Case of the Month | July 2022

Case of the Month
August 1, 2022
The Case
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Photos
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Answer

The Case

The patient was a 90-year-old man with a history of wet AMD in the right eye for which he had received Avastin treatments since October 2020. There was no acute choroidal neovascular membrane activity in either eye in April 2022. His visual acuity at that time was 20/400 OD and 20/20-1 OS. Two months later, he presented with decreased vision in the left eye to 20/200. OCT showed a broad PED with variable height, overlying subretinal fluid, and some macular edema. OCTA revealed a choroidal neovascular membrane. He was treated with Avastin, and one month later he presented with a visual acuity of 20/400 in the left eye but unchanged subjective vision. What is the most likely diagnosis? What treatment would you recommend?

The patient has a large RPE rip, which results from retraction of a fibrovascular network under the RPE. RPE rips can occur in the natural course of choroidal neovascular membranes as they undergo involution from an active network of blood vessels to a retracted, fibrotic scar. Anti-VEGF therapy can also precipitate RPE rips by inducing rapid involution of the CNVM. The effect of RPE rips on vision is variable, and in this case it did not seem to change the vision significantly.

There is some evidence that anti-VEGF treatment might increase the risk of RPE rips. However, the literature gives highly variable results on the incidence of RPE rips in the natural course of wet AMD as well as after anti-VEGF treatment. There does not seem to be a significant difference between Avastin, Lucentis, and Eylea on the risk of developing an RPE rip. Most authorities recommend continuing anti-VEGF treatment after RPE rips.

Ersoz, MG, Karacorlu M, Arf S, Muslabas, IS, Hocaoglu M. Retinal pigment epithelium tears: Classification, pathogenesis, predictors, and management. Survey of Ophthalmology 2017;  62(4):493-525.

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Case Photos

Click the Images below to enlarge
OCT OS 04-2022
OCT OS 06-2022 (#1)
OCT OS 06-2022 (#2)
OCTA 06-2022
OCT OS 07-2022
Wide Field Fundus Photo OS 07-2022
The Answer

The patient has a large RPE rip, which results from retraction of a fibrovascular network under the RPE. RPE rips can occur in the natural course of choroidal neovascular membranes as they undergo involution from an active network of blood vessels to a retracted, fibrotic scar. Anti-VEGF therapy can also precipitate RPE rips by inducing rapid involution of the CNVM. The effect of RPE rips on vision is variable, and in this case it did not seem to change the vision significantly.

There is some evidence that anti-VEGF treatment might increase the risk of RPE rips. However, the literature gives highly variable results on the incidence of RPE rips in the natural course of wet AMD as well as after anti-VEGF treatment. There does not seem to be a significant difference between Avastin, Lucentis, and Eylea on the risk of developing an RPE rip. Most authorities recommend continuing anti-VEGF treatment after RPE rips.

Ersoz, MG, Karacorlu M, Arf S, Muslabas, IS, Hocaoglu M. Retinal pigment epithelium tears: Classification, pathogenesis, predictors, and management. Survey of Ophthalmology 2017;  62(4):493-525.

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