Retinal pigment epithelial tear after intravitreal ranibizumab

PURPOSE: To report two cases of a retinal pigment epithelial (RPE) tear after intravitreal injection of 0.05 mg ranibizumab. DESIGN: Observational case report. METHODS: Two patients with choroidal neovascularization (CNV) resulting from age-related macular degeneration (AMD) were treated with an intravitreal injection of ranibizumab. RESULTS: Both patients were found to have a RPE tear on follow-up visits at one month, confirmed by optical coherence tomography (OCT) and by fluorescein or indocyanine green angiography. CONCLUSIONS: RPE tears may occur after intravitreal injection of ranibizumab. Further study is needed to determine whether CNV membranes associated with pigment epithelial detachments (PED) are more likely to develop RPE tears after treatment with anti-vascular endothelial growth factor (anti-VEGF) agents.     

Retinal pigment epithelial tears after pegaptanib injection for exudative age-related macular degeneration

PURPOSE: To report two cases of retinal pigment epithelium (RPE) tears following intravitreal pegaptanib injections for occult choroidal neovascularization. DESIGN: Noncomparative case series. METHODS: The charts of two patients with pigment epithelial tears after receiving intravitreal pegaptanib were reviewed. Approval from the institutional review board and informed consent were obtained before chart review. Fundus photos, intravenous fluorescein angiograms, and optical coherence tomography (OCT) were obtained before and after therapy confirmed the diagnosis. RESULTS: Two patients had turbid pigment epithelial detachments (PEDs) and occult choroidal neovascular membranes (CNVMs) treated with intravitreal pegaptanib. Both patients developed RPE tears weeks following one intravitreal pegaptanib injection. CONCLUSIONS: This report describes the development of RPE tears after intravitreal pegaptanib injection. Caution should be taken in cases of turbid pigment epithelial detachments in the monocular patient when treatment with intravitreal pegaptanib is entertained. Future studies should be performed to evaluate which subtypes of lesions are most susceptible to this devastating visual complication.     

RPE tears after pegaptanib treatment in age-related macular degeneration

PURPOSE: To describe retinal pigment epithelial (RPE) tears in patients with age-related macular degeneration (AMD) status post pegaptanib (Macugen) injection. METHODS: Six eyes from six patients who developed RPE tears while undergoing treatment with pegaptanib for AMD-related fibrovascular pigment epithelial detachment (PED) and occult choroidal neovascularization (CNV) were identified retrospectively. Diagnosis of pre-pegaptanib fibrovascular PED and post-pegaptanib RPE tears were made by clinical examination, fluorescein angiography (FA), and optical coherence tomography (OCT) imaging of the macula. RESULTS: Four patients developed an RPE tear within 8 weeks after the first pegaptanib injection, while RPE tears were found in two patients following a second injection. Only one of the patients reported acute vision loss, although three of six eyes had a decrease in objective visual acuity in the affected eye to the count fingers level. All six cases displayed the classic clinical and angiographic appearance of RPE tears. In addition, OCT imaging showed an irregular, hyperreflective RPE layer with a focal defect. CONCLUSIONS: RPE tears are known to occur in the setting of PED spontaneously or after laser treatment, but have only recently been described in association with intravitreal pegaptanib. OCT imaging of eyes status post pegaptanib therapy may be helpful in identifying this complication. Patients with AMD, especially those with occult CNV and fibrovascular PED, receiving pegaptanib therapy should be monitored for RPE tears, which may warrant deferral of further injections.     

Retinal angiomatous proliferation: clinical characteristics and treatment options.

BACKGROUND: A new form of exudative age-related macular degeneration (ARMD), retinal angiomatous proliferation (RAP), has been described in which neovascularization begins in the deep retina, extends through the subretinal space, and eventually communicates with choroidal neovascularization. METHODS: Case series. RESULTS: Common clinical features of RAP include small multiple intra-retinal hemorrhages, intra-retinal edema, vascularized pigment epithelial detachments (PEDs), and retinal choroidal anastomosis (RCA). Fluorescein angiography (FA) reveals ill-defined, occult choroidal neovascularization. Indocyanine green (ICG) angiography is useful in early stages because 'hot spots' can be detected before clinical or FA characteristics are present. Optical coherence tomography (OCT) is useful in illustrating some of the clinical and FA characteristics. The use of photodynamic therapy (POT), combined with intravitreal triamcinolone injection, was successful in stabilizing the RAP lesion in one case discussed in this report. CONCLUSIONS: Retinal angiomatous proliferation is a newly recognized entity of exudative age-related macular degeneration with its own set of clinical, FA, ICG angiography, and OCT features. Experimental treatments such as the use of PDT combined with intravitreal triamcinolone injection demonstrate potential success with this entity. The biggest hope appears to be anti-angiogenic factors currently in clinical trials for the treatment of exudative ARMD.     

