RPE Tear

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Case presentation

• Presented By
• Dr. MAB
• Dr. ABJ
• Dr. KSD

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• A male patient, 76 years old
• Main complaints DOV in the right eye since 1
  year back .

Past Ocular History OU Cataract surgery done
VA OD? 3/60,N36 ?6/24 with PH OS? 6/9,N6
IOP OD 18 mmHg OS 20 mmHg Anterior segment
was WNL OUPseudophakia
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fundus
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FFA
a large feeder net with temporal leakage s/o
mature vessels
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OCT Before 1st injection
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• Action Plan
• OD Ranibizumab injection under TA
•  
•  OD 6 Ranibizumab injection under TA last one
  on 22.05.2015
• The Right eye show good response for the
  injection and doing well now
• The following OCT tests done during follow up
  between injections and show good response for
  injection

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• OD Post 1st injection

• OD Post 2nd injection

OD Post 3rd injection
OD Post 4th injection
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OD Post 4th Inj. Before 5th Inj.
Action Plan To be watch

• OD Post 5th injection

• OD Post 6th injection

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On 9.7.2015
The patient came for regular follow up without
any ocular complaints VA OD? 6/18,N24 OS?
6/6,N6 IOP OD15 mmHg OS16 mmHg Anterior
segment was WNL OU Psuedophakia
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Fundus.

• OD Stable

• OS Has SRF at the fovea with increase in PED size

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OCT
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AF

• OS Speckled fluorscence with a single area of
  increased hyperfluorescence ST to the fovea

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FFA

• OS Speckled fluorscence with a single area of
  increased hyperfluorescence ST to the fovea

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• Action Plan
• OS Ranibizumab injection under TA
•  
•  OS Ranibizumab injection under TA monotherapy
  given on 14.07.2015
• On 15.07.2015
• OS 1st Day post injection Accentrix Fundus Show
  RPE RIP (small sparing fovea)
• On 18.07.2015
• OS 3rd Day post injection Accentrix Fundus
  Show RPE RIP progressing

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On 30.07.2015
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On 2015-08-31
The patient felt Vision dropped since three
months C/O metamorphopsia in left eye Right eye
stable VA OD? 6/18,N18 OS? 6/9,N8 ? BCVA 6/9,
N6 IOP OD 14 mmHg OS14 mmHg Anterior segment
was WNL
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Fundus
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OCT
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RPE tear In era of anti VEGF agents
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• First described by Hoskin et al
• Varied etiologies
• Trauma, CSC, Angioid streak, Myopia
• AMD
• PCV
• RAP

Hoskin A, Bird AC, Sehmi K. Tears of detached
retinal pigment epithelium. Br J Ophthalmol
198165(6)417-422.
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• Most commonly associated with neovascular AMD
• Can be spontaneous or associated with treatment
• Anti VEGF, PDT, Laser photocogaulation
• Incidence spontaneous tear rate 10-12
• Bilateral incidence 53

Chuang EL, Bird AC. The pathogenesis of tears of
the retinal pigment epithelium. Am J Ophthalmol
1988105285290.
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Theories proposed

• Increased intra PED hydrostatic pressure due to
  enlargement
• Tangential forces on posterior surface of
  detached RPE
• Stretched RPE- blow out tear

Goldstein BG, Pavan PR. Blow-outs in the retinal
pigment epithelium. Br J Ophthalmol
198771676681
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RPE tear post anti VEGF injections

• Bevacizumab, Ranibizumab, Pegaptinib,Afliberept
• Overall incidence 5-19.7
• Average number of injections before RPE tear 1.3
• Duration of appearance
• Earliest 1st day postoperative in our patient
  (Unpublished data)
• Literature 11 days after initial injection (Range
  11 days to 46.3 weeks)

Chang LK, Sarraf D. Tears of the retinal pigment
epithelium an old problem in a new era. Retina
200727523-534 M Gutfleisch et al. Long-term
visual outcome of pigment epithelial tears in
association with anti-VEGF therapy of pigment
epithelial detachment in AMD. Eye 201125118186
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• IOP shifts post anti VEGF injection
• Interruption of tight junction maintenance post
  anti VEGF
• Vitreomacular traction
• CTGF VEGF imbalance post anti VEGF

Nagiel A, Freund KB, Spaide RF, Munch IC, Larsen
M, Sarraf D. Mechanism of retinal pigment
epithelium tear formation following intravitreal
anti-vascular endothelial growth factor therapy
revealed by spectral-domain optical coherence
tomography. Am J Ophthalmol 2013156(5)981-988.e9
82.
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Clinical features

• Abrupt sudden onset loss of vision
• Clinically, a well demarcated area of bare
  choroid visible adjacent to hyperpigmented area,
  which is retracted, redundant retina
• Temporal edge of PED most commonly affected
• Often accompanied by subretinal
  hemorrhages,exudation or break through vitreous
  hemorrhage
• Initial course, good prognosis
• Long term follow up- progressive visual loss
• Depends of foveal involvement
• Foveal involvement incidence range 23-75

• Chang LK, Sarraf D. Tears of the retinal pigment
  epithelium an old problem in a new era. Retina
  200727(5)523-534.
• Gamulescu MA, Framme C, Sachs H. RPE-rip after
  intravitreal bevacizumab (Avastin) treatment for
  vascularised PED secondary to AMD. Graefes Arch
  Clin Exp Ophthalmol 2007 245103740.

