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RPE Tear

Case Report of RPE Tear

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RPE Tear

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  1. Case presentation Presented By: Dr. MAB Dr. ABJ Dr. KSD

  2. A male patient, 76 years old • DOV in the right eye since 1 year back . OU Cataract surgery done • VA: OD: 6/24 with PH • OS: 6/9,N6 • IOP: OD: 18 mmHg OS: 20 mmHg • Anterior segment was WNL • OU:Pseudophakia

  3. Fundus:

  4. FFA: A large feeder net with temporal leakage s/o mature vessels

  5. OCT Before 1st injection OD: - SF I/R Fluid - Schitic Spaces - Retinal Thickening, - SF Scarring CNVM - PED OS: Normal Foveal DIP Drusenoid PEDs Close to Fovea FT: OD: 473 MICRONS OS: 200 MICRONS

  6. OD Post 1st injection OD Post 2nd injection OD Post 3rd injection OD Post 4th injection

  7. OD Post 5th injection OD Post 4th Inj. & Before 5th Inj. • OD Post 6th injection

  8. OS: Sequential OCT’s 28.08.2014 09.10.2014 01.01.2015 16.03.2015 14.05.2015 09.07.2015

  9. OD: Ranibizumab injection under TA Right eye showed good response to Ranibizumab OD: 6 Ranibizumab injection under TA last one on 22.May.2015

  10. On 9.July.2015 The patient came for regular follow up VA: OD: 6/18,N24 OS: 6/6,N6 IOP: OD:15 mmHg OS:16 mmHg Anterior segment was WNL OU: Pseudophakia

  11. Fundus:. OD: Stable OS: SRF at the fovea with increase in PED size

  12. OCT: 2539µ 383µ

  13. AF:

  14. FFA OS: Speckled fluorescence with single area of increased hyperfluorescence ST to the fovea

  15. OS: Ranibizumab injection under TA on 14.July.2015 • OS: 1st Day post injection Fundus showed RPE Tear + (small sparing fovea)

  16. OS: 3rd Day post injection Fundus showed RPE Tear + (progressed to involve fovea)

  17. On 30.July.2015

  18. On 31.August.2015 Vision in left had improved, though patient still c/o metamorphopsia in left eye Right eye stable VA: OD: 6/18,N18 OS: 6/9, N6 IOP: OD: 14 mmHg OS:14 mmHg Anterior segment was WNL OU Pseudophakia

  19. Fundus :

  20. OCT:

  21. RPE TEAR Associated conditions, incidences and Clinical features Investigations How does RPE Tear occur? Grading of RPE tear Risk factors What to be done if we have significant risk factors? Why it is more common in AMD compared to PCV? Fate of RPE tear Should we continue Anti VEGF Rx in patients with RPE tear? Prognostic indicators

  22. RPE tear- Associated conditions, incidences and Clinical features

  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 1981;65(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 1988;105:285–290.

  25. 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 • Chang LK, Sarraf D. Tears of the retinal pigment epithelium: an old problem in a new era. Retina 2007;27(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; 245:1037–40.

  26. Clinical features • 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 2007;27(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; 245:1037–40.

  27. FFA,ICG and OCT • FFA- Hyperfluorescence in area of bare choroid and hypofluorescence 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 hyperfluorescence in area of retracted RPE • 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 1997;123:377–385.

  28. OCT • Interruption of hyperreflective RPE layer with elevated or scrolled edge of torn RPE flap • Three configurations of retracted RPE- Dome shaped Pleated Tented • Increased reflectivity in area of bare choroid • Giovannini A, Amato G, Mariotti C, Scassellati-Sforzolini B. Optical coherence tomography in the assessment of retinal pigment epithelial tear. Retina 2000;20:37–40.

  29. How does RPE Tear occur

  30. Theories proposed • Increased intra PED hydrostatic pressure due to enlargement • Tangential forces on posterior surface of detached RPE Gass JD (1984) Pathogenesis of tears of the retinal pigment epithelium. Br J Ophthalmol 68:513–519

  31. Grading of RPE tear

  32. RPE tears grading based on the greatest length in the vector direction of the tear and involvement of the fovea using FA analysis Sarraf D, Reddy S, Chiang A, Yu F, Jain A. A new grading system for retinal pigment epithelial tears. Retina 2010;30(7):1039-1045.

  33. Risk factors

  34. Fibrovascular PED > Serosanguinous PED> Serous • Height of PED • Greatest linear dimension of PED • A Prospective study: • Incidence of RPE tear -14% • RPE tear + PED height >550μ-31% • RPE tear + PED height > 550μ + ring sign on FFA/Grade 1 tear- 67% • Hyperreflective linear lines on Near Infrared Imaging 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 2013;33(8):1551-1557.

  35. Clemens CR, Bastian N, Alten F, et al. Prediction of retinal pigment epithelial tear in serous vascularized pigment epithelium detachment. Acta Ophthalmol 2014;92:e50–56.

  36. What to be done if we have significant risk factors

  37. PED height >400 µm • Presence of hyperreflective lines in NIR images Pause anti- VEGF therapy Re-evaluate the lesion in 1–2 weeks Look for contraction of CNV membrane that has relaxed to some extent and to re-inject again. Chan et al. Optical coherence tomography–measured pigment epithelial detachment height as a predictor for retinal pigment epithelial tears associated with intravitreal bevacizumab injections. Retina 2010;30:203–11. Clemens CR, Bastian N, Alten F, et al. Prediction of retinal pigment epithelial tear in serous vascularized pigment epithelium detachment. Acta Ophthalmol 2014;92:e50–56.

  38. Why it is more common in AMD compared to PCV?

  39. 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 2007;143(5):883-885.

  40. Does Anti-VEGF predisposes to RPE tear

  41. RPE tear post anti VEGF injections • Bevacizumab, Ranibizumab, Pegabtinib, Aflibercept • 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 2007;27:523-534 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 2011;25:1181–86

  42. 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 2013;156(5):981-988.e982.

  43. FATE OF RPE TEAR

  44. Repair mechanism • Within 24 hours, the area where the RPE is absent becomes covered by hypopigmented RPE cells • Persistent SRF after an RPE tear may lead to subsequent repair with thickened proliferative tissue at the area where the RPE was lost • Early resolution of the SRF after the RPE tear, the • outer retina appeared to be directly attached to Bruch membrane.

  45. Persistent SRF and active CNV may result in the horizontal proliferation of the CNV membranes along Bruch membrane within the SRF at the area where the RPE was lost. • Weak leakage from inactive CNV may result in a rapid resolution of the SRF. In addition, inactive CNV may not cause any pooling of the SRF or cause any growth horizontally at the area where the RPE disappeared. As a result, this may lead to the attachment of the outer retina to Bruch membrane • An ingrowth of a faintly opaque tissue layer into the area of the tear, which gave the appearance of blunting of the edges of the tear.

  46. Mukai R, Sato T, Kishi S. Repair mechanism of retinal pigment epithelial tears in Age-related macular degeneration. Retina 35:473–480, 2015

  47. Mukai R, Sato T, Kishi S. Repair mechanism of retinal pigment epithelial tears in Age-related macular degeneration. Retina 35:473–480, 2015

  48. Should we continue Anti VEGF Rx in patients with RPE tear?

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