RETINAL PIGMENT EPITHELIAL TEAR AND ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY IN EXUDATIVE AGE-RELATED MACULAR DEGENERATION: Clinical Course and Long-Term Prognosis

Long-term Follow-Up and Regeneration of Retinal Pigment Epithelium (RPE) after Tears of the Epithelium in Exudative Age-Related Macular Degeneration (AMD)

BACKGROUND

The goals of this study are to evaluate potential long-term visual deterioration associated with retinal pigment epithelial (RPE) tears in patients with neovascular age-related macular degeneration (nAMD) and to find treatment-related and morphological factors that might influence the outcomes.

PATIENTS AND METHODS

This retrospective study enrolled 21 eyes of 21 patients from the database of Vista Eye Clinic Binningen, Switzerland, diagnosed with RPE tears, as confirmed by spectral domain optical coherence tomography (SD-OCT), with a minimum follow-up period of 12 months. Treatment history before and after RPE rupture with anti-VEGF therapy, visual acuity, and imaging (SD-OCT) were analyzed and statistically evaluated for possible correlations.

RESULTS

Mean patient age was 80.5 ± 6.2 years. The mean length of total follow-up was 39.7 ± 13.9 months. The mean pigment epithelial detachment (PED) height increased by 363.8 ± 355.5 µm from the first consultation to 562.8 ± 251.5 µm at the last consultation prior to rupture. Therefore, a higher risk of RPE rupture is implied as a result of an increase in PED height (p = 0.004, n = 14). The mean visual acuity before rupture was 66.2 ± 16.0 letters. Mean visual acuity deteriorated to 60.8 ± 18.6 letters at the first consultation after rupture (p = 0.052, n = 21). A statistically nonsignificant decrease in vision was noted in the follow-up period. After 2 years, the mean BCVA decreased by 10.5 ± 23.7 ETDRS letters (p = 0.23, n = 19). PED characteristics before rupture and amount of anti-VEGF injections after rupture did not affect the visual outcome. None of the 21 patients included in our study showed a visual improvement in the long-term follow-up. RPE atrophy increased significantly from 3.35 ± 2.94 mm2 (baseline) to 6.81 ± 6.25 mm2 over the course of 2 years (p = 0.000 013, n = 20).

CONCLUSIONS

The overall mean vision decrease after rupture was without statistical significance. There was no significant change in BCVA at the 2-year follow-up, independent of the amount of anti-VEGF injections provided. In this study, there was a significant increase in RPE defect over a follow-up of 2 years, implying progression of contraction of RPE and/or macular atrophy.

Hyperreflective Material Boundary Remodeling in Neovascular Age-Related Macular Degeneration: A Post Hoc Analysis of the AVENUE Trial

OBJECTIVE

To describe the spatial and temporal characteristics of hyperreflective material (HRM) on spectral-domain OCT (SD-OCT) in neovascular age-related macular degeneration (nAMD) during antiangiogenic treatment and explore associations with best-corrected visual acuity (BCVA) and macular atrophy (MA).

DESIGN

Retrospective regrading of SD-OCT-images from the multicenter, randomized controlled AVENUE trial (NCT02484690, conducted from August 2015 to September 2017).

PARTICIPANTS

Treatment-naive nAMD patients enrolled from 50 sites in the US.

METHODS

Retrospective regrading and secondary analysis.

MAIN OUTCOME MEASURES

Spectral-domain OCT images from 207 study eyes that fit criteria for the present analysis were graded for HRM features, its evolution, and associated hypertransmission into choroid (HTC), a proxy for MA. The appearance of a well-defined hyperreflective inner boundary that separated persistent HRM from the neurosensory retina continuous with the adjacent retinal pigment epithelium layer was defined as hyperreflective material boundary remodeling (HRM-BR). Patterns of HRM composition/evolution were defined as follows: (1) no subretinal HRM at baseline, (2) fully resolved, (3) persistent with complete HRM-BR, or (4) partial/absent HRM-BR. Associations of HRM patterns with BCVA and HTC were analyzed. Predictive factors for complete HRM-BR were explored.

