a 31-year - old - male , a diagnosed case of stargardt disease [ fig . 1a and b ] on follow - up since 6 years presented with gradual diminution of vision in the right eye since 2 months . his best - corrected visual acuity ( bcva ) had dropped from 20/40 , n6 to 20/400 , n36 in the right eye while left eye was 20/40 , n6 as before . fundus examination revealed the presence of a thick erm with macular edema [ fig.1c ] . 1-month later macular thickness increased to 796 . no obvious vascular pathology was noted that could account for increased thickness . the rapid increase in the thickness of the retina could have been due to an attempt at spontaneous posterior vitreous detachment which did not occur . 1d ] and restoration of the foveal contour on sd - oct [ fig.2b ] and unchanged autofluorescence pattern [ fig.2c and d ] . at 6 months follow - up , bcva had improved to 20/120 n18 . ( a and b ) colour fundus picture of the postpole of right and left eyes of case 1 showing numerous flecks in the perifoveal area and posterior pole ( c ) colour fundus picture of the right eye 6 years later showing a thick epiretinal membrane at the macula . ( d ) postoperative colour fundus picture of the right eye showing absence of epiretinal membrane with retinal pigment epithelial atrophy at the macula ( a ) preoperative optical coherence tomography ( oct ) of case 1 showing increased macular thickness secondary to thick epiretinal membrane . ( c ) preoperative autofluorescence image showing hypoautofluorescence corresponding to central area of retinal pigment epithelial atrophy . ( d ) postoperative autofluorescence image showing no change in the hypoautofluorescent area a 24-year - old myopic male , a diagnosed case of stargardt disease [ fig . 3a ] on follow - up since 3 years with a bcva of 20/400 , n36 in both eyes , presented with sudden onset metamorphopsia in the left eye of 1-week duration . though , bcva was unchanged , fundus showed an erm causing traction on the macula with associated edema and subretinal hemorrhage [ fig . choroidal neovascular membrane was ruled out on fundus fluorescein angiography ( ffa ) [ fig . the ill defined leak seen on ffa could be due to traction on the capillaries , which is one of the causes for leakage in erms on ffa . on review 1-month sd - oct revealed thick erm with a taut posterior hyaloid and increased retinal thickness of 1198 microns [ fig . 25 g pars plana vitrectomy with erm removal was done . with an uneventful postoperative period , 3d and 5b ] and a slight increase in the hypoautofluorescence due to unfolding of the retina was noted [ figs . ( a ) colour fundus picture of right eye of case 2 patient at 3 years follow - up showing beaten metal appearance at the macula . ( b ) colour fundus picture of the left eye showing thick epiretinal membrane causing macular traction and associated with subretinal hemorrhage . ( c ) colour fundus picture of the left eye 1-month later showing further increase in the macular traction with resolution of subretinal hemorrhage . ( d ) postoperative colour fundus picture at 5 month follow - up showing traction relief at macula with retinal pigment epithelial atrophy colour photograph and fundus fluorescein angiography ( ffa ) images of second patient showing the epiretinal membrane with traction and hemorrhage . ffa shows an ill defined leak from distorted capillaries , temporal to the fovea and late staining in the foveal region . no choroidal neovascular membrane can be made out ( a ) preoperative optical coherence tomography picture showing increased macular thickness due to thick epiretinal membrane . ( b ) postoperative optical coherence tomography picture showing restoration of foveal contour with foveal thinning . ( c ) preoperative autofluorescence image showing an area of hypoautofluorescence corresponding to area of retinal pigment epithelium atrophy . ( d ) postoperative autofluorescence image showing an apparent increase in the hypoautofluorescence due to unfolding of the retina a 31-year - old - male , a diagnosed case of stargardt disease [ fig . 1a and b ] on follow - up since 6 years presented with gradual diminution of vision in the right eye since 2 months . his best - corrected visual acuity ( bcva ) had dropped from 20/40 , n6 to 20/400 , n36 in the right eye while left eye was 20/40 , n6 as before . fundus examination revealed the presence of a thick erm with macular edema [ fig.1c ] . 1-month later macular thickness increased to 796 . no obvious vascular pathology was noted that could account for increased thickness . the rapid increase in the thickness of the retina could have been due to an attempt at spontaneous posterior vitreous detachment which did not occur . 