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RPE tear Case report and Discussion

Seventy-six years old female phakic presented to me with reduced vision. Her BCVA is 20/40 in her right eye, while in her left eye, the BCVA is 20/30 fundus examination showed drusen.


Fundus examination shows drusen, RPE elevation, and subretinal fluid, while OCT features PED with smooth RPE elevations, which contains clear fluids that look like homogeneous hyporeflective area, subretinal fluids accompanied by ellipsoid zone disruption, and drusen.


The patient was treated with seven Ranibizumab injections and maintained BCVA 20/40 with reduced PED volume and persistent subretinal fluid.


The patient received the 8th injection and reduced vision to 20/150. OCT shows RPE tear, which indents the retina and increases hyperreflectivity in the area of contracted RPE with underlying shadowing hinders choroidal view in contrast to the area where RPE where it ripped off which only Bruch's membrane is visible and increasing the visibility of the underlying choroid.


Diagnosis


Wet ARMD with serous pigment epithelial detachment complicated with RPE tear after 8th intravitreal AntiVEGF injection.


Management: The patient managed with continuing  Intravitreal injection of Ranibizumab monthly until 21st injection, where subretinal fluid was resolved, and PED was reduced significantly with subretinal scar formation and improved vision again to 20/35.


OCT cross-sections showing neovascular ARMD with PED and SRF treated with Ranibizumab and developed RPE tear after the 8th injection but with countinouse injection it the CNV has regressed. These images are courtasy of Sengul Ozdek
OCT cross-sections showing neovascular ARMD with PED and SRF treated with Ranibizumab and developed RPE tear after the 8th injection but with countinouse injection it the CNV has regressed. These images are courtasy of Sengul Ozdek


Discussion 


RPE tear can occur in PEDs spontaneously or due to a complication of laser treatment or intravitreal AntiVEGF treatment, which causes a rapid contraction of CNVm inducing traction on the RPE surface and shrinking of RPE surface. Thus two opposite forces, the regression of CNVm and remaining attached RPE. AntiVEGF treatment continued despite the RPE tear.


This case was managed with continuous monthly intravitreal Ranibizumab to regress choroidal neovascular membrane despite the RPE tear complication. Although the subretinal scar formation and disruption of the ellipsoid zone occurred, BCVA improved near the baseline level.


A take-home message


Although RPE tear is a complication of intravitreal AntiVEGF treatment

Intravitreal AntiVEGF should NOT be stoped as regressing choroidal neovascular membrane may stabilize vision.



Acknowledgments


Special thanks to My colleague Şengül Özdek for the case and OCT images courtesy.


Please check Clinical guidelines for ARMD and course of clinical changes in RPE


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