The Photoreceptor Layer As a Prognostic Factor for

Visual Acuity in the Secondary Epiretinal Membrane

After Retinal Detachment Surgery: Imaging Analysis By
Spectral-Domain Optical Coherence Tomography
PANAGIOTIS G. THEODOSSIADIS, GEORGE P. THEODOSSIADIS, ALEXANDER CHARONIS,
IOANNIS EMFIETZOGLOU, VLASSIS G. GRIGOROPOULOS, AND VASILIOS S. LIARAKOS
PURPOSE: To study the prognostic factors that influence best-corrected visual acuity (BCVA) outcome in
patients with secondary epiretinal membrane (ERM)
after retinal detachment surgery.
DESIGN: Retrospective case series.
METHODS: Forty-two patients with ERM were divided
into macula-on and macula-off groups based on the
macular status before retinal detachment surgery and
were studied using the same spectral-domain optical
coherence tomography device. Several variables, including the integrity of the external limiting membrane
(ELM), the status of the photoreceptor inner segment/
outer segment (IS/OS) junction line, and central foveal
thickness were evaluated in 17 treated and 25 untreated
patients. Linear regression analysis was used to determine the best combination of all variables affecting
BCVA.
RESULTS: Final BCVA was significantly better in
macula-on and macula-off eyes with intact ELMs and
IS/OS junction lines (0.35 0.18 logarithm of the
minimal angle of resolution [logMAR] and 0.51 0.17
logMAR, respectively) than in macula-off eyes with
disrupted or absent ELMs and IS/OS junction lines
(0.83 0.17 logMAR and 1.04 0.05 logMAR,
respectively; P < .001, analysis of variance). Final
BCVA also was better in the treated group than in the
controls (0.55 0.31 logMAR and 0.73 0.26 logMAR, respectively; P .05, t test). ELM and IS/OS
junction line integrity were the main variables significantly affecting the final BCVA outcome ( 0.42;
P .006, linear regression analysis). Disruption of
the ELM and IS/OS junction line was observed in 21
of the 42 cases studied.
CONCLUSIONS: ERM secondary to retinal detachment
surgery is accompanied by a high incidence (50%) of
Accepted for publication Dec 31, 2010.
From the Attikon University Hospital, 2nd Department of Ophthalmology, University of Athens, Athens, Greece (P.G.T., A.C., V.S.L.);
and the 2nd Department of Ophthalmology, Henry Dynan Hospital,
Athens, Greece (G.P.T., I.E., V.G.G.).
Correspondence to George P. Theodossiadis, 13 Lykiou Street, 10674
Athens, Greece; e-mail: theodossiadisg@ath.forthnet.gr
0002-9394/$36.00
doi:10.1016/j.ajo.2010.12.014

2011 BY

IS/OS junction line and ELM disruption. Among the

variables studied, the condition of the IS/OS junction
layer and the ELM are the main factors that predict final
BCVA after ERM peeling. (Am J Ophthalmol 2011;
151:973980. 2011 by Elsevier Inc. All rights
reserved.)

PIRETINAL MEMBRANE (ERM) FORMATION MAY FOL-

low retinal detachment (RD) surgery, thus affecting

visual function outcome. Pathogenesis includes proliferation of retinal pigment epithelium (RPE) cells, retinal
glia, perivascular connective tissue, and hyalocytes.1,2 In
accordance with the Gass classification, ERMs were characterized as either cellophane maculopathy (CM) or macular pucker (MP).3 ERMs develop in approximately 6%4 to
7%5 of eyes with primary rhegmatogenous RD after successful surgical repair with a scleral buckle (SB). A higher
incidence of ERM formation (12.8%) has been found after
pars plana vitrectomy (PPV), with one third of these
patients undergoing reoperation for membrane peeling.6
Wilkins and associates first described structural distortion
of the macula resulting from ERM using optical coherence
tomography (OCT) and proposed an initial categorization.7 In subsequent years, OCT became more sensitive
than clinical examination in detecting and monitoring
ERMs.8,9
Peeling of an ERM secondary to primary RD surgery
contributes to anatomic restoration of the macula. However, visual acuity does not always improve proportionally
as a result. Although most patients show an improvement
in visual acuity after ERM removal, 12% do not, despite
good anatomic restoration of the macula.10
The purpose of this study was to use high-resolution
OCT to investigate foveal microstructural changes, in
particular changes in the status of the external limiting
membrane (ELM) and inner segment/outer segment
(IS/OS) junction line in the photoreceptor layer, in
secondary ERMs after successful RD surgery and to
evaluate visual outcomes after ERM peeling by PPV. A
further aim was to determine possible prognostic factors

ELSEVIER INC. ALL

RIGHTS RESERVED.

