Macular pucker also known as epiretinal membrane is a scar tissue that develops on top of the retina. When it forms over the macula, it can cause blurriness and distortion in the central vision.

Overview

The retina is a layer of photoreceptor cells and glial cells at the back of the eye that captures light entering the eye and converts it into images.

The macular pucker, also known as epiretinal membrane (ERM) or cellophane maculopathy, develops as a thin layer of scar tissue or membrane on the retina's surface when the vitreous gel inside the eye undergoes age-related changes, causing superficial irritation in the retina.

This happens as part of the healing response and can cause slight shrinking, leading to mechanical wrinkling and distortion of the retina. 

In most patients, the scar tissue grows very slowly and eventually stops growing. These membranes are usually clear, and in many people do not produce any significant disruptions in vision. 

Sometimes, a thicker membrane may form over time, contracting and pulling on the retina, resulting in a wrinkled appearance. This can cause central vision to become blurred, with noticeable distortions in lines or letters. Surgery for macular pucker may be necessary to remove the membrane and correct the vision.¹ Macular pucker is distinct from age-related macular degeneration.

The article discusses symptoms, causes, diagnostic methods, and available treatments for macular pucker.

Symptoms and causes 

What are the symptoms of macular pucker?

Most patients with macular pucker do not experience symptoms; their epiretinal membranes are often discovered incidentally during routine eye exams, such as dilated retinal exams or non-invasive ocular coherence tomography (OCT). In such cases, patients have a normal or near-normal vision. However, epiretinal membranes can slowly progress, resulting in a vague visual distortion that becomes more noticeable when the non- or less-affected eye is closed. 

Patients may experience metamorphopsia, a symptom that causes visual distortion. In advanced cases, this can result in decreased vision. 

Occasionally, epiretinal membranes may also be associated with double vision, light sensitivity, or images appearing larger or smaller than they are.

On rare occasions, a macular pucker can result in severe vision loss or lead to a related eye condition called a macular hole.

What causes a macular pucker?

The primary cause of macular pucker is often attributed to a condition related to ageing known as posterior vitreous detachment (PVD). With ageing, the vitreous, the gel that fills the eye shrinks and detaches from the retina. 

In some people, a membrane forms on the retinal surface. This membrane can create wrinkles or “pluckers.” If the membrane develops over a part of the retina known as the macula, it can cause a macular pucker. If there is no specific cause apart from the PVD, the macular pucker is called idiopathic (of uncertain origin).

A macular pucker can be associated with several eye-related conditions such as: 

• Prior retinal tears or detachment
• Retinal vascular diseases ( diabetes-retinopathy or venous occlusive disease)
• Post-traumatic (following eye surgery)
• Intraocular (inside the eye) inflammation.

What are the risk factors for macular pucker?

In addition to ageing, additional risks of macular pucker include:

• Separation of the vitreous from the retina.
• Past laser eye therapy or eye surgery like cataract surgery.
• Retinal tear or detachment.
• Uveitis or eye inflammation.
• Diabetes-related retinopathy.
•  Severe eye injury.

Diagnosis

How is macular pucker diagnosed?

An eye care provider will do a detailed eye exam after asking patients about symptoms and taking a medical history. They’ll use eye drops to dilate the eyes so the retina is more visible.

What tests are used to diagnose macular pucker?

They may also use the following tests to diagnose macular pucker:

Amsler grid eye test is used to check whether lines appear wavy or distorted, or if there are any missing areas of the visual field.

Optical coherence tomography (OCT) is a non-invasive imaging test that uses light waves to capture cross-sectional images of the retina. With OCT, the eye care provider can visualize the layers of the retina, enabling them to map and measure their thickness.

These measurements aid in the diagnosis of the condition, but also in diagnosing other conditions such as glaucoma, as well as other retinal diseases like age-related macular degeneration (AMD) and diabetic eye disease.

Occasionally, additional tests such as fluorescein angiography can used to identify if other underlying retinal conditions have caused the macular pucker.

Treatment and prognosis

How is macular pucker treated?

Most people may not need treatment for macular pucker but may instead require monitoring of the condition. In cases where treatment is necessary, there are non-invasive and surgical options.

Non-invasive treatments for macular pucker

• A new prescription for eyeglasses may help optimise the overall vision, but they cannot correct the issues caused by macular pucker
• Good lighting, such as reading lamps
• Magnifying devices

Surgical treatments for macular pucker

There are two different types of surgery: 

• Vitrectomy: Surgical removal of the vitreous gel from the centre of the eye 
• Membranectomy: Procedure during which the surgeon removes the membrane of the retina
• Vitrectomy carries a low risk of complications, with approximately 1 in 100 patients developing retinal detachment while about 1 in 2000 may develop an infection after surgery. Patients who retain their natural lenses will develop accelerated progression of a cataract in the surgical eye following surgery.

Factors influencing visual outcome include:

• How long macule pucker has been present
• The degree of traction (or pulling)
• The cause of macular pucker. The prognosis for idiopathic macular pucker is better compared to eyes with previous retinal detachment or retinal vascular diseases

Surgery for macular pucker has a good outcome, and most patients experience improved vision and decreased metamorphopsia following vitrectomy.

Summary

Macular pucker is a scar tissue that forms on top of the retina. It is also known as epiretinal membrane or cellophane maculopathy. The retina is the part of the eye that reacts to light and converts it into images. A macular pucker doesn’t always cause significant problems with the vision, but it can sometimes distort the vision. The primary symptom is distorted central vision, where straight lines appear wavy. Another term for this type of distorted vision is metamorphopsia. The condition can also be associated with double vision, or it can cause the image from one eye to appear larger than the other. Causes of macular pucker include tears in the retina, eye trauma, infection, eye inflammation, prior eye surgery, prior history of retinal detachment, and diabetes-related retina disease. Eye care providers typically check for macular pucker during a dilated eye exam. They may also use additional tests like the Amsher grid eye test and Optical Coherence Tomography. Treatment is unnecessary for the majority of macular pucker cases. While a prescription for new eyeglasses won’t fix the issue, it can help optimize the overall vision. Surgical treatment may include vitrectomy and membranectomy. People may have vision problems with macular pucker, but it’s unlikely to cause blindness. A macular pucker is distinct from a macular hole.