RESULTS

Of 207 included eyes, subretinal HRM was present in 159 (76.8%) at baseline and persisted until month 9 in 118 (57.0%) eyes. Of these 118 eyes, 44.9% developed complete HRM-BR and had similar BCVA outcomes by month 9 compared with no/fully resolved subretinal HRM. Partial/absent HRM-BR had a strong negative association with BCVA outcome (-6.1 ETDRS letters; P = 0.016) and a higher frequency of intralesional HTC (69.2%) compared with eyes with complete HRM-BR (20.8%) at month 9. Older age (odds ratio [OR], 0.96; P = 0.054) and presence of intralesional HTC (OR, 0.06; P = 0.010) at baseline were associated with lower odds of complete HRM-BR at month 9.

CONCLUSIONS

In nAMD eyes under antiangiogenic treatment, complete HRM-BR occurred frequently and was associated with better BCVA than when HRM-BR was only partial/absent.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Computational Modeling of Ophthalmic Procedures: Computational Modeling of Ophthalmic Procedures

PURPOSE

To explore how finite-element calculations can continue to contribute to diverse problems in ophthalmology and vision science, we describe our recent work on modeling the force on the peripheral retina in intravitreal injections and how that force increases with shorter, smaller gauge needles. We also present a calculation that determines the location and stress on a retinal pigment epithelial detachment during an intravitreal injection, the possibility that stress induced by the injection can lead to a tear of the retinal pigment epithelium.

BACKGROUND

Advanced computational models can provide a critical insight into the underlying physics in many surgical procedures, which may not be intuitive.

METHODS

The simulations were implemented using COMSOL Multiphysics. We compared the monkey retinal adhesive force of 18 Pa with the results of this study to quantify the maximum retinal stress that occurs during intravitreal injections.

CONCLUSIONS

Currently used 30-gauge needles produce stress on the retina during intravitreal injections that is only slightly below the limit that can create retinal tears. As retina specialists attempt to use smaller needles, the risk of complications may increase. In addition, we find that during an intravitreal injection, the stress on the retina in a pigment epithelial detachment occurs at the edge of the detachment (found clinically), and the stress is sufficient to tear the retina. These findings may guide physicians in future clinical research. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Managing Neovascular Age-Related Macular Degeneration in Clinical Practice: Systematic Review, Meta-Analysis, and Meta-Regression

The use of anti-vascular endothelial growth factor (VEGF) agents has profoundly changed the prognosis of neovascular age-related macular degeneration (nAMD). As clinical experiences have accumulated, it has become mandatory to summarize data to give information that can be useful in everyday practice. We conducted a systematic review to identify randomized controlled trials (RCTs) and observational studies that reported 12-month changes in best-corrected visual acuity (BCVA) in patients with nAMD on anti-VEGF monotherapy. Data were analyzed in a random-effects meta-analysis with BCVA change as the primary outcome. Meta-regression was conducted to evaluate the impact of multiple covariates. Four hundred and twelve heterogeneous study populations (109,666 eyes) were included. Anti-VEGFs induced an overall improvement of +5.37 ETDRS letters at 12 months. Meta-regression showed that mean BCVA change was statistically greater for RCTs (p = 0.0032) in comparison with observational studies. Populations following a proactive regimen had better outcomes than those following a reactive treatment regimen. Mean BCVA change was greater in younger populations, with lower baseline BCVA and treated with a higher number of injections (p < 0.001). Our results confirm that anti-VEGFs may produce a significant functional improvement at 12 months in patients with nAMD.