973

Off

ANOVA analysis of variance; BCVA best-corrected visual acuity; CFT central foveal thickness; ERM epiretinal membrane; IS/OS inner segment/outer segment; logMAR logarithm
of the minimal angle of resolution; RD retinal detachment; SD standard deviation.
a
Not significant (P 1, Bonferroni post hoc analysis).
b
Not significant (P .2, Bonferroni post hoc analysis).

225.30 30.11
0
0
292.18 30.70
349.00 112.07
431.00 42.20
314.43 106.32
P .001
0.35 0.18b
0
0
0.51 0.17b
0.83 0.17
1.04 0.05
0.66 0.29
P .001
270.90 97.31
0
0
303.18 103.62
362.06 126.98
444.60 52.90
334.76 117.87
P .024
Intact (n 10)
Disrupted (n 0)
Absent (n 0)
Intact (n 11)
Disrupted (n 16)
Absent (n 5)
1A
1B
1C
2
2A
2B
2C
Average (n 42)
One-way ANOVA
1
On

Subgroups
Groups
Macula Status
(before RD Surgery)

2.7 1.4
0
0
10.0 6.6
30.3 27.6
48.0 21.7
20.5 23.9
P .001

0.55 0.80a
0
0
0.48 0.15a
0.78 0.16
1.12 0.13
0.69 0.25
P .001

7:3
0
0
4:7
5:11
1:4
17:25
P .171

Final CFT (m),

Mean SD
Final BCVA
(LogMAR),
Mean SD
ERM Peeling
(Yes:No)
CFT with the ERM
(m),
Mean SD
BCVA with the
ERM
(LogMAR),
Mean SD
Duration of
RD (Days),
(Mean SD)
Photoreceptor IS/OS
Junction Layer Status
(When ERM Was
Diagnosed)

TABLE 1. Characteristics of Cases with Secondary Epiretinal Membrane after Successful Primary Retinal Detachment Surgery

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regarding visual outcomes of ERM surgery using modern

OCT technology.

AMERICAN JOURNAL

METHODS
THE MEDICAL RECORDS OF 451 CONSECUTIVE RD PATIENTS

who underwent surgery from July 2007 through December

2009 were evaluated retrospectively. Only cases with an
anatomically successful primary operation were included in
this retrospective study. RD cases treated with pneumatic
retinopexy, patients with lens opacities graded above N03
or NC3 according to the Lens Opacities Classification
System III11 at any point during the study, and eyes with
concomitant diseases at presentation or during follow-up,
such as diabetic retinopathy, age-related macular degeneration, various maculopathies, or uveitis, were excluded.
Cases with best-corrected visual acuity (BCVA) worse
than 20/200 after initial RD surgery also were excluded
because a BCVA of at least 20/200 was required to achieve
sufficient target fixation during examination with highresolution spectral-domain (SD) OCT.
Finally, 389 patients met the inclusion criteria, each of
whom had been operated on either with an SB or with
standard PPV without dye in 2 different centers by
different surgeons (P.G.T., G.P.T., A.C., V.G.). Routine
follow-up after initial RD surgery revealed the formation of
an ERM in 42 patients 1 to 3 months after surgery.
SPECTRAL-DOMAIN OPTICAL COHERENCE TOMOGRAPHY EXAMINATION: ERM was diagnosed both clinically,

