM peeling does not appear to provide substantially better final visual acuity than membrane peeling alone, but it reduces the risk of recurrent epiretinal membrane and further surgery.

How Does an Epiretinal Membrane Form?

Age-Related Vitreous Change

The vitreous is the transparent gel filling the centre of the eye.

With age, the vitreous becomes more liquid and gradually separates from the retina. This is called a posterior vitreous detachment.

Minor changes at the retinal surface during this process may allow cells to migrate and multiply over the internal limiting membrane.

These cells may produce collagen and other extracellular material, creating a thin membrane that can later contract.

Cell Contraction

The cells within the membrane may contract over time.

Because the membrane is attached to the macula, this contraction can produce:

• Surface wrinkling
• Retinal folds
• Displacement of retinal vessels
• Thickening of the macula
• Loss of the foveal contour
• Distortion of the retinal layers

Not Every Posterior Vitreous Detachment Causes a Membrane

Posterior vitreous detachment is common with ageing.

Only a proportion of people subsequently develop a clinically detectable epiretinal membrane.

Primary and Secondary Epiretinal Membranes

Idiopathic Epiretinal Membrane

An idiopathic epiretinal membrane develops without an identifiable underlying retinal disorder.

Age-related vitreous separation is believed to contribute in many cases.

This is the most common form seen in older adults.

Secondary Epiretinal Membrane

A secondary membrane may occur after or alongside:

• Retinal tear
• Retinal detachment
• Retinal-detachment surgery
• Diabetic retinopathy
• Retinal-vein occlusion
• Uveitis
• Eye trauma
• Previous retinal laser
• Intraocular inflammation
• Cataract surgery
• Vitreoretinal surgery

The visual outcome may depend not only on the membrane but also on the underlying retinal condition.

Epiretinal Membrane After Retinal-Detachment Repair

An epiretinal membrane may develop after successful retinal-detachment surgery.

Membrane peeling can improve vision in selected patients, but the final result also depends on:

• Whether the macula was detached
• Duration of detachment
• Photoreceptor damage
• Retinal folds
• Previous proliferative vitreoretinopathy
• Other surgical changes

Studies have shown meaningful visual improvement after membrane peeling in many eyes following retinal-detachment repair.

Epiretinal Membrane With Diabetic Retinopathy

Diabetes may be associated with secondary epiretinal tissue, particularly when there is:

• Diabetic macular oedema
• Previous retinal laser
• Proliferative diabetic retinopathy
• Vitreomacular traction
• Previous vitrectomy

Treatment must distinguish mechanical traction from vascular leakage because injections may treat oedema but do not remove a contracting membrane.

What Symptoms Can an Epiretinal Membrane Cause?

No Symptoms

A mild membrane may be discovered incidentally during:

• Routine eye examination
• Diabetic retinal screening
• Cataract assessment
• OCT imaging
• Examination of the other eye

Observation may be all that is required.

Blurred Central Vision

The patient may describe vision as:

• Soft
• Hazy
• Less crisp
• Slightly smeared
• Difficult to focus
• Unequal between the eyes

The degree of blur may not correspond exactly to the retinal thickness measured on OCT.

Metamorphopsia

Metamorphopsia means visual distortion.

Straight objects may appear:

• Bent
• Wavy
• Kinked
• Compressed
• Stretched
• Broken

Patients may notice distortion when viewing:

• Door frames
• Window blinds
• Bathroom tiles
• Lines of text
• Lamp posts
• Spreadsheet rows
• The Amsler grid

Distortion may be more functionally troublesome than the reduction in eye-chart acuity.

Micropsia and Macropsia

Objects may appear:

• Smaller in the affected eye, known as micropsia
• Larger in the affected eye, known as macropsia

These differences may make the images from the two eyes difficult for the brain to combine.

Aniseikonia

Aniseikonia refers to unequal perceived image size between the eyes.

It may cause:

• Eye strain
• Reading difficulty
• Poor binocular comfort
• Depth-perception problems
• A sensation that the two eyes are not working together

Binocular dysfunction and image-size inequality can affect quality of life even when monocular visual acuity remains relatively good.

Monocular Double Vision

The affected eye may produce:

• A shadow image
• Overlapping letters
• Ghosting
• Two outlines around an object

This persists when the other eye is covered.

True binocular double vision that disappears when either eye is covered may have an eye-alignment or neurological cause.