Retinal pigment epithelial tears after intravitreal bevacizumab injection for neovascular age-related macular degeneration

PURPOSE: To study retinal pigment epithelium (RPE) tears after off-label intravitreal bevacizumab (Avastin; Genentech, Inc., South San Francisco, CA) injection for neovascular age-related macular degeneration. Eyes with a vascularized pigment epithelial detachment (PED) that developed an RPE tear were compared with eyes with a vascularized PED but without an RPE tear. METHODS: Nine retina specialists across the United States and in Europe participated in this retrospective case series. All eyes that received intravitreal bevacizumab injection for choroidal neovascularization (CNV) over 12 months (October 2005 to September 2006) were included. Eyes without all three confirmed tests (fluorescein angiography, fundus photography, and optical coherence tomography) were excluded from analysis. Statistical analyses were performed on multiple characteristics of eyes with a vascularized PED that did and did not develop an RPE tear. RESULTS: Among 2,785 intravitreal bevacizumab injections for 1,064 eyes, RPE tears were found in 22 eyes in 22 patients (2.2%). A vascularized PED was present in 21 of 22 eyes that developed an RPE tear (17.1% of PED eyes; 15, 100% occult CNV; 6, predominantly occult CNV). Mean interval from bevacizumab injections to RPE tears was 37.3 days. Mean follow-up time was 124.9 days. Mean subfoveal PED size was larger for eyes with tears than for those without tears (13.97 mm vs 9.9 mm, respectively; P = 0.01; odds ratio, 1.09). There was substantially smaller mean ratio of CNV size to PED size for eyes with tears than for those without tears (27.9% vs 67.6%, respectively; P = 0.005). Mean pre-bevacizumab injection best-corrected Snellen visual acuity was 20/162, and mean post-RPE tear best-corrected visual acuity was 20/160 (P = 0.48). CONCLUSION: Large PED size is a predictor for RPE tears, and a small ratio of CNV size to PED size (<50%) is more common in eyes with RPE tears. Vision may be preserved despite RPE tears.     

Intravitreal bevacizumab for refractory pigment epithelial detachment with occult choroidal neovascularization in age-related macular degeneration

PURPOSE: New medications targeting vascular endothelial growth factor show promise in the treatment of wet macular degeneration. This study describes the clinical response and optical coherence tomography (OCT) findings for patients with refractory pigment epithelial detachment (PED) and occult choroidal neovascular membranes (CNVMs) who were treated with intravitreal bevacizumab. METHODS: A retrospective analysis of data for 10 patients with fibrovascular PEDs, initially treated with intravitreal pegaptanib, thermal laser, or photodynamic therapy with or without triamcinolone acetonide administration, was performed. All patients were refractory to previous treatment. They received monthly injections of bevacizumab and were followed by clinical examination, angiography, and OCT. RESULTS: Nine of 10 patients had stable or improved vision. Angiogram findings showed resolution of leakage from CNVMs. OCT demonstrated resolution of the subretinal or intraretinal fluid but persistence of the PED itself. Vision improvement was correlated with OCT changes. CONCLUSION: Intravitreal bevacizumab may be a viable option in treating patients with fibrovascular PEDs. OCT findings suggest that visual improvement is secondary to resolution of subretinal and intraretinal edema without resolution of the PED.     

Retinal pigment epithelial tear following intravitreal ranibizumab injections for neovascular age-related macular degeneration

Background To report the development of retinal pigment epithelial (RPE) tear after intravitreal injection of ranibizumab (Lucentis, Novartis, Basel, Switzerland). Methods Case report with presentation of the fundus photography, fluorescein angiography (FA) and optical coherence tomography (OCT) findings. Results A 70-year-old man received intravitreal injections of ranibizumab for the treatment of occult choroidal neovascularisation (CNV) with fibrovascular pigment epithelial detachment due to age-related macular degeneration. One day after the third intravitreal ranibizumab injection, fundus examination showed a RPE defect at the foveal region. FA and OCT confirmed the presence of RPE tear sparing the fovea. No further progression of the RPE tear was observed after withholding subsequent ranibizumab injection and his right eye visual acuity remained at 20/100 at 3 months from the last injection. Conclusions As with other anti-vascular endothelial growth factor treatment for CNV, RPE tear might occur after intravitreal ranibizumab injection even after previous uneventful intravitreal injections.     