using fundus examination after pupil dilation, and using

SD-OCT examination. The same SD OCT device was
used in all cases (Cirrus HD-OCT; Carl Zeiss Meditec, Inc,
Dublin, California, USA). This SD OCT device provides
noninvasive, cross-sectional imaging of the tissues using an
830-nm wavelength light source. It allows an ultra-high
scan speed of 27 000 A scans per second, resulting in an
axial resolution of 5 m and a transverse resolution of 15
m. A raster line protocol consisting of 5 parallel highresolution scan lines was used for qualitative evaluation of
the fovea. Additional horizontal and vertical crosshair
scan lines were obtained (a minimum of 3 were obtained in
each direction). The precise position of scan lines was
displayed on high-definition fundus images captured simultaneously. The macular thickness protocol resulting in a
macular cube (512 128 scans) was used for quantitative
evaluation of macular thickness. Central foveal thickness
(CFT) was determined as the value of the innermost
central circle (1000 m in diameter) in the macular
thickness protocol. BCVA and CFT changes were assessed.
PHOTORECEPTOR LAYER EVALUATION: Retinal microstructure was evaluated in detail, with special emphasis
placed on the integrity of the ELM and the photoreceptor
IS/OS.1215 The ELM and the photoreceptor IS/OS juncOF

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tion line were evaluated based on horizontal and vertical

scans for 500 m in either direction of the center of the
fovea and were identified either as intact, disrupted, or
completely absent. When the IS/OS junction line was
continuous, it was characterized as intact. When it was
interrupted by gaps shorter than 200 m, it was characterized as disrupted. When the gaps were 200 m or longer,
it was characterized as absent. The status of the ELM and
the IS/OS junction line were confirmed using a minimum
of 2 horizontal or vertical crosshair scan lines. Evaluation
was accomplished using the same masked OCT specialist
(V.S.L.).
GROUP FORMATION:

To evaluate final visual outcomes

in relation to foveal microstructure, patients with secondary ERM (n 42) initially were divided into 2 groups: the
macula-on group, with an attached fovea before initial RD
surgery, and the macula off group, with a detached fovea
before initial RD surgery. These groups were divided
further according to the ELM and the photoreceptor IS/OS
junction layer status (intact, disrupted, or absent) as
evaluated based on the SD OCT results (Table 1).
A second operation for ERM peeling was proposed to all
patients. Treated eyes underwent PPV (standard 3-port
PPV without using dye) with membrane peeling and
simultaneous lens extraction within 3 months after ERM
was diagnosed (treated group). The remaining patients,
who were reluctant to undergo a second operation, served
as controls (untreated group).
PARAMETERS ASSESSED:

Visual acuity before and after

RD surgery, duration of RD from the onset of symptoms
until surgery (time elapsed) and macular status (macula on
or macula off) were evaluated retrospectively. The extent
of RD was measured in quarters of the retina. BCVA and
CFT were measured before and after ERM removal. Foveal
thickness, presence of subretinal fluid, IS/OS junction
layer integrity, ELM status, and RPE changes were assessed
using the same SD OCT device.
FOLLOW-UP PROTOCOL: Treated eyes with ERM peeling were examined after surgery on day 1, at 1 and 2 weeks
and at 1, 3 and 6 months. Untreated eyes were examined
in the first, third, and sixth months after the ERM was
diagnosed. All patients included underwent a 6-month
follow-up examination. Final BCVA and final foveal
thickness were determined in the treated group as BCVA
and CFT 6 months after ERM peeling and in the untreated
(control) group as BCVA and CFT 6 months after the
ERM was diagnosed. During follow-up, all patients underwent detailed ophthalmic examination including BCVA
(logMAR), slit-lamp examination after pupil dilation, and
SD OCT. For statistical analysis, BCVA was measured
using a Snellen chart and was analyzed based on a
logarithm of minimal angle of resolution (logMAR) scale.

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IN

LogMAR values of 2.0 and 3.0 were assigned for counting

fingers and hand movements, respectively.16
All examinations performed adhered to the tenets of the
Declaration of Helsinki and European legislation. The
study was approved by the Institutional Scientific Board of
Attikon University Hospital and Henry Dunant
Hospital.
STATISTICAL ANALYSIS:

Statistical analysis was performed using SPSS software version 13.0 (SPSS inc,
Chicago, Illinois, USA). A number of factors (independent variables) related to the target variable assessed (i.e.,
final BCVA) were evaluated, for example, BCVA before
RD surgery, time elapsed between RD appearance and
surgery, macular status (macula on or off), RD extension,
the procedure chosen (SB or PPV), ERM type (CM or
MP), CFT after ERM formation, ELM and IS/OS junction
status, and peeling (or not) of the ERM. We assumed that
final BCVA was not affected by each factor independently,
but rather by a combination of several factors. Therefore,
linear regression analysis was conducted to determine the
best linear combination of all independent variables assessed, as indicated.17 A hierarchical approach was chosen to correct multicollinearity. We examined whether
the combination of these factors could predict final
BCVA. Additionally, we evaluated the impact of each
of the independent variables. Multifactorial analysis of
variance (ANOVA), one-way ANOVA with Bonferroni post hoc analysis, and unpaired and paired t tests
also were used as appropriate. Statistical significance was
determined as P .05.