Difficulty Reading

Reading may become difficult because:

• Letters are distorted.
• Words appear crowded.
• The line of text appears uneven.
• The patient loses their place.
• Reading speed decreases.
• The two eyes see different-sized images.

Reading ability may improve after successful membrane surgery even in patients whose standard visual acuity was relatively good before surgery.

Reduced Contrast

Patients may have difficulty seeing:

• Pale print
• Faces in dim light
• Steps with low contrast
• Objects in fog or rain
• Details at dusk

Difficulty Recognising Faces

Fine facial details may appear distorted or blurred.

Problems With Depth Perception

Unequal visual quality between the eyes may interfere with:

• Pouring liquids
• Reaching for objects
• Ball sports
• Driving
• Walking on stairs
• Fine hand-eye coordination

Colour or Brightness Difference

Some patients perceive colours, contrast or brightness differently between the two eyes.

Other causes such as cataract, macular disease and optic-nerve dysfunction should also be considered.

Does an Epiretinal Membrane Affect Both Eyes?

An epiretinal membrane can occur in one or both eyes.

When both eyes are affected:

• One eye may be much worse.
• The OCT stages may differ.
• Symptoms may be dominated by the eye with more distortion.
• Surgery may be appropriate for only one eye.
• Each eye should be assessed separately.

A patient may remain unaware of significant distortion in one eye because the better eye compensates.

Testing one eye at a time can reveal the difference.

Risk Factors

Increasing Age

Age is the most consistent risk factor.

Population studies show a marked increase in prevalence among older adults.

Posterior Vitreous Detachment

Age-related vitreous separation is strongly associated with the development of many idiopathic membranes.

Retinal Tear or Detachment

Retinal injury and repair processes may stimulate membrane formation.

Retinal Vascular Disease

Possible associated conditions include:

• Diabetic retinopathy
• Retinal-vein occlusion
• Retinal arterial disease

Uveitis

Inflammation inside the eye may promote cellular proliferation on the retinal surface.

Previous Eye Surgery

Epiretinal membranes may develop after:

• Retinal surgery
• Retinal laser
• Cataract surgery
• Vitrectomy

This does not mean that the procedure was necessarily performed incorrectly. Surgery and the underlying retinal condition may both alter the vitreoretinal environment.

Eye Trauma

Blunt or penetrating injury may cause inflammation, retinal tears or other changes that lead to secondary membrane formation.

Is an Epiretinal Membrane the Same as Macular Degeneration?

No.

Both affect the macula, but they are different conditions.

Epiretinal Membrane

An epiretinal membrane is tissue on the surface of the retina that produces mechanical traction and distortion.

Age-Related Macular Degeneration

Age-related macular degeneration affects deeper retinal structures and may involve:

• Drusen
• Retinal pigment epithelium damage
• Geographic atrophy
• Abnormal blood vessels
• Bleeding or fluid

A patient may have both conditions.

OCT helps determine which abnormality is responsible for the symptoms.

Epiretinal Membrane Versus Vitreomacular Traction

Vitreomacular Traction

Vitreomacular traction occurs when the vitreous remains abnormally attached to the macula and pulls on it.

The traction originates from the vitreous rather than from a separate surface membrane alone.

They May Coexist

An eye may have:

• Epiretinal membrane without vitreomacular traction
• Vitreomacular traction without a significant membrane
• Both conditions together

The surgical plan depends on the anatomy.

Epiretinal Membrane Versus Macular Hole

Full-Thickness Macular Hole

A full-thickness macular hole is an opening through the central retina.

It usually causes:

• Central blur
• Distortion
• A central missing area
• Reduced reading vision

Lamellar Macular Hole

A lamellar hole is a partial-thickness defect in the fovea.

Some lamellar holes are associated with epiretinal proliferation or conventional tractional epiretinal membrane.

Macular Pseudohole

A contracting epiretinal membrane may steepen the foveal edges and create the appearance of a hole without a complete loss of retinal tissue.

This is called a macular pseudohole.

OCT distinguishes these conditions and guides management.

How Is an Epiretinal Membrane Diagnosed?

Visual-Acuity Testing

Vision is measured:

• Without glasses
• With the current glasses
• After refraction

A careful refraction helps determine how much blur is caused by prescription rather than retinal distortion.

Amsler Grid

An Amsler grid may reveal:

• Wavy lines
• Compressed squares
• Missing areas
• Unequal distortion between the eyes

The test should be performed one eye at a time.