Modern trends in diagnostics and prediction of results of anti-vascular endothelial growth factor therapy of pigment epithelial detachment in neovascular agerelated macular degeneration using deep machine learning method (literature review)

Detachment of the pigment epithelium is the separation of the basement membrane of the retinal pigment epithelium from the inner collagen layer of Bruch’s membrane, which occurs in 80 % of cases in patients with neovascular age-related macular degeneration. The outcome of anti-VEGF therapy for pigment epithelial detachment may be adherence of the pigment epithelium, the formation of pigment epithelium tear, or preservation of the detachment. The pigment epithelium tear of 3–4th degrees can lead to a sharp decrease in visual acuity.Most retrospective studies confi rm the absence of a proven correlation between anatomical and functional outcomes in the treatment of pigment epithelial detachment in cases of maintaining the integrity of the pigment epithelium monolayer, and therefore the main attention of researchers is focused on studying the morphological features of pigment epithelial detachment during therapy with angiogenesis inhibitors. Modern technologies of spectral optical coherence tomography make it possible to evaluate detailed quantitative parameters of pigment epithelium detachment, such as height, width, maximum linear diameter, area, volume and refl ectivity within the detachment.Groups of Russian and foreign authors identify various biomarkers recorded on optical coherence tomography images. Dynamic registration of such biomarkers expands the ability of clinicians to predict morphological changes in pigment epithelial detachment during anti-VEGF therapy, as well as to optimize treatment regimens to prevent complications in the form of pigment epithelium tear leading to a decrease in visual acuity.Modern methods of deep machine learning and the use of neural networks allow achieving higher accuracy in diff erentiating the types of retinal fluids and automating the quantitative determination of fl uid under the pigment epithelium. These technologies allow achieving a high level of compliance with manual expert assessment and increasing the accuracy and speed of predicting morphological results of treatment of pigment epithelium detachments.

Clinical associations and prognostic implications of repair tissue proliferation in eyes with retinal pigment epithelium tears

PURPOSE

To investigate demographic and clinical factors influencing the longitudinal changes of retinal pigment epithelium (RPE) dehiscence area after RPE tears, including the presence of RPE tear-associated repair proliferation (TARP), and identify factors associated with TARP development over follow-up.

METHODS

Retrospective, single-center, observational cohort study of patients with a history of macular neovascularization and RPE tear. The area of RPE dehiscence was measured on repeated short-wavelength fundus autofluorescence imaging. Associations between potential covariates and RPE dehiscence areas were tested with multivariable linear mixed models. Associations between TARP development and clinical variables were investigated with Cox regression models. Factors associated with visual acuity changing rates were explored with linear mixed models.

RESULTS

Thirty-seven eyes of 36 patients were included in this study and followed for a median time of 18 months. TARP was identified in 27 eyes (73%). The median time for TARP detection was 112 days; none of the investigated factors was significantly associated with TARP occurrence. The presence of TARP (β estimate: -0.042 mm2/month, p=0.001) and female gender (β estimate: -0.035 mm2/month, p=0.006) were associated with slower rates of RPE dehiscence enlargement over time. Faster rates of visual improvement were seen in eyes with TARP compared with those without TARP (β = -0.010 LogMAR/month if TARP was present, p=0.008).

CONCLUSION

RPE tear repair with TARP and female gender were associated with slower RPE degeneration after RPE tears. The presence of TARP was associated better visual prognosis. Additional research on factors promoting TARP development may have therapeutic and prognostic implications.

[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.

THE OCCURRENCE, CHARACTERISTICS, MANAGEMENT, AND PROGNOSIS OF RETINAL PIGMENT EPITHELIUM TEARS IN PATIENTS WITH POLYPOIDAL CHOROIDAL VASCULOPATHY: A Retrospective Study of 397 Patients

PURPOSE

To investigate retinal pigment epithelium (RPE) tears in patients with polypoidal choroidal vasculopathy.

METHOD

A retrospective review of polypoidal choroidal vasculopathy cases with confirmed RPE tears was conducted. Patients' comprehensive clinical data were collected and analyzed. The treatment strategy was a loading dose of one intravitreal antivascular endothelial growth factor injection, combined with additional injections if exudative activities or visual deterioration were detected.