RESULTS
THE STUDY INCLUDES 42 CASES. THE MEAN AGE OF THE

patients was 63.5 6.4 years (mean standard deviation); 17 (40.5%) were male and 25 (59.5%) were female.
When RD was diagnosed, the mean BCVA of the 42
patients in whom secondary ERM subsequently developed
was 0.78 0.57 logMAR (mean standard deviation); 27
(64%) were phakic, and the rest were pseudophakic. Time
elapsed from the onset of symptoms until RD surgery was
20.5 23.9 days; 10 RDs (10/42; 23.8%) were macula on
and 32 (32/42; 76.2%) were macula off at the time of RD
surgery; 2.6 1.2 quarters of the retina were detached; 10
RDs (10/42; 23.8%) were operated on using an SB procedure and 32 (32/42; 76.2%) were operated on with PPV.
Peripheral proliferative vitreoretinopathy (PVR) sparing
the macula was observed in 5 cases (5/42; 11.9%). Any
existing vitreoretinal traction was removed in all cases
during initial PPV. Subretinal fluid was seen in 4 cases
(4/42; 9.5%) subfoveally after primary SB, and this resolved spontaneously within 4 months. Submacular RPE
atrophies also were noted in another 2 cases (2/42; 4.7%).
When ERM first was observed after initial RD surgery,

SECONDARY ERM AFTER RD SURGERY

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BCVA best-corrected visual acuity; CFT central foveal thickness; ERM epiretinal membrane; logMAR logarithm of the minimal angle of resolution; PPV pars plana vitrectomy;
RD retinal detachment; SD standard deviation.

P .003 (paired t test)

P .86 (paired t test)
291.82 100.45
329.80 109.43
P .26 (t test)
0.55 0.31
0.73 0.26
P .0503 (t test)
0.70 0.24
0.68 0.26
P .8 (t test)
Treated (n 17)
Untreated (controls; n 25)

PPV ERM Peeling

BCVA with the ERM

(LogMAR), Mean SD

Final BCVA (LogMAR),

Mean SD

P .001 (paired t test)

P .003 (paired t test)

343.65 124.77
328.72 115.17
P .69 (t test)

Final CFT (m), Mean SD

CFT with the ERM (m),
Mean SD

CFT Change in Treated and Not Treated Eyes

BCVA Change in Treated and Not Treated Eyes

TABLE 2. Secondary Epiretinal Membrane after Successful Primary Retinal Detachment Surgery

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FIGURE 1. (Top) Spectral-domain optical coherence tomography (SD OCT) images from a 62-year-old woman with secondary epiretinal membrane (ERM)macular pucker diagnosed 2
months after successful macula-off retinal detachment surgery.
The photoreceptor inner segment/outer segment (IS/OS) junction line and the external limiting membrane (ELM) were
disrupted extensively subfoveally (white arrowheads), resulting
in a best-corrected visual acuity (BCVA) of 20/200. (Bottom)
Six months after vitrectomy with ERM peeling, edema clearly
was resolved. However, the ELM and IS/OS junction line
remained disrupted subfoveally (white arrowheads), resulting
in a poor visual outcome (BCVA was 20/100 after surgery).

