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RPE Tear
RPE Tear
Presented By:
Dr. MAB
Dr. ABJ
Dr. KSD
A male patient, 76 years old
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
OD Post 1st injection OD Post 2nd injection
01.01.2015 16.03.2015
14.05.2015 09.07.2015
•OD: Ranibizumab injection under TA
Right eye showed good response to Ranibizumab
VA:
OD: 6/18,N24
OS: 6/6,N6
IOP:
OD:15 mmHg
OS:16 mmHg
Anterior segment was WNL
OU: Pseudophakia
Fundus:
.
2539µ
383µ
AF:
FFA
OS: Speckled
fluorescence with
single area of
increased
hyperfluorescence
ST to the fovea
•OS: Ranibizumab injection under TA on 14.July.2015
•OS: 1st Day post injection Fundus showed RPE Tear + (small
sparing fovea)
•OS: 3rd Day post injection
Fundus showed RPE Tear + (progressed to involve fovea)
On 30.July.2015
On 31.August.2015
Vision in left had improved, though patient still c/o
metamorphopsia in left eye
VA:
OD: 6/18,N18
OS: 6/9, N6
IOP:
OD: 14 mmHg
OS:14 mmHg
•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.
•Most commonly associated with neovascular AMD
Chuang EL, Bird AC. The pathogenesis of tears of the retinal pigment epithelium. Am J Ophthalmol
1988;105:285–290.
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.
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.
FFA,ICG and OCT
•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.
OCT
•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.
How does RPE Tear occur
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
Grading of RPE tear
•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.
Risk factors
•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%
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.
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.
What to be done if we have
significant risk factors
PED height >400 µm
Presence of hyperreflective lines in NIR images
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.
Why it is more common in AMD
compared to PCV?
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
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
•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.
FATE OF RPE TEAR
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.
•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.
•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.
Mukai R, Sato T, Kishi S. Repair mechanism of retinal pigment epithelial tears in
Age-related macular degeneration. Retina 35:473–480, 2015
Mukai R, Sato T, Kishi S. Repair mechanism of retinal pigment epithelial tears in
Age-related macular degeneration. Retina 35:473–480, 2015
Should we continue Anti VEGF Rx in
patients with RPE tear?
•Chan et al reported continued improvement in visual acuity in
67% eyes treated with bevacizumab/ranibizumab after
developing RPE tear
•Gamulescu et al reported mean BCVA to be stable at 12 months
in eyes that received additional anti VEGF treatment
•Continuing anti VEGF Rx may reduce possible fibrotic ingrowth
replacing RPE tear
•Chan CK, Meyer CH, Gross JG, et al. Retinal pigment epithelial tears after intravitreal bevacizumab injection for
neovascular age-related macular degeneration. Retina 2007;27:541–551.
•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: 1037–1040.
Sarraf D, Reddy S, Chiang A, et al. A new grading system for retinal pigment epithelial tears. Retina 2010;30:1039–1045.
Prognostic indicators
Prognostic indicators
•Pre injection PED height >400 μ
•PED height predicts RPE tear risk with 85% sensitivity
and 92% specificity
•GLD of PED- 5 mm
•PED duration <4.5 months- Predicts RPE tear risk with
77% sensitivity and 98% specificity
•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.
•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 ;34:1156–62.
•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.
Prognostic indicators
•Additional prognostic factor-Fibrovascular scarring and
atrophy in RPE free area
•Fibrovascular-poorer prognosis