a 73-year - old diabetic patient presented with a recent - onset visual decline od .
1a ] with mild non - proliferative diabetic retinopathy with no macular edema ; left fundus was normal .
optical coherence tomography ( oct ) revealed vitreomacular traction ; central macular thickness ( cmt ) was 630m [ fig .
1b ] . after obtaining an informed consent from the patient , he underwent vitrectomy , erm removal , and membrane peeling with dual staining : trypan blue dye 0.15% ( retiblue , aurolab , madurai , india ) for erm and brilliant blue g 0.05% ( ocublue plus , aurolab , madurai , india ) for internal limiting membrane .
4 weeks later , bcva had improved to 20/40 ; cmt was 379 m [ fig .
, bcva gradually declined to 20/60 with cmt increasing again to 412 m and recurrence of macular cystic changes [ fig .
the patient received intravitreal triamcinolone acetonide ( ivta , 4 mg/0.1 ml ) od . within 4 weeks , bcva recovered to 20/40 ( cmt : 323 m ) . over the next 10 weeks , the bcva improved to 20/20 od [ fig .
( a ) fundus od reveals macular epiretinal membrane , ( b ) horizontal oct scan reveals vitreomacular traction ; central macular thickness ( cmt ) is 630. note the central defect in the inner segment - outer segment ( is - os ) junction , ( c , d ) one month postoperatively , macula is free of membrane , oct shows partial recovery of foveal contours ( cmt : 379 ) , ( e , f ) 2.5 months postoperatively , macula developed cystoid thickening ( cmt : 412 ) , ( g - h ) six months postoperatively , macular edema resolved ( cmt : 319 ) , with an intact is - os junction and external limiting membrane
persistence of macular edema after vitrectomy for erm removal is well - known ; and is generally attributed to chronic vascular leakage .
but recurrence of edema after an initial post - surgical resolution has been rarely reported .
we attempted treatment of recurrent macular edema with ivta on the basis that it would favorably affect macular edema due to both vascular and inflammatory etiologies .
remarkably , ivta did not merely restore the post - operative visual outcome , but improved it to 20/20 ; a rare event in erm surgery in spite of the excellent visual gains reported .
this outcome was obtained in spite of an interrupted inner segment - outer segment ( is - os ) junction in the pre - operative oct [ fig .
finally , visual recovery is reported to peak around 12 - 24 months after erm removal with reconstitution of is - os junction ; we obtained both the milestones much earlier , at 6 months postoperatively in this case .
konstantinidis et al used ivta routinely after vitrectomy for erm ; they reported excellent visual outcomes , which were obtained in a short time , as in our case .
however , proactive use of ivta as reported by these authors may invite other problems like secondary glaucoma and cataract ; and can be recommended as a default part of surgical protocol only after a head - to - head trial against vitrectomy without ivta for erm .
i propose a case for using ivta to enhance surgical outcome when residual or recurrent macular edema is observed after erm removal .
 a patient underwent successful vitrectomy for macular epiretinal membrane with anatomical and functional improvement . 
 10 weeks later , there was a recurrence of macular edema with corresponding visual decline . 
 an intravitreal injection of triamcinolone acetonide not only restored the macular anatomy but also improved the visual outcome beyond that achieved after surgery . 
Case Report
Discussion