It can be used for home monitoring but does not replace retinal examination or OCT.

Dilated Retinal Examination

Dilating drops allow the ophthalmologist to assess:

• The macular surface
• Retinal folds
• Vessel distortion
• Other retinal disease
• Retinal tears
• The peripheral retina
• The vitreous

A thin membrane may be difficult to assess without OCT.

Fundus Photography

Photography may demonstrate:

• A cellophane-like reflex
• Retinal folds
• Vessel displacement
• Macular distortion
• Associated haemorrhage or vascular disease

Optical Coherence Tomography

OCT is the most useful imaging test for an epiretinal membrane.

It can show:

• The membrane itself
• Retinal thickness
• Loss of the foveal depression
• Retinal folds
• Ectopic inner foveal layers
• Intraretinal cystic spaces
• Photoreceptor integrity
• Vitreomacular traction
• Lamellar or full-thickness macular hole
• Other macular disease

OCT allows the ophthalmologist to compare structural changes over time and plan surgery.

OCT Stages of Epiretinal Membrane

A widely used OCT staging system describes progressive anatomical disruption.

The stage is useful, but surgery should not be based on the stage alone. Symptoms, function and the health of the outer retina remain essential.

Stage 1

Typical features include:

• A mild membrane
• Preserved foveal depression
• Relatively normal retinal-layer organisation

Vision may remain good.

Stage 2

Typical features include:

• Loss of the normal foveal depression
• Retinal thickening
• Retinal layers that remain individually identifiable

Stage 3

Typical features include:

• Continuous ectopic inner foveal layers crossing the central fovea
• Greater retinal thickening
• Preserved but altered retinal-layer definition

Stage 4

Typical features include:

• Ectopic inner foveal layers
• Marked retinal thickening
• Significant distortion and disorganisation of the retinal layers

Higher stages are generally associated with poorer visual function and more advanced anatomical change, although individual symptoms vary.

Other OCT Findings That Affect Prognosis

Ectopic Inner Foveal Layers

Inner retinal layers may be pulled across the foveal centre.

Their presence is associated with more advanced traction and may predict a less complete visual result.

Ellipsoid-Zone Integrity

The ellipsoid zone represents an important part of the photoreceptor structure on OCT.

Disruption may indicate photoreceptor damage and may limit final visual acuity.

External Limiting Membrane

Disruption of the external limiting membrane may also indicate more advanced outer-retinal injury.

Retinal Thickness

A thick retina may improve anatomically after surgery.

However, thickness alone does not fully predict symptoms or postoperative visual quality.

Intraretinal Cystic Spaces

Small cyst-like spaces may represent tractional changes or oedema.

Their significance depends on the overall OCT pattern and any accompanying retinal vascular disease.

Will an Epiretinal Membrane Get Worse?

Many Remain Stable

A mild membrane can remain stable for years.

Patients with:

• Good visual acuity
• Mild distortion
• Preserved retinal structure

may reasonably be monitored.

Some Progress Gradually

Possible changes include:

• Increasing retinal thickness
• Loss of the foveal depression
• Increasing distortion
• Development of ectopic inner foveal layers
• Worsening reading ability
• Declining binocular visual comfort

In a long-term observational study of eyes with good visual acuity, progression to surgery occurred gradually, reaching approximately 21% at four years.

Spontaneous Separation Can Occur

Rarely, the membrane may partially or completely separate from the retinal surface.

This has been observed more often in younger patients and selected anatomical patterns, but it should not be expected in most older adults.

Monitoring an Epiretinal Membrane

Clinical Follow-Up

Monitoring may include:

• Visual acuity
• Refraction
• Symptom review
• Dilated retinal examination
• OCT
• Amsler-grid testing
• Comparison with previous scans

How Often Should It Be Checked?

The interval depends on:

• Severity
• Symptoms
• OCT stage
• Recent progression
• Vision in the other eye
• Associated retinal disease
• Whether cataract surgery is planned

A mild stable membrane may be reviewed less frequently than a symptomatic or progressing membrane.

Home Monitoring

Test each eye separately.

Report:

• New waviness
• Increasing blur
• A new central missing area
• Increasing image-size difference
• Difficulty reading that is progressing
• New binocular discomfort

When Is Surgery Considered?