1d ] and restoration of the foveal contour on sd - oct [ fig.2b ] and unchanged autofluorescence pattern [ fig.2c and d ] . at 6 months follow - up , bcva had improved to 20/120 n18 . ( a and b ) colour fundus picture of the postpole of right and left eyes of case 1 showing numerous flecks in the perifoveal area and posterior pole ( c ) colour fundus picture of the right eye 6 years later showing a thick epiretinal membrane at the macula . ( d ) postoperative colour fundus picture of the right eye showing absence of epiretinal membrane with retinal pigment epithelial atrophy at the macula ( a ) preoperative optical coherence tomography ( oct ) of case 1 showing increased macular thickness secondary to thick epiretinal membrane . ( c ) preoperative autofluorescence image showing hypoautofluorescence corresponding to central area of retinal pigment epithelial atrophy . a 24-year - old myopic male , a diagnosed case of stargardt disease [ fig . 3a ] on follow - up since 3 years with a bcva of 20/400 , n36 in both eyes , presented with sudden onset metamorphopsia in the left eye of 1-week duration . though , bcva was unchanged , fundus showed an erm causing traction on the macula with associated edema and subretinal hemorrhage [ fig . choroidal neovascular membrane was ruled out on fundus fluorescein angiography ( ffa ) [ fig . 4 ] . the ill defined leak seen on ffa could be due to traction on the capillaries , which is one of the causes for leakage in erms on ffa . on review 1-month sd - oct revealed thick erm with a taut posterior hyaloid and increased retinal thickness of 1198 microns [ fig . 25 g pars plana vitrectomy with erm removal was done . with an uneventful postoperative period , 3d and 5b ] and a slight increase in the hypoautofluorescence due to unfolding of the retina was noted [ figs . ( a ) colour fundus picture of right eye of case 2 patient at 3 years follow - up showing beaten metal appearance at the macula . ( b ) colour fundus picture of the left eye showing thick epiretinal membrane causing macular traction and associated with subretinal hemorrhage . ( c ) colour fundus picture of the left eye 1-month later showing further increase in the macular traction with resolution of subretinal hemorrhage . ( d ) postoperative colour fundus picture at 5 month follow - up showing traction relief at macula with retinal pigment epithelial atrophy colour photograph and fundus fluorescein angiography ( ffa ) images of second patient showing the epiretinal membrane with traction and hemorrhage . ffa shows an ill defined leak from distorted capillaries , temporal to the fovea and late staining in the foveal region . no choroidal neovascular membrane can be made out ( a ) preoperative optical coherence tomography picture showing increased macular thickness due to thick epiretinal membrane . ( b ) postoperative optical coherence tomography picture showing restoration of foveal contour with foveal thinning . ( c ) preoperative autofluorescence image showing an area of hypoautofluorescence corresponding to area of retinal pigment epithelium atrophy . ( d ) postoperative autofluorescence image showing an apparent increase in the hypoautofluorescence due to unfolding of the retina reports of spontaneous separation of idiopathic erms in the young as well as in a child with stargardt disease suggest observation rather than surgical intervention . though a compromised retinal structure hampers the expected results of surgical intervention , some visual improvement can be expected if the deterioration is mainly due to the erm . as both our patients were on regular follow - up , reduction in visual acuity corresponded to the development of a thick erm , which further progressed during the short period of observation . both on oct and intraoperatively case 1 had always had better vision than case 2 , and this patient had a significant improvement following surgery . subretinal fibrosis and hyperlipofuscinosis have been reported previously in these patients following blunt ocular trauma with resultant visual loss suggesting the need for protection from even minor ocular trauma . in our patients , there was no apparent surgical damage to the retinal pigment epithelium , which is depicted by the preoperative and postoperative autofluorescence images . in the second patient , an apparent increase in the area of hypoautofluorescence seen temporally could have been due to unfolding of the retina following release of traction caused by the erm . epiretinal membranes have been described in stargardt disease and observation rather than surgery has been one option in the past , with isolated reports suggesting limited improvement after surgery . our experience shows that visual improvement following surgery is possible in these eyes without compromise or worsening of the preexisting pathology .
epiretinal membranes ( erms ) in stargardt disease have been known to undergo spontaneous separation in children . 
 results of surgical intervention in adult patients with stargardt disease have rarely been reported . 
 a retrospective review of results of surgical intervention for erm causing visual impairment in two adult patients of stargardt disease was carried out . 
 both patients developed erm in one eye during their follow - up period with the resultant drop in their preexisting visual acuity . 
 postsurgery , restoration of foveal contour with some improvement in visual acuity was observed in both patients . 
 no adverse effect of surgery was noted .