the mean BCVA was 0.69 0.25 logMAR (mean

standard deviation), and the CFT was 334.76 117.87
m (mean standard deviation; Table 1). The ERM had
the characteristics of MP in 37 eyes (37/42; 88%) and of
CM in 5 eyes (5/42; 12%). SD OCT revealed significant
correlation between macular status (on or off) and IS/OS
junction layer status (Pearson r 0.503; P .001).
Indeed, all 21 eyes with disrupted or absent IS/OS junction
layer had been diagnosed initially with macula-off RD
(21/42; 50%). BCVA was significantly lower in the macula-off group than in the macula-on group (0.73 0.26
logMAR vs 0.55 0.08 logMAR, respectively; P .002,
t test).
During follow-up of the 42 patients, macula-on and
macula-off cases with intact ELM and IS/OS junction line
had significantly better BCVA than did eyes with disrupted or absent IS/OS junction lines (P .001; Table 1).
Disruption or absence of the ELM and IS/OS junction
lines were found only after macula-off RD with delayed
initial repair. On the contrary, macula-on and macula-off
RDs treated without delay were characterized by an intact
IS/OS junction line (Table 1).
There was significant difference in BCVA between cases
with intact and disrupted or absent IS/OS junction lines
(P .001, one-way ANOVA), as shown in Table 1.
However, the difference between macula-on and maculaoff eyes with an intact IS/OS junction line was not
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FIGURE 2. (Top) Spectral-domain optical coherence tomography (SD OCT) image from a 67-year-old woman with secondary
epiretinal membrane (ERM) cellophane membrane diagnosed 45
days after successful macula-on retinal detachment surgery. The
photoreceptor inner segment/outer segment (IS/OS) junction
line and the external limiting membrane (ELM) were intact
subfoveally (white arrowheads) and best-corrected visual acuity
(BCVA) was 20/50. (Bottom) Six months after vitrectomy
with ERM peeling, edema had resolved. The ELM and IS/OS
junction line remained intact subfoveally, resulting in a satisfactory visual outcome (BCVA was 20/30 after surgery).

statistically significant (P .2, Bonferroni post hoc analysis). CFT also was significantly higher in macula-off eyes
with disrupted or absent IS/OS junction lines than in macula-on and macula-off eyes with an intact IS/OS junction
layers (P .001, one-way ANOVA). No change in IS/OS
junction layer status was noted during follow-up. In cases with
IS/OS junction layer disruption, both the ELM and the IS/OS
junction layer were involved. Eyes with an intact IS/OS junction
layer also were characterized by an intact ELM. During followup, a positive correlation was observed between IS/OS junction
layer integrity and BCVA.
Seventeen of the patients diagnosed with secondary
ERM (17/42; 40%) were reoperated with PPV and membrane peeling (treated group). No significant complications resulting in reduction of BCVA or macular distortion
were observed in treated eyes. In the remaining 25 patients
(25/42; 60%) who served as controls (untreated group),
the lens status remained unchanged during the 6-month
follow-up period. A comparison of treated and control cases
showed that BCVA improved significantly in treated eyes
after surgery (from 0.70 0.24 logMAR to 0.55 0.31
logMAR, respectively; P .001, paired t test), as shown in
Table 2. Mean final BCVA was better in treated eyes than in
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IN

control eyes (0.55 0.31 logMAR and 0.73 0.26 logMAR, respectively; P .0503, t test). Further analysis of the
BCVA in the treated eyes revealed that, despite general
improvement, the final BCVA remained unaltered in 5
eyes (BCVA 20/100). In all of these eyes, SD OCT
showed disruption or absence of the ELM and the IS/OS
junction layer (Figure 1). On the contrary, BCVA decreased in the untreated controls during follow-up (from
0.68 0.26 logMAR to 0.73 0.26 logMAR; P .003,
paired t test). Additionally, CFT was reduced significantly
in treated eyes (from 343.65 124.77 m to 291.82
100.45 m; P .003, paired t test), whereas CFT
remained unaltered in the untreated eyes (Table 2).
During follow-up, we observed that the status of IS/OS
junction layer and ELM remained unaltered in both
treated and untreated cases (Figure 2).
Linear regression analysis was conducted to evaluate the
impact of all possible factors with regard to final BCVA
(BCVA at 6 months). The coefficients evaluated were:
time elapsed to primary RD repair, initial macular status
(macula on or off), initial procedure chosen (SB or PPV),
the type of ERM (cellophane membrane or macular
pucker), ELM and IS/OS junction layer status (intact,
disrupted, or absent), ERM peeling, and CFT at 6 months.
Analysis showed that the combination of all these factors
significantly predicted final BCVA (adjusted R2 0.726;
F(6, 35) 19.106; P .001, multifactorial ANOVA).
The plot of regression standardized residuals showed good
agreement between the expected cumulative probability
and observed cumulative probability. Analysis of the coefficients ( weights) suggested that the ELM and IS/OS
junction layer status was the major factor determining final
BCVA ( 0.42; P .003, linear regression analysis).
Time elapsed to primary repair also was statistically significant ( 0.29; P .012; linear regression analysis)
compared with the remaining coefficients.