RESULTS

Among 397 polypoidal choroidal vasculopathy patients, 33 patients with RPE tears (8.3%) were included. 42.4% of them happened spontaneously. Pigment epithelial detachment (PED) occurred more frequently in RPE tear patients and most of them had serous vascularized or hemorrhagic PED. The height and greatest linear diameter of PED, and the subfoveal choroidal thickness of these cases were significantly larger, whereas the central foveal thickness was significantly smaller. Most of the RPE tears occurred at the edge of the PED. After our treatment strategy, patients' best-corrected visual acuity improved significantly from 2.13 ± 1.24 (median 20/52) to 1.32 ± 1.31 (median 20/166). Large subretinal hemorrhage may increase the risk of the formation of subretinal fibrosis (P < 0.05).

CONCLUSION

Retinal pigment epithelium tears in polypoidal choroidal vasculopathy are associated with high subRPE hydrostatic pressure, produced by a large PED or hemorrhage. After our intervention strategy, this condition may not necessarily result in poor prognosis.

Optical coherence tomography features of the repair tissue following RPE tear and their correlation with visual outcomes

To assess the optical coherence tomography (OCT) features of the repair tissue after retinal pigment epithelial (RPE) tear in neovascular age-related macular degeneration. Retrospective, observational study. Medical and imaging records of patients that developed tears after starting anti-VEGF treatment and with at least 12 months of follow-up were reviewed. OCT reflectivity of the RPE-subretinal hyperreflective tissue (SHT) complex was measured at 6, 12 and 18 months (when available). Reflectivity of the adjacent unaffected RPE-Bruch’s membrane was taken as internal reference. Other variables: grade and rip occurrence (early/late); number of intravitreal injections; type of macular neovascularization; sub-macular hemorrhage (SMH) at onset. Forty-nine eyes (age: 76.1 ± 7.0 years; VA: 0.54 ± 0.27 LogMAR) were included. Thirty-eight eyes had OCT signs of healing during the follow-up, with 21 showing SMH at baseline. Final VA positively correlated with the number of injections and negatively correlated with the RPE-SHT reflectivity and the presence of SMH (p < 0.001). Reflectivity of the RPE-SHT complex was positively associated with time and SMH at baseline (p < 0.05). In our study, most eyes showed signs of tissue repair after RPE tear. The reflectivity of repair tissue, the SMH presence and the number of anti-VEGF injections appeared to be major predictors of visual outcomes.

Predicting retinal pigment epithelium remodelling and its functional impact

PURPOSE

To identify predictive factors for RPE tear remodelling and its correlation with functional and morphological outcomes.

METHODS

Retrospective longitudinal study of patients with retinal pigment epithelium (RPE) tears secondary to age-related macular degeneration (AMD). Imaging was performed using spectral-domain optical coherence tomography (SD-OCT) and fundus autofluorescence (FAF). RPE layer integrity in the RPE-denuded area was examined with SD-OCT, and variation in the RPE-denuded homogeneous hypofluorescent area was examined with FAF over time for each case (eye). Patients were divided in two groups, according to the presence (Rem) or absence (No Rem) of evidence of RPE tear remodelling. Data were collected at three different time points: at baseline (at diagnosis of exudative AMD), at RPE tear diagnosis, and at the last available follow-up. Using SD-OCT, the following parameters were evaluated: type of CNV, type of PED and its dimensions, presence of subretinal (SRF) or intraretinal (IRF) fluid, central retinal thickness (CRT), presence and location of hyperreflective dots, and dimension and location of RPE tear.

RESULTS

This study included 32 eyes from 31 patients (19 female and 12 male), with RPE tears secondary to AMD. RPE remodelling after tear development was evident in 17 (53.1%) eyes after 7 [1-59] months. Anatomical recovery was associated with a younger age at RPE tear diagnosis (73 ± 7 vs. 81 ± 7 years old, p=0.01), smaller and narrower retinal pigment epithelial detachment (PED) at tear diagnosis (height 369 vs. 602 μm, p=0.02; width 2379 vs. 3378 μm, p=0.04), and the presence of SRF at tear diagnosis (94% vs. 53%, p=0.02). After adjusting for other covariates, a younger age at RPE tear diagnosis maintained significant association with RPE tear remodelling. RPE tear remodelling did not correlate with a better visual outcome at last follow-up (43 ± 22.8 vs. 34 ± 23.8 ETDRS letters, p=0.30). Final VA was directly proportional to VA at tear diagnosis (r= 0.654; p<0.001) and correlated negatively with PED width at tear diagnosis (r = -0.388; p=0.03).