Symptoms Affect Daily Function

Surgery may be discussed when the membrane interferes with:

• Reading
• Driving
• Work
• Facial recognition
• Fine hobbies
• Computer use
• Depth perception
• Comfortable binocular vision

Distortion May Matter More Than Eye-Chart Vision

A patient may still read the 6/9 or 6/12 line but find the vision functionally unacceptable because every line is bent.

The decision should therefore consider:

• Metamorphopsia
• Aniseikonia
• Reading speed
• Binocular function
• Visual quality
• Patient priorities

Progressive Visual Decline

Surgery may be considered when serial testing shows:

• Worsening visual acuity
• Increasing distortion
• Progressive OCT changes
• Declining binocular function

Mild Symptoms May Be Observed

Randomised evidence comparing immediate surgery with watchful waiting for mild symptomatic disease is limited. A Cochrane review found no clear evidence that immediate surgery was superior to observation with surgery performed if progression occurred.

There Is No Universal Visual-Acuity Threshold

The same eye-chart acuity may be acceptable to one patient and disabling to another.

Surgery is not mandatory simply because an OCT shows a membrane.

What Happens During Epiretinal-Membrane Surgery?

Pars Plana Vitrectomy

The operation begins with vitrectomy.

Small instruments are introduced through the white part of the eye to remove the vitreous gel.

Removing the vitreous:

• Provides access to the macula
• Releases residual vitreous traction
• Creates space for membrane peeling

Membrane Peeling

The surgeon uses fine forceps to lift and peel the membrane from the retinal surface.

Special dyes may be used to make the tissue more visible.

Internal Limiting Membrane Peeling

The ILM may also be stained and removed around the macula.

A meta-analysis found that ILM peeling lowered recurrence and reoperation risk, while final visual acuity was similar whether or not the ILM was peeled.

Anaesthesia

The procedure may be performed under:

• Local anaesthesia
• Local anaesthesia with sedation
• General anaesthesia in selected circumstances

The patient should not feel sharp pain but may notice:

• Pressure
• Touch
• Bright lights
• Movement

Gas or Air

Gas is not routinely required for every uncomplicated epiretinal-membrane peel.

It may be used when there is:

• A macular hole
• A retinal tear
• Retinal detachment
• Another intraoperative indication

Postoperative positioning and flying restrictions apply only when gas is inserted.

What Results Can Be Expected?

Visual Acuity

Most appropriately selected patients improve after surgery.

The American Academy of Ophthalmology notes that vitrectomy for symptomatic epiretinal membrane commonly improves visual acuity and metamorphopsia, with a substantial majority achieving meaningful improvement.

Long-term studies show that visual gains may remain stable for many years after successful surgery.

Distortion

Metamorphopsia often improves, but it may not disappear completely.

Improvement may continue for:

• Several months
• One year
• Occasionally longer

Studies have demonstrated progressive improvement in distortion and quality of life during the first postoperative year.

Reading and Quality of Life

Surgery may improve:

• Reading speed
• Binocular visual function
• Vision-related quality of life
• Visual confidence

These benefits may occur even when the change in conventional eye-chart acuity appears modest.

Anatomical Recovery

OCT commonly shows:

• Reduced retinal thickness
• Less surface wrinkling
• More regular retinal contour
• Gradual restoration of some retinal layers

Complete return to normal anatomy is not guaranteed.

Why May Vision Remain Limited?

Long-Standing Retinal Distortion

Chronic traction may cause permanent rearrangement or damage within the retinal layers.

Photoreceptor Damage

Disruption of the outer retinal layers may limit final acuity.

Macular Ischaemia

Reduced macular circulation from diabetes or retinal vascular disease may limit improvement.

Previous Retinal Detachment

Vision may remain affected by earlier photoreceptor injury.

Glaucoma or Optic-Nerve Disease

Removing the membrane cannot reverse optic-nerve damage.

Corneal Disease

Corneal irregularity or scarring may continue to affect image quality.

Cataract

A cataract may limit early postoperative improvement or progress after vitrectomy.

Amblyopia

An eye that never developed normal vision during childhood may have limited visual potential.

How Long Does Recovery Take?

The First Few Days

Vision may initially be:

• Blurred
• Hazy
• Sensitive to light
• Affected by pupil dilation
• Disturbed by air or gas bubbles
• Worse than before surgery

The eye may feel:

• Gritty
• Watery
• Mildly sore
• Red

The First Few Weeks

The retinal surface begins to relax, but vision commonly remains unstable.