DISCUSSION
THE INCIDENCE OF SECONDARY ERM AFTER PRIMARY RD

surgery in our patients was consistent with that reported in

the literature.1,4 6 Secondary ERM was diagnosed in
7.17% of the SB group and in 12.57% of the PPV group.
According to the Blue Mountains Eye Study, the prevalence of ERM formation in the general population older
than 49 years is 5.3%, with 5-year cumulative incidence
rates of 1.5% and 3.8% for MP and CM, respectively.18 In
another study, the prevalence in a general white population older than 40 years was found to be 7.9%.19 Dispersion of RPE cells through the retinal break into the
vitreous cavity is considered to be the major cause of ERM
formation, secondary to RD.2,4 In eyes with RD, ERM
histopathologic examinations have revealed predominantly pigment epithelial origin of the membrane.1

SECONDARY ERM AFTER RD SURGERY

977

In our study, we used the same SD OCT device in all

cases and at all visits, such that evaluation was uniform
and the results were comparable. SD OCT is a highresolution OCT that can differentiate fine structures or
structures with low contrast, such as the ELM or the IS/OS
junction layer.20 The interpretation of OCT images regarding the photoreceptor layer has been well documented
in the literature.2123 The highly reflective IS/OS junction
layer is clearly visualized parallel to the RPE backreflection
toward the vitreous cavity.12 The backreflection from the
ELM represents the border between the outermost part of
the outer nuclear layer, which is composed of the cell
bodies and inner segment myoid portions of the photoreceptors. Artifacts caused by the presence of a thick ERM or
excessive macular edema could not be precluded. However, recent clinical research confirms that SD OCT allows
for the precise visualization of intraretinal morphologic
features such as the ELM and the photoreceptor layer,14
thereby enabling reliable evaluation of the IS/OS junction
line even in the presence of a thickened retina caused by
an ERM.12,13,15,24 Additionally, we performed repeated
scans to preclude acquisition mistakes. Three recent studies evaluating the role of the photoreceptor IS/OS junction
layer after ERM formation13,15 and the course after ERM
peeling14 included only primary ERMs. The present study
comprises only ERMs induced by RD surgery. As far as we
know, secondary ERMs have not been evaluated in conjunction with photoreceptor status. Secondary ERMs are
characterized by different histopathologic features25; different expression levels of specific cytokines, growth factors, or both26 28; and by more severe mechanical traction
resulting from focal adhesion to the retina.29 Subsequently,
the course and prognosis of secondary ERMs may be
different than that of idiopathic ERMs.
In our study, the percentage of cases with disrupted ELM
and IS/OS junction layer was higher than that for idiopathic ERMs.13,14 This may be attributed to permanent
damage of the photoreceptors in macula-off RD cases,
especially those that were treated late. The increased
number of cases with ELM and IS/OS junction layer
disruption in secondary ERM is probably the result of the
prolonged presence of subretinal fluid and to irreversible
damage of the neurosensory retina. This finding agrees
with previous experimental studies that have shown photoreceptor degeneration immediately after RD and apoptotic changes that occur soon after, which are followed by
the progressive loss of photoreceptors in eyes with longstanding RDs.30 33
In the 42 cases studied here, the status of the macula on
the day of RD surgery is correlated strongly with the
condition of the photoreceptors (IS/OS junction layer
integrity) and final BCVA (P .001, Pearson R2).
However, in some macula-off cases (n 11/32), the IS/OS
junction layer was found to be intact, and therefore, ERM
surgery had a good prognosis regarding BCVA. Time
elapsed from the onset of RD symptoms and initial
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AMERICAN JOURNAL

