Title: RPE Tear
1Case presentation
- Presented By
- Dr. MAB
- Dr. ABJ
- Dr. KSD
2- 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
3fundus
4FFA
a large feeder net with temporal leakage s/o
mature vessels
5OCT Before 1st injection
6- 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
7OD Post 3rd injection
OD Post 4th injection
8OD Post 4th Inj. Before 5th Inj.
Action Plan To be watch
9On 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
10Fundus.
- OS Has SRF at the fovea with increase in PED size
11OCT
12AF
- OS Speckled fluorscence with a single area of
increased hyperfluorescence ST to the fovea
13FFA
- OS Speckled fluorscence with a single area of
increased hyperfluorescence ST to the fovea
14- 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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16On 30.07.2015
17On 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
18Fundus
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20OCT
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22RPE tear In era of anti VEGF agents
23- 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.
24- 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.
25Theories 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
26RPE 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
27- 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.
28Clinical 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.
29- 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.
30- 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.
31AMD 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.
32FFA,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.
33Prognostic 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.
34- 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?
35Thanks