Reading and distortion may improve gradually rather than immediately.

Three to Six Months

Meaningful visual recovery often occurs over several months.

Some studies report that the timing of final recovery varies from approximately one to six months, with further improvement possible beyond that period.

Up to One Year or Longer

Retinal remodelling and neuroadaptation can continue for a year or more.

Patients should not judge the final result solely from the first postoperative month.

Risks of Epiretinal-Membrane Surgery

Cataract Progression

Vitrectomy commonly accelerates nuclear cataract formation in eyes that still have a natural lens.

Many phakic patients subsequently require cataract surgery. In some studies, more than half developed clinically relevant cataract progression after membrane surgery, while other series report that most phakic patients require cataract surgery within one to two years.

Retinal Tear

A retinal tear may occur during or after surgery.

Laser treatment may be applied if a tear is identified.

Retinal Detachment

Retinal detachment is uncommon but potentially sight-threatening.

Symptoms include:

• New flashes
• A sudden shower of floaters
• A curtain
• Missing peripheral vision

Infection

Endophthalmitis is a rare but serious infection inside the eye.

Possible symptoms include:

• Increasing pain
• Increasing redness
• Worsening vision
• Marked light sensitivity
• Discharge

Macular Oedema

Inflammatory swelling may develop after surgery.

Treatment may include:

• Anti-inflammatory drops
• Steroid treatment
• Other retinal therapy

Raised or Reduced Eye Pressure

Eye pressure may change because of:

• Inflammation
• Steroid response
• Gas
• Surgical changes
• Pre-existing glaucoma

Bleeding

Minor bleeding may occur during surgery.

Significant intraocular haemorrhage is less common.

Macular Hole

A full-thickness macular hole can rarely develop during or after membrane peeling.

Recurrent Epiretinal Membrane

The membrane may recur.

Removing the ILM lowers the risk but does not make recurrence impossible.

Persistent Distortion

The membrane may be removed successfully while some visual distortion remains because of previous retinal damage or displacement.

Cataract and Epiretinal Membrane

Both Conditions May Cause Blur

A cataract commonly causes:

• Haze
• Glare
• Faded colour
• Poor night vision

An epiretinal membrane more characteristically causes:

• Wavy lines
• Image-size difference
• Distortion
• Central retinal thickening

Both may be present simultaneously.

Cataract Surgery Alone

Cataract surgery may improve vision when the cataract contributes significantly.

However:

• Retinal distortion will remain.
• The final visual improvement may be limited.
• Macular oedema risk may be higher.
• The membrane may later require vitrectomy.

A large clinical study found that eyes with primary epiretinal membrane generally improved after cataract surgery, but achieved less visual gain and had a higher rate of cystoid macular oedema than eyes without ERM.

Does Cataract Surgery Make the Membrane Worse?

Recent OCT-based studies suggest that mild membranes do not invariably progress rapidly after cataract surgery, although some eyes develop greater retinal thickening or macular oedema and a minority later undergo vitrectomy.

Combined Cataract and Membrane Surgery

When both conditions are visually significant, cataract extraction and vitrectomy may be performed during the same operation.

Advantages may include:

• One operation
• One recovery period
• Immediate removal of the cataract
• Avoiding rapid postoperative cataract progression

Disadvantages may include:

• Longer surgery
• More inflammation
• Less predictable IOL calculation
• Difficulty determining how much blur came from each condition
• Loss of the opportunity to assess vision after one procedure first

Sequential Surgery

The procedures may instead be performed separately.

Possible approaches include:

• Cataract surgery first, followed by retinal reassessment
• Membrane surgery first, followed later by cataract surgery

Studies comparing combined and sequential surgery generally report similar final visual outcomes, although refractive prediction may be less accurate after combined phacovitrectomy.

Which Cataract Lens Is Suitable With an Epiretinal Membrane?

Monofocal Lens

A monofocal lens is commonly selected when the membrane is visually significant because it concentrates light at one principal focal distance.

Toric Monofocal Lens

A toric monofocal may be appropriate when regular corneal astigmatism is present and the measurements are reliable.

Multifocal and Trifocal Lenses

These lenses divide light between several focal ranges.

Caution is generally appropriate when an epiretinal membrane affects:

• Macular anatomy
• Contrast
• Visual acuity
• Image quality
• Binocular function

A presbyopia-correcting lens cannot compensate for retinal distortion and may make reduced contrast or visual artefacts more troublesome.