CONCLUSION

RPE remodelling was evident in half of our sample and was associated with a younger age, smaller and narrower PED at RPE tear diagnosis, and presence of SRF also at tear diagnosis. Nevertheless, this structural recovery did not result in a better functional outcome.

ROCK Inhibitor-Induced Promotion of Retinal Pigment Epithelial Cell Motility during Wound Healing

Purpose

No standard therapy for RPE tear, a complication of neovascular age-related macular degeneration, exists even though RPE tears cause severe vision loss, and promotion of cell proliferation and/or migration could be a candidate RPE tear therapy. The aim of this study is to evaluate the effect of Rho-associated coiled-coil containing kinase (ROCK) inhibitor Y27632 on retinal pigment epithelial (RPE) cell motility during wound healing.

Methods

Human RPE cells were cultured in media with and without 10 μM Y27632. A luminescent cell viability assay and vinculin immunocytochemistry were used to test the Y27632 effect on RPE cell adhesion. The mean size of vinculin puncta was quantified from immunofluorescence images. RPE cell motility during wound healing was evaluated using time-lapse imaging and measuring cell migration distances and cell coverage rate in wound fields.

Results

The number of adhered RPE and mean size of vinculin puncta were, respectively, 20519 cells and 3.65 μm² under nontreatment and 23569 cells and 0.66 μm² under Y27632 treatment. Cell migration distance and cell coverage percentage for untreated and Y27632-treated cells were 98.9 and 59.4% and 203.4 and 92.5%, respectively.

Conclusions

Inhibition of ROCK signaling by using 10 μM Y27632 promoted RPE cell motility during wound healing by reducing RPE cell adhesion strength.

Retinal pigment epithelial tears

A retinal pigment epithelial (RPE) tear is a well-known complication of retinal pigment epithelial detachments (PED) and may cause a significant visual impairment. The most common cause is a vascularized PED in patients with exudative age-related macular degeneration (AMD). The development of diagnostic imaging techniques brings us closer to the etiology and pathophysiological mechanisms of this entity, offering us new strategies for treatment and follow-up. The advent of intravitreal antiangiogenic treatment (anti-VEGF) has led to an increase in the number of reported cases of RPE tears, which are an important vision-limiting factor during treatment. However, RPE tears may occur spontaneously or as a consequence of thermal laser treatment, photodynamic therapy or anti-VEGF therapy. It is accepted that the mechanism of RPE tears is multifactorial. The optimization of the functional outcome of this complication has been described with continuous treatment with antiangiogenic drugs. The goal of the present review is to evaluate the incidence, risk factors and treatment of RPE tears.

LONGITUDINAL CHANGE OF OUTER NUCLEAR LAYER AFTER RETINAL PIGMENT EPITHELIAL TEAR SECONDARY TO AGE-RELATED MACULAR DEGENERATION

PURPOSE

To investigate longitudinal changes of outer nuclear layer (ONL) thickness in patients with retinal pigment epithelium tears secondary to neovascular age-related macular degeneration.

METHODS

This is an institutional retrospective interventional case series. Twenty-six eyes of 22 patients with retinal pigment epithelium tears identified between April 2009 and March 2015. The patients underwent intravitreal injection of anti-vascular endothelial growth factor agents as needed. Volume scans of optical coherence tomography at first diagnosis of tear (baseline) and after 12 months were analyzed. Outer nuclear layer was segmented, and average ONL thickness inside the tear area, at the border of the tear, and in areas outside the tear was measured. Change of ONL thickness. We also explored several factors for their association with ONL thinning including tear area, number of treatments, and the duration with persistent subretinal fluid.

RESULTS

Thinning of ONL was found in all the investigated areas (P < 0.01, respectively). Among the investigated factors, larger tear area was associated with greater ONL thinning outside the tear area (standardized β = -0.37, P = 0.030), and younger age was associated with greater ONL thinning inside the tear area (standardized β = 0.37, P = 0.041).