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• RPE tears graded based on the greatest length in
  the vector direction of the tear and involvement
  of the fovea using FA analysis, a measurement of
  greatest linear diameter millimeter was obtained

Sarraf D, Reddy S, Chiang A, Yu F, Jain A. A new
grading system for retinal pigment epithelial
tears. Retina 201030(7)1039-1045.
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• Prospective study
• Incidence of RPE tear -14
• RPE tear PED height gt550µ-31
• RPE tear PED height gt 550µ ring sign on
  FFA/Grade 1 tear- 67

Sarraf D, Chan C, Rahimy E, Abraham P.
Prospective evaluation of the incidence and risk
factors for the development of RPE tears after
high- and low-dose ranibizumab therapy. Retina
201333(8)1551-1557.
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AMD v/s PCV

• More common in AMD 3.5 v/s 0.62 in PCV
• Pathogenesis differs
• Element of FVPED in AMD
• Anti VEGF causes fibrotic contraction ripping
  overlying RPE
• Large serosanguinous PED in PCV
• Vascular complexes in PCV may not contract enough
• AntiVEGF reduces leakage, but shrinkage of
  polypoidal dilatations hardly affected.
• Adhesions of PCV components to RPE might be weak
• Micro rips (7.1) at margin of PED reduces intra
  PED pressure and thereby frank RPE tear

• Shin et al. Pigment epithelial tears after
  ranibizumab injection in polypoidal choroidal
  vasculopathy and typical age-related macular
  degeneration. Graefes Arch Clin Exp Ophthalmol
  DOI 10.1007/s00417-015-2977-3
• Musashi K, Tsujikawa A, Hirami Y, et al.
  Microrips of the retinal pigment epithelium in
  polypoidal choroidal vasculopathy. Am J
  Ophthalmol 2007143(5)883-885.

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FFA,ICG and OCT

• FFA-Hyperfluoresecence in area of bare choroid
  and hypofluoresence in area of retracted and
  elevated RPE flap
• No leak in area of bare choroid-Atrophy of
  choriocapillaris
• ICG- Normal choroidal fluorescence in area of
  bare choroid and varying degrees of
  hyperfluoresence in area of retracted RPE
• OCT- Interrruption of hyperreflective RPE layer
  with elevated or scrolled edege of torned RPE
  flap
• Three configurations of retracted RPE-Dome
  shaped, pleated, tent like
• Increased reflectivity in area of bare choroid

• Arroyo JG, Schatz H, McDonald R, Johnson RN.
  Indocyanine green videoangiography after acute
  retinal pigment epithelial tears in age-related
  macular degeneration. Am J Ophthalmol
  1997123377385.
• Giovannini A, Amato G, Mariotti C,
  Scassellati-Sforzolini B. Optical coherence
  tomography in the assessment of retinal pigment
  epithelial tear. Retina 2000203740.

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Prognostic indicators

• Pre injection PED height gt400 µ
• PED height predicts RPE tear risk with 85
  sensitivity and 92 specificity
• GLD of PED- 5 mm
• PED duration lt4.5 months- Predicts RPE tear risk
  with 77 sensitivity and 98 specificity
• Additional prognostic factor-Fibrovascular
  scarring and atrophy in RPE free area
• Fibrovascular-poorer prognosis

• Chan et al. Optical coherence tomographymeasured
  pigment epithelial detachment height as a
  predictor for retinal pigment epithelial tears
  associated with intravitreal bevacizumab
  injections. Retina 20103020311.
• Doguizi and Ozdek. Pigment epithelial tears
  associated with anti-VEGF therapy. Incidence,
  long-term visual outcome, and relationship with
  pigment epithelial detachment in age-related
  macular degeneration. Retina 2014 34115662.
• Sarraf D, Chan C, Rahimy E, Abraham P.
  Prospective evaluation of the incidence and risk
  factors for the development of RPE tears after
  high- and low-dose ranibizumab therapy. Retina
  201333(8)1551-1557.

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• Does anti VEGF cause RPE tear?
• Why it is more common in AMD?
• What are the risk factors? Height and GLD
• What is the prognosis?
• What is the further course of treatment?

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Thanks