EDOF and Enhanced Monofocal Lenses

Suitability depends on:

• ERM severity
• Macular OCT
• Contrast sensitivity
• Visual potential
• Patient priorities
• The specific optical design

The decision should be individualised.

Can Glasses Help?

Refractive Blur

Glasses can correct:

• Short-sightedness
• Long-sightedness
• Regular astigmatism
• Presbyopia

Retinal Distortion

Glasses cannot straighten a retinal image distorted by macular traction.

A new prescription may make the letters sharper but leave them wavy.

Prisms

Prisms do not usually correct monocular distortion from an epiretinal membrane.

They may be considered only when there is a separate binocular alignment problem.

Can Injections or Laser Treat an Epiretinal Membrane?

Anti-VEGF Injections

Anti-VEGF injections do not remove an epiretinal membrane.

They may be used when there is accompanying:

• Diabetic macular oedema
• Retinal-vein occlusion
• Neovascular macular disease

Steroid Injections

Steroids may treat associated inflammation or oedema but do not peel away the membrane.

Retinal Laser

Laser treatment cannot remove an epiretinal membrane.

It may be used for a separate retinal tear, diabetic retinopathy or vascular condition.

YAG Laser

YAG laser is used for posterior capsule opacification behind an intraocular lens.

It does not treat an epiretinal membrane.

Driving With an Epiretinal Membrane

Driving ability depends on:

• Visual acuity
• Distortion
• Contrast
• Vision in the other eye
• Glare
• Local licensing requirements
• Ability to judge distance safely

A patient may meet a basic eye-chart standard but still feel unsafe because:

• Road markings appear bent.
• Vehicles appear different in size between the eyes.
• Depth judgement is poor.
• Reading signs is difficult.

Stop driving and arrange reassessment if vision no longer feels safe.

Epiretinal Membrane in Children and Young Adults

Epiretinal membranes are much less common in children and young adults.

Possible associations include:

• Trauma
• Inflammation
• Retinal vascular disease
• Retinal dystrophy
• Previous retinal surgery
• Congenital vitreoretinal abnormalities

Some idiopathic membranes in younger patients may separate spontaneously, but careful evaluation is required because the causes and natural history differ from typical age-related disease.

Can an Epiretinal Membrane Cause Blindness?

An isolated epiretinal membrane usually affects central image quality rather than causing complete loss of all vision.

Severe disease may cause significant difficulty with:

• Reading
• Driving
• Recognising faces
• Fine work

Peripheral vision is usually preserved unless another retinal condition is present.

Common Myths

“It Is a Film Growing Over the Front of the Eye”

False.

The membrane lies on the retinal surface at the back of the eye.

It cannot be seen in a mirror or wiped away.

“If the OCT Looks Thick, Surgery Is Mandatory”

False.

Treatment depends on:

• Symptoms
• Functional impact
• Progression
• Visual potential
• Patient preference

“Good Eye-Chart Vision Means the Membrane Is Not Significant”

False.

A patient may have good high-contrast acuity but disabling distortion or image-size inequality.

“The Membrane Will Always Become Severe”

False.

Many membranes remain stable for years.

“Eyedrops Can Dissolve It”

False.

No eyedrop removes an established membrane.

“Surgery Guarantees Perfect Vision”

False.

Surgery releases traction but cannot always reverse permanent retinal changes.

“The Membrane Grows Back in Every Patient”

False.

Recurrence is possible but not inevitable, and ILM peeling reduces the risk.

Frequently Asked Questions

What Causes an Epiretinal Membrane?

Most are associated with age-related vitreous changes.

Others develop after retinal disease, inflammation, trauma or surgery.

Is It the Same as Scar Tissue?

It is often described as scar-like tissue because it contains cells and extracellular material that can contract.

It is more accurately a fibrocellular membrane on the retinal surface.

How Quickly Does It Progress?

Progression is usually gradual.

Some membranes remain stable, while others worsen over months or years.

Can It Suddenly Become Worse?

The membrane itself usually progresses slowly.

Sudden deterioration should prompt urgent examination for:

• Retinal tear
• Retinal detachment
• Vitreous haemorrhage
• Retinal vascular occlusion
• Macular haemorrhage
• Other acute disease

Can It Disappear by Itself?

Spontaneous separation can occur but is uncommon, particularly in older adults.