CONCLUSION

After an retinal pigment epithelium tear, thinning of ONL occurs in the area devoid of retinal pigment epithelium and also in adjacent areas. Few factors were predictive for the degree of ONL thinning. These results provide new insight in disease progression of this particular neovascular age-related macular degeneration subphenotype.

Early and Late Retinal Pigment Epithelium Tears after Anti-Vascular Endothelial Growth Factor Therapy for Neovascular Age-Related Macular Degeneration

PURPOSE

To investigate when retinal pigment epithelium (RPE) tears occur and their associated treatment patterns and long-term visual outcomes in patients with neovascular age-related macular degeneration (nAMD) during anti-vascular endothelial growth factor (VEGF) treatment.

DESIGN

Case-control analysis from a prospectively designed observational database.

PARTICIPANTS

Treatment-naïve eyes enrolled in the Fight Retina Blindness! observational study that commenced anti-VEGF treatment for nAMD between January 2006 and January 2017 were identified. Cases were defined as eyes in which an RPE tear developed during treatment. Three control eyes per case were matched for age, baseline visual acuity (VA), lesion size, treatment duration before tearing, and duration of follow-up.

METHODS

Cases were classified as having early or late tears using a segmented regression model. Baseline characteristics were compared between the 2 groups. Comparisons of VA and injections received between tear eyes and control eyes were performed at baseline, before and immediately after the tear, and then 12 and 24 months later. Visual acuity also was compared among different visits within each group.

MAIN OUTCOME MEASURES

Visual acuity, time to tear, and injections received.

RESULTS

Fifty-five cases and 165 matched control eyes were included. The segmented regression estimated a breakpoint for the time to tear at 182 days. We therefore defined eyes as having early tears if they tore before the breakpoint (38/55 eyes [69%]), and as late tears if they tore afterward (17/55 eyes [31%]). Baseline VA was significantly lower in early compared with late tears (53.6 vs. 63.4 letters; P = 0.009). Visual acuity had improved in early tears before the tear (+5.6 letters from baseline; P = 0.01), decreased immediately after the tear (-8.3 letters; P = 0.002), then recovered with no difference compared with control eyes 12 and 24 months later (P > 0.05 for both). Late tear eyes had significantly lower VA than control eyes before tearing (55.5 vs. 66.9 letters; P < 0.001). Visual acuity did not decrease significantly after the tear, but continued to decline compared with control eyes at all end points. Both early and late tear eyes received more injections than control eyes after tearing.

CONCLUSIONS

Retinal pigment epithelium tears act differently depending on when they occur. Long-term visual outcomes in eyes affected by RPE tearing may be related more to the patient's response to therapy than to the tear itself.

OCT angiography documented reperfusion of translocated autologous full thickness RPE-choroid graft for complicated neovascular age-related macular degeneration

PurposeThe purpose of this study is to investigate the reperfusion of translocated retinal pigment epithelium (RPE)-choroid graft in the treatment of patients with neovascular age-related macular degeneration (nAMD), using OCT angiography (OCTA), a novel non-invasive, high-resolution imaging modality.Patients and methodsEighteen eyes of 18 consecutive patients suffering from complicated nAMD underwent RPE-choroid patch graft translocation surgery using a peripheral retinotomy and flap-over technique. We analyzed functional and anatomical outcome using visual acuity, Spectral Domain OCT and OCTA.ResultsWith a mean follow-up of 11 months, out of 18 patients, 15 gained vision, 1 remained stable, and 2 lost vision. Overall, the visual acuity improved with a mean of 30 letters. Perfusion of the graft tissue was confirmed in all patients. Two patients developed signs of a recurrent neovascular membrane during follow-up. No cases of proliferative vitreoretinopathy occurred in this series.ConclusionsOCTA images show signs of perfusion in all grafts. Encouraging functional results and low risk of severe complications suggest that RPE-choroid graft translocation is a valid option in patients with complicated nAMD.