Retinal pigment epithelial tears

Clinical and multimodal imaging findings in a case of serous maculopathy with absence of retinal pigment epithelium (SMARPE)

INTRODUCTION

The differential diagnosis for serous SRF can involve diseases with widely different pathogenic mechanisms that can range from vascular ocular diseases to ocular tumours and paraneoplastic syndromes. Recently, van Dijk et al. have described in three patients a new entity which they have called serous maculopathy with an absence of retinal pigment epithelium (SMARPE). We hereby describe a case of this infrequent macular disease and report its characteristic findings on multimodal imaging.

CASE DESCRIPTION

We present the case of a 65-year-old hyperopic woman with a three-year history of visual acuity (VA) loss in her left eye. Prior optical coherence tomography (OCT) had revealed the presence of serous subretinal fluid that had shown no response to treatment with intravitreal injections. On swept source OCT angiography scan, no macular alterations in the retinal vascular plexus structure were noted and there was no evidence of choroidal neovascularization. Ultra-widefield fluorescence angiography of the left eye revealed an early hyperfluorescent macular spot corresponding to the area of absent RPE and late fluorescein pooling. On ultra-widefield indocyanine green angiography there were no central or peripheral abnormalities of choroidal vascularization.

CONCLUSION

This recently described entity should be considered as a differential diagnosis in persistent serous subretinal fluid. Multimodal imaging helps differentiate SMARPE from its main differential diagnoses, and care should be taken to identify and differentiate it from similar conditions to avoid unnecessary treatment with its possible side effects and complications.

INVESTIGATION OF INCIDENCE AND CAUSES OF ACUTE VISION LOSS DURING ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY FOR NEOVASCULAR AGE-RELATED MACULAR DEGENERATION DURING A FOUR-YEAR FOLLOW-UP

PURPOSE

To investigate the incidence, risk factors, and outcomes of patients with age-related macular degeneration who experienced acute vision loss despite periodic injections of anti-vascular endothelial growth factor treatment for 4 years.

METHODS

This retrospective cohort study included patients who were diagnosed with treatment-naive neovascular age-related macular degeneration and completed a 4-year follow-up. The incidence and risk factors for the occurrence of three or more lines of visual loss at every checkup were investigated.

RESULTS

The analysis included 76 eyes of 76 patients. Acute vision loss occurred in 30 eyes (39.5%) over 4 years. Lower baseline best-corrected visual acuity and disrupted ellipsoid zone were independent predictors of vision loss occurrence. Although the causes and timing of visual acuity loss varied, retinal pigment epithelium tears were observed only in the first year. Most patients (86.7%) who experienced vision loss recovered their vision to pre-loss levels at least once; however, the final best-corrected visual acuity was worse than that in the group that did not experience acute vision loss.

CONCLUSION

Approximately half of the patients with age-related macular degeneration experienced acute vision loss during a 4-year follow-up, despite continuous anti-vascular endothelial growth factor treatment. Most patients recovered from vision losses temporarily; however, they experienced worse visual outcomes subsequently.

Predictive value of pigment epithelial detachment markers for visual acuity outcomes in neovascular age-related macular degeneration

BACKGROUND

To determine the predictive value of quantitative morphological parameters for pigment epithelial detachment (PED) of neovascular age-related macular degeneration (nAMD) patients.

METHODS

One eye from each of 159 patients with nAMD were studied. Polypoidal choroidal vasculopathy (PCV) group included 77 eyes, and non-PCV group 82. Patients received conbercept 0.05 ml (0.5 mg) in a 3 + ProReNata (PRN) treatment regimen. Correlations between retinal morphologic parameters at baseline and best-corrected visual acuity (BCVA) gain at 3 or 12 months after treatment (structure-function correlations) were assessed. Optical coherence tomography (OCT) scans were used to assess retinal morphologic features including intraretinal cystoid fluid (IRC), subretinal fluid (SRF), PED or PED type (PEDT), and vitreomacular adhesion (VMA). Greatest height (PEDH) and width of PED (PEDW), and volume of PED (PEDV) at baseline were also measured.

RESULTS

For non-PCV group, BCVA gain from 3 or 12 months after treatment was negatively correlated with PEDV at baseline (r = -0.329, -0.312, P = 0.027, 0.037). BCVA gain at 12 months after treatment was negatively correlated with PEDW at baseline (r = -0.305, P = 0.044). For PCV group, there were no correlations with PEDV, PEDH, PEDW, and PEDT in BCVA gain between baseline and 3 or 12 months after treatment (P > 0.05). SRF, IRC, VMA at baseline did not correlate with short-term and long-term BCVA gain in patients with nAMD (P > 0.05).