When Is Surgery Recommended?

Surgery may be recommended when distortion or reduced vision significantly affects daily life and the expected benefit justifies the risks.

Should I Operate Before the Vision Becomes Very Poor?

There is no universal rule.

Earlier surgery may preserve better retinal structure in selected progressing cases, but mild stable disease can often be observed safely.

The decision should be individualised.

Is Surgery Painful?

The eye is anaesthetised.

Patients usually notice pressure, light and movement rather than sharp pain.

Will I Need Face-Down Positioning?

Not usually after an uncomplicated membrane peel without gas.

Positioning may be required if gas is used for another condition.

Can I Fly After Surgery?

Flying is prohibited while an intraocular gas bubble remains.

If no gas is used, travel restrictions depend on postoperative recovery and the surgeon’s advice.

Will I Develop a Cataract After Surgery?

Cataract progression is common in phakic adults after vitrectomy.

How Long Before I Can Read Normally?

Reading may remain difficult initially.

Improvement commonly occurs over weeks to months and may continue for a year or longer.

Can Distortion Become Worse Immediately After Surgery?

Vision may initially appear more blurred or distorted because of:

• Inflammation
• Retinal swelling
• Pupil dilation
• Air or gas
• Temporary retinal displacement
• Early healing

Persistent or worsening symptoms should be assessed.

Can the Membrane Recur?

Yes, but recurrence is less common when the surrounding ILM is also removed.

Can Surgery Be Repeated?

Repeat surgery may be considered for a significant recurrent membrane, although the risks and expected benefit must be reassessed.

Can I Have Cataract Surgery First?

Yes, in selected patients.

The decision depends on whether the cataract or membrane is contributing more to the symptoms.

Can I Have Cataract and Membrane Surgery Together?

Yes.

Combined and sequential approaches can both provide good outcomes. The choice depends on cataract severity, refractive priorities, retinal findings and surgeon assessment.

When to Seek Urgent Eye Care

An established epiretinal membrane usually does not require emergency treatment.

Seek urgent same-day assessment for:

• Sudden visual loss
• New flashes
• A sudden shower of floaters
• A curtain or shadow
• A new missing visual field
• Sudden severe distortion
• Eye pain and redness
• Trauma
• Sudden haze or bleeding in the vision

These symptoms may indicate a retinal tear, retinal detachment, vitreous haemorrhage or another acute condition rather than gradual ERM progression.

An Epiretinal-Membrane Monitoring Checklist

Symptoms to Track

• Blurred central vision
• Wavy lines
• Reading difficulty
• Unequal image size
• Ghosting
• Depth-perception problems
• Reduced driving confidence
• Increasing dependence on the other eye

Tests That May Be Used

• Visual acuity
• Refraction
• Amsler grid
• Dilated retinal examination
• OCT
• Fundus photography
• Metamorphopsia testing
• Aniseikonia assessment

Questions to Ask

• Is the membrane the main cause of my symptoms?
• Is the OCT stable?
• Is the outer retina healthy?
• Do I also have a cataract?
• What improvement is realistic?
• How much distortion may remain?
• Will the ILM be peeled?
• Is gas likely to be used?
• How quickly might a cataract progress?
• Should cataract surgery be combined or staged?
• What are my individual retinal risks?

The Bottom Line

An epiretinal membrane is a thin layer of tissue that develops over the macula.

It may cause:

• Blurred central vision
• Wavy or distorted lines
• Unequal image size
• Ghosting
• Difficulty reading
• Reduced binocular comfort
• Poor depth perception

Many mild membranes remain stable and require only monitoring.

OCT is the key imaging test because it shows:

• The membrane
• Retinal thickening
• Loss of the foveal contour
• Retinal-layer distortion
• Photoreceptor health
• Associated vitreomacular traction or macular holes

Eyedrops, vitamins, glasses and laser cannot remove the membrane.

When symptoms significantly interfere with daily life, treatment involves:

• Pars plana vitrectomy
• Epiretinal-membrane peeling
• Frequently, internal limiting membrane peeling

Most appropriately selected patients experience improvement in vision, distortion or functional quality of life, but recovery is gradual and complete restoration of normal vision cannot be guaranteed.

The decision to operate should not be based solely on retinal thickness or a single eye-chart measurement.

The most important question is:

“How much is the membrane affecting the way I actually see and function—and is the expected benefit of surgery greater than its risks?”

References

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