Should we use steroids as an adjuvant to epiretinal membrane peeling?

When there is significant visual impairment, epiretinal membranes are treated by pars plana vitrectomy (PPV) and epiretinal membrane peeling. First performed by Machemer in 1978, the surgery has recently evolved to include the use of certain pharmacologic agents to assist with the surgery. For example, triamcinolone acetonide (TA), an anti-inflammatory agent used to treat various inflammatory ocular diseases, has been used for visualization of the vitreous during PPV and for staining of the epiretinal membrane prior to peeling. Additionally, TA has been shown to facilitate fluid absorption from the edematous retinal tissue by both stimulating endogenous adenosine signaling in Muller cells and by downregulating vascular endothelial growth factor production. This suggests that the use of TA could be beneficial in the postoperative period for resolving macular edema and suppressing immune response, preventing the reproliferation of the membrane. One case series nonrandomized study by Hiroshi et al. noted that overall, intravitreal TA assisted vitrectomy patients had a lower incidence of reoperation compared to those without TA administration.

In our pilot study published prior, we evaluated patients treated with IVTA at the end of ERM surgery. Visual acuity three months after operation was improved in both groups of patients receiving intravitreal injection of TA and control group (p=0.001 for the TA and p=0.002 for control). However, there was no statistically significant difference in their final visual acuity between groups.

In addition, there are known risks associated with intravitreal TA administration. Previous reports have shown that complications include secondary ocular hypertension, development of cataract, and increase in intraocular pressure (IOP) post-operatively. And most recently, Sisk and colleagues report a series of patients who develop a triad of sterile endophthalmitis, atrophic retinal breaks under the depot IVTA in the inferior retina, and rhegmatogenous retinal detachment. All retinal detachment surgeries required silicone oil tamponade. Poor visual outcome at 6 months was common for eyes requiring PPV for RD repair. The photograph demonstrates a patient 1 week after surgery with an inferior retinal detachment from an atrophic retinal breaks with sterile endophthalmitis. Learn more in this month’s issue of OSLI-Retina.

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