CONCLUSION

For patients with non-PCV, PEDV at baseline was negatively correlated with short-term and long-term BCVA gain, and PEDW was negatively correlated with long-term BCVA gain. On the contrary, quantitative morphological parameters for PED at baseline had no correlation with BCVA gain in patients with PCV.

Dexamethasone implant prior to anti-VEGF therapy in pigment epithelium detachments with high-risk rupture characteristics secondary to neovascular age-related macular degeneration

OBJECTIVE

Evaluate the incidence of pigment epithelial tear when intravitreal delayed-release dexamethasone implant is administered (off-label use) prior to antiangiogenic treatment in pigment epithelium detachments (PED) secondary to neovascular age-related macular degeneration (nAMD) with high-risk rupture characteristics and investigate if it causes a decrease in the PED size.

METHODS

Patients with nAMD, PED height >500 microns and Ozurdex implant prior to the antiangiogenic therapy were included. The presence of pigment epithelium rupture in optical coherence tomography scans, best-corrected visual acuity (BCVA) and PED measurements (maximum height and diameter) were registered.

RESULTS

The study included 14 eyes of 14 patients: mean age 77 ± 7 years, 11 (79%) females. 25 ± 13 days after the Ozurdex, patients started with at least 3 anti-VEGF monthly injections. BCVA improved from 64 ± 14-69 ± 11 letters after anti-VEGF therapy (p > 0.05). Mean baseline PED height was 817 ± 269 µm, being 639 ± 268 µm after Ozurdex and 370 ± 260 µm after anti-VEGF injections (p = 0.035 and p = 0.009). One retinal pigment epithelium tear occurred (7%). No other adverse effects were reported.

CONCLUSIONS

Dexamethasone implant prior to anti-VEGF therapy may represent a promising therapeutic modality for large PED in nAMD, reducing PED dimensions and the risk of pigment epithelium tears prior to anti VEGF therapy.

Complications Associated with Worse Visual Outcomes in Patients with Exudative Neovascular Age-Related Macular Degeneration

BACKGROUND

Neovascular age-related macular degeneration (AMD) represents a leading cause of vision loss in older subjects. The introduction of anti-vascular endothelial growth factor therapy has enormously improved the visual prognosis in these patients.

SUMMARY

However, severe complications may still occur in this disease and their development may significantly affect short- and long-term visual outcomes. Key Messages: In this article, we provided a review of these complications, highlighting their distinctive signs or symptoms and focusing on the current evidence of treatment. To place the complications related to neovascular AMD in a proper context, this review deals with core components essential for proper comprehension of neovascular AMD that includes pathogenesis, clinical signs, and basic principles of treatment.

OCT Biomarkers in Neovascular Age-Related Macular Degeneration: A Narrative Review

Age-related macular degeneration (AMD) is the leading cause of legal blindness in elderly people. Neovascular AMD (nAMD) is responsible for the majority of cases of severe visual loss in eyes with AMD. Optical coherence tomography (OCT) is the most widely used technology for the diagnosis and follow-up of nAMD patients, which is widely used to study and guide the clinical approach, as well as to predict and evaluate treatment response. The aim of this review is to describe and analyze various structural OCT-based biomarkers, which have practical value during both initial assessment and treatment follow-up of nAMD patients. While central retinal thickness has been the most common and one of the first OCT identified biomarkers, today, other qualitative and quantitative biomarkers provide novel insight into disease activity and offer superior prognostic value and better guidance for tailored therapeutic management. The key importance of retinal fluid compartmentalization (intraretinal fluid, subretinal fluid, and subretinal pigment epithelium (RPE) fluid) will be discussed firstly. In the second part, the structural alterations of different retinal layers in various stages of the disease (photoreceptors layer integrity, hyperreflective dots, outer retinal tubulations, subretinal hyperreflective material, and retinal pigment epithelial tears) will be analyzed in detail. The last part of the review will focus on how alterations of the vitreoretinal interface (vitreomacular adhesion and traction) and of the choroid (sub-RPE hyperreflective columns, prechoroidal clefts, choroidal caverns, choroidal thickness and choroidal volume, and choroidal vascular index) interact with nAMD progression. OCT technology is evolving very quickly, and new retinal biomarkers are continuously described. This up-to-date review article provides a comprehensive description on how structural OCT-based biomarkers provide a valuable tool to monitor the progression of the disease and the treatment response in nAMD patients. Thus, in this perspective, clinicians will be able to allocate hospital resources in the best possible way and tailor treatment to the individual patient's needs.

