A 68-year-old woman reports difficulty reading 2 weeks after uncomplicated cataract surgery. She is using topical steroid and NSAID eye drops. Anterior segment exam shows a clear cornea, well-positioned posterior chamber IOL, and clear posterior capsule. The view of the posterior segment preoperatively was limited due to a dense cataract. The right fundus is shown on the right.
What is the differential diagnosis?
Macular hole, pseudohole, lamellar hole, cystoid macular edema, vitreomacular traction syndrome, solar retinopathy, and exudative maculopathies.
What exam findings would be helpful to determine the correct diagnosis?
Visual acuity (reduced or normal), refraction (hyperopic shift in CME), Amsler grid testing (scotoma, metamorphopsia, or normal), dilated fundus examination with evaluation for a Watzke sign (absolute scotoma in a macular hole) and pathology in the fellow eye (solar retinopathy and exudative maculopathy).
What additional testing would you perform?
Optical coherence tomography (OCT) can distinguish among the various entities in the differential diagnosis, demonstrate any intraretinal abnormalities such as edema, thickening, traction, and subretinal fluid, and differentiate the stages of a macular hole.
Additional findings: the patient’s vision is 20/25 OD with a refraction of -0.25+0.50x165. The target refraction preop was -0.30 D. She notices some paracentral metamorphopsia on Amsler grid testing, and there is no Watzke sign on fundus examination. An OCT is obtained:
What is the diagnosis?
Epiretinal membrane with pseudohole
How would you treat this patient?
This patient has very good visual acuity and should be observed. She is at risk for CME due to the ERM and having undergone recent cataract surgery. Her topical steroid should be continued for at least 2 more weeks and the topical NSAID for at least 4-6 more weeks to help prevent CME. Pars plana vitrectomy and membrane peel can be considered for symptoms and visual acuity worse than 20/40.