operation seems to play a significant role in the final

condition of the photoreceptor IS/OS junction layer (Table 1). In our study, macula-off RDs that were operated on
shortly after the loss of central vision (10 days, on average)
were characterized by a better condition of the photoreceptor IS/OS junction layer after surgery compared with
the condition after delayed RD surgery (30 to 48 days on
average; Table 1). Subretinal fluid, which was seen subfoveally after primary SB, resolved spontaneously within 4 to
6 months, as observed in previous studies34, without
affecting IS/OS junction layer status. Peripheral PVR was
diagnosed in 5 eyes and was removed properly during
initial PPV. Central PVR cases involving the macula were
excluded because RD patients with various maculopathies
did not meet the inclusion criteria. The correlation between visual acuity after RD repair and the photoreceptor
OCT signal has been described previously.12,35,36 Poor
postoperative BCVA with a disrupted IS/OS junction layer
also was observed in a recent retrospective observational
study using high-resolution OCT.37 Nakanishi and associates recently showed that dropout or undulation of the
photoreceptor layer may reach 40% and 47%, respectively,
in macula-off RDs, as assessed using SD OCT.35 Such
conditions may affect postoperative BCVA. Lai and associates suggest that disruption of not only the IS/OS
junction layer, but also of the ELM, detected with SD
OCT, is associated significantly with poor postoperative
BCVA after successful repair of RD.36 In a recent study,
Wakabayashi and associates found that disruption of the
photoreceptor IS/OS junction layer was seen only in
macula-off eyes.12 They also concluded that the integrity
of the photoreceptor IS/OS junction layer and ELM signals
detected using SD OCT may account for visual restoration
in patients with preoperative macula-off RDs and that
preservation of the ELM after surgery may predict the
subsequent restoration of the photoreceptor layer.
Regardless of the percentage of ELM and IS/OS junction
layer disruption in primary (28%)13 and secondary ERM
(50% in our study), the impact of ELM and IS/OS junction
layer integrity on visual acuity seems to be the main
finding. This extends the significance of IS/OS junction
layer evaluation to secondary ERMs and provides further
evidence that the evaluation of the photoreceptor layer
with SD OCT may predict final foveal function regardless
of the cause of the ERM.
Of note, in all of the eyes we studied, the status of the
ELM was in accordance with the status of the IS/OS
junction line. Until recently, CFT was the main variable
assessed regarding preoperative evaluation of ERM peeling
outcomes. In our study, although CFT affects final BCVA
significantly, the integrity of the ELM and IS/OS junction
layer were of greater importance ( 0.02, P .862; and
0.42, P .006, respectively, linear regression analysis). It is worth noting that the ELM and IS/OS junction
layer status remained unaltered in treated and untreated
eyes during follow-up, given that final evaluation was
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limited to 6 months. BCVA increased in the treated group,

whereas it decreased in the untreated control eyes, although CFT and IS/OS junction layer status remained
unaltered. This may be attributed to anatomic changes in
the vitreoretinal interface because, in most cases, ERM had
the characteristics of MP.
The study was based on only 42 cases. This rather small
number of participants could be considered as a limitation
of this clinical investigation. However, evaluation of the
cases was uniform and the results were comparable because
the same OCT device was used in all patients and during
all visits. Therefore, the results of this study may help in
the prediction of BCVA in the presence of secondary
ERM, which is characterized by a high incidence (50%) of
disrupted IS/OS junction layer and ELM.

This study, based on linear regression analysis of the

factors that influence final BCVA, showed that the preoperative condition of the ELM and IS/OS junction layer is
the most important and significant factor affecting postoperative BCVA after secondary ERM peeling. The combination of preoperative BCVA, CFT, and ERM type also
were important, but were not as significant.
Conclusively, SD OCT findings provide valuable information regarding the evaluation and course of the ELM
and IS/OS junction layer in cases diagnosed with ERM
after primary RD repair. The integrity of the ELM and
IS/OS junction layer seems to be critical for predicting
final visual acuity.

THE AUTHORS INDICATE NO FINANCIAL SUPPORT OR FINANCIAL CONFLICT OF INTEREST. INVOLVED IN DESIGN OF STUDY
(P.G.T., G.P.T.); Conduct of study (P.G.T., G.P.T., A.C., I.E., V.G.G.); Collection and management of data (P.G.T., G.P.T., V.S.L.); Analysis and
interpretation (G.P.T., V.S.L.) of data; writing article (G.P.T., V.S.L.); Provision of materials (P.G.T., V.S.L.); Statistical expertise (V.S.L.); Literature
search (P.G.T., G.P.T., V.S.L.); and Critical revision (G.P.T.) and final approval (G.P.T.) of article. Every procedure was conducted in accordance with
the Declaration of Helsinki and all relative European Union and Greek laws and regulations.

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