[Retinal pigment epithelial tear in age-related macular degeneration]

Retinal pigment epithelial tear (RPET) occurs in a number of diseases, most often in age-related macular degeneration (AMD). RPET develops in the setting of retinal pigment epithelium (RPE) detachment and represents a violation of the integrity of its monolayer accompanied by the formation of a demarcation line between the RPE atrophy area and RPE folds. Its incidence varies widely. In the earlier studies, diagnosis of RPET was performed using fluorescent angiography or angiography with indocyanine green (ICG-FA). The advent of optical coherence tomography made the detection of RPET easier and more accessible. The mechanism of RPET formation is quite polymorphic and ambiguous. Scientific literature contains descriptions of the occurrence of RPET when using both ranibizumab and aflibercept, and bevacizumab in equal proportions, implying that the drug choice does not affect the occurrence of complications. Continuous monitoring and adherence to anti-VEGF therapy leads to better anatomical and functional results in the long term, which is crucial for improving the quality of life of patients with age-related macular degeneration. This article reviews the literature and presents current data on RPET, identifies risk factors and mechanisms of its development, provides classification, and describes modern options for its diagnosis and treatment.

MANAGEMENT OF RETINAL PIGMENT EPITHELIUM TEAR DURING ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY

PURPOSE

This article aims to review current evidence on the development, diagnosis, and management of retinal pigment epithelium (RPE) tear during anti-vascular endothelial growth factor (VEGF) therapy.

METHODS

Literature searches were performed using MEDLINE/PubMed databases (cut-off date: August 2019).

RESULTS

Three key recommendations were made based on existing literature and clinical experience: 1) Multimodal imaging with color fundus photography, optical coherence tomography, near-infrared reflectance imaging, fundus autofluorescence imaging, optical coherence tomography-angiography, and/or fluorescein angiography are recommended to diagnose RPE tear and assess risk factors. Retinal pigment epithelium tears can be graded by size and foveal involvement. 2) Patients at high risk of developing RPE tear should be monitored after each anti-VEGF injection. If risk factors worsen, it is not yet definitively known whether anti-VEGF administration should be more frequent, or alternatively stopped in such patients. Prospective research into high-risk characteristics is needed. 3) After RPE tear develops, anti-VEGF treatment should be continued in patients with active disease (as indicated by presence of intraretinal or subretinal fluid), although cessation of therapy should be considered in eyes with multilobular tears.

CONCLUSION

Although evidence to support the assumption that anti-VEGF treatment contributes to development of RPE tear is not definitive, some data suggest this link.

[Different types localisation of retinal fluid as prognostic biomarkers in the choice of anti-VEGF therapy for age-related macular degeneration]

Age-related macular degeneration is an advanced chronic disease and the main cause of vision loss in geriatric patients. Optical coherence tomography (OCT) is a modern method of retinal imaging allowing to detect different types of fluid: intraretinal fluid (IRF), subretinal fluid (SRF) and fluid under pigment epithelial detachment (PED). Finding relevant imaging biomarkers is necessary for identification of basic activity criteria of the disease, choosing treatment algorithms, determining treatment duration and termination criteria, and predicting the outcomes. Presence of IRF is associated with poor functional outcomes. Its presence is an indication for early beginning of treatment aimed at full resorption of the fluid with further possible careful extension of anti-VEGF therapy intervals with a regular follow-up. Degenerative intraretinal cysts developing in the background of subretinal fibrosis in absence of choroidal neovascularization (CNV) should be a sign for discontinuation of anti-VEGF therapy due to the lack of targets. Presence of SRF is associated with favorable outcomes and good treatment prognosis and is not a barrier to the extension of treatment intervals even up to the maximum of 16 weeks as described in existing randomized controlled trials, on the condition of no other CNV activity. PED with active CNV is one of the biomarkers that reveal the need for long-term aggressive therapy. In case of its size gain, it is necessary to restart the anti-VEGF treatment to prevent visual loss in the long-term. Combination of different fluid types is a sign of lasting disease history with a poor outcome prognosis. In this case, anti-VEGF treatment should be started as soon as possible with long-term fixed regimen or Treat-and-extend (T&E) with minimal suitable interval for the patient and precise monitoring of the condition of retina until complete suppression of activity. Developing a personalized approach in each case plays an important role in preserving visual functions.