Optimal timing for idiopathic ERM peeling based on pre-op visual acuity threshold
Reviewed by Sofia Rokerya

This single-centre retrospective study aimed to evaluate the efficacy and safety of vitrectomy-peeling for idiopathic epiretinal membrane (iERM) in patients with preserved preoperative best-corrected visual acuity (BCVA) compared to those with reduced BCVA, to determine the optimal preoperative VA threshold for surgical intervention. Epidemiological, surgical, and spectral domain optical coherence tomography data were collected preoperatively and at each follow-up visit for 415 eyes from 368 patients who underwent iERM surgery. These were carried out by the same surgeon between January 2019 and July 2023. Patients were divided into 3 groups based on preoperative BCVA using Early Treatment Diabetic Retinopathy Study (ETDRS) scale: poor ≤60 ETDRS, moderate (61–76 ETDRS) and good (≥77 ETDRS). The median age of the patients was 75 years (interquartile range (IQR) 71–81); 218 eyes were in female patients (52.5%). 203 (48.9%) were right eyes, with bilateral involvement in 49 patients. The median initial preoperative BCVA for the cohort was 75 ETDRS letters (IQR 70–80). The median central foveal thickness (CFT) was 409μm (IQR 358–456). At the time of diagnosis, all patients presented at least 1 symptom. These included loss of vision, metamorphopsia, central scotoma, macropsia, micropsia and diplopia. They were present alone or in combination. The median follow-up time was 18 weeks (IQR 6–60) after surgery, with a maximum range from 4 to 264 weeks (1–66 months). The primary outcome was final BCVA at the last visit. Secondary outcomes included analysing surgical complications and preoperative predictive factors to develop a predictive model of postoperative BCVA. The results showed that median preoperative BCVA was 75 ETDRS letters (IQR 70–80), improving significantly postoperatively to 80 ETDRS (IQR 75–85) (p<0.001). BCVA improved across all groups: from 60 to 67.5 (IQR 60–77) in the poor group (p<0.001), from 70 to 80 (IQR 75–83.5) in the moderate group (p<0.001), and from 80 to 82 (IQR 80–85) in the good group (p<0.001). The optimal preoperative BCVA threshold was 75 letters, through an iterative process increasing in 5 ETDRS letter increments, with no significant differences in complications between groups (p=0.81). This study demonstrates the benefit of performing vitrectomy and peeling surgery in patients with symptomatic iERM at an early stage. It showed that the best final BCVA was achieved in the good BCVA group, i.e. BCVA >75 ETDRS letters. Limitations mainly include its retrospective nature, and non-standardisation of its data. Mean follow-up period of the cohort was variable which may have introduced selection bias, influencing results. Additionally, symptom detection, such as metamorphopsia, was self-reported or by use of the Amsler grid during consultations, rather than validated tests like M-charts. Other symptoms, including monocular diplopia or macropsia/micropsia, were also reliant on patient reports during consultations. Furthermore, missing data from the patients’ medical records, such as the duration of symptoms, could not be analysed. The study cohort was recruited from a single tertiary centre treating severe cases, therefore, the question of monitoring or surgery in asymptomatic patients was not addressed. Strengths: large cohort, single centre, and single (experienced) surgeon intervention.

Optimal timing for idiopathic epiretinal membrane peeling surgery based on a preoperative visual acuity threshold.
Fricker J, Sejournet L, Allignet B, et al. 
OPHTHALMOLOGICA
2026;249(2):182–96.