One-year results of combined photodynamic therapy and intravitreal bevacizumab injection for retinal pigment epithelial detachment secondary to age-related macular degeneration

Background  To evaluate the efficacy of combined photodynamic therapy (PDT) and intravitreal bevacizumab injection in eyes with a serous pigment epithelial detachment (PED) associated with age-related macular degeneration (AMD). Methods  Twenty-two eyes with a serous PED exceeding two disc areas associated with AMD with choroidal vascular abnormalities [choroidal neovascularization (n = 10), polypoidal choroidal vasculopathy (n = 9), and retinal angiomatous proliferation (n = 3)] received combined PDT and intravitreal bevacizumab, and were followed about every 6 weeks for more than 1 year. Additional treatments were given for residual or recurrent lesions. The main outcome measures were changes in the PED height measured by optical coherence tomography, and the best-corrected visual acuity. Results  After one treatment, the PED resolved in 12 eyes (55%) and the PED decreased in ten eyes (45%). There was no recurrence in eight (36%) eyes; however, PED recurred in 14 eyes. At 1 year, the average PED height decreased to 413 microns from the baseline 751 microns (p < 0.001). Twenty eyes (91%) had improved or stabilized vision; two eyes had decreased vision due to a retinal pigment epithelial tear and subretinal hemorrhage. Conclusions  Combined PDT and intravitreal bevacizumab may decrease the PED height and stabilize visual acuity at 1 year. The authors have no proprietary and financial interest in any aspect of this report.     

Complete resolution of a giant pigment epithelial detachment secondary to exudative age-related macular degeneration after a single intravitreal ranibizumab (lucentis) injection: results documented by optical coherence tomography

Aim

To describe a patient with a giant pigment epithelial detachment (PED) secondary to exudative age-related macular degeneration (ARMD) successfully treated with a single intravitreal ranibizumab (Lucentis) injection (0.5 mg/0.05 ml).

Methods

An 89-year-old woman presented with a six-day history of reduced vision and distortion in the left eye. Best-corrected visual acuity in that eye was 6/15. Fundoscopy revealed a giant PED and exudates temporally to the fovea. Optical coherence tomography showed a PED associated with subretinal and intraretinal fluid. Fluorescein angiography confirmed the diagnosis of an occult choroidal neovascularization. Treatment with intravitreal injections of ranibizumab (Lucentis) was recommended, although the increased risk of retinal pigment epithelium (RPE) rip was mentioned.

Results

Four weeks after the first intravitreal Lucentis injection, the visual acuity in the left eye improved to 6/7.5, with a significant improvement of the distortion and a complete anatomical resolution of the PED confirmed by optical coherence tomography.

Conclusion

Giant PED secondary to exudative ARMD can be successfully treated with intravitreal ranibizumab, despite the increased risk of RPE rip. To our knowledge, this is the first case presenting with complete resolution of PED after a single ranibizumab injection.Key Words: Age-related macular degeneration, Anti-VEGF, Pigment epithelial detachment, Ranibizumab (Lucentis), Retinal pigment epithelium rip     

Intravitreal injection of triamcinolone combined with bevacizumab for choroidal neovascularization associated with large retinal pigment epithelial detachment in age-related macular degeneration

Purpose  

To discuss the effect and outcome of a combined intravitreal triamcinolone acetonide (IVTA) injection with intravitreal bevacizumab (IVB) in treating choroidal neovascularization (CNV) associated with large retinal pigment epithelial detachment (PED) in age-related macular degeneration (AMD).     

Retinal microangiopathies overlying pigment epithelial detachment in age-related macular degeneration

PURPOSE: To evaluate alterations in the retinal vasculature overlying pigment epithelial detachments (PED) in exudative age-related macular degeneration (ARMD) using indocyanine green and fluorescein angiography. METHODS: Forty-one patients (41 eyes) with a clinical diagnosis of exudative ARMD with PED underwent simultaneous fluorescein and indocyanine green angiography, also under high (10 degrees ) magnification. Vascular abnormalities in the retina were compared between patients with vascularized (n = 34, group 1) and nonvascularized (n = 7, group 2) PED on indocyanine green angiography and correlated with the size of the PED and the presence of serous retinal detachment. RESULTS: In all, 67 vascular abnormalities were found by indocyanine green angiography and only 22 by fluorescein angiography; this finding was statistically significant (P < 0.0001). The finding of retinal vasculopathy (32 patients in group 1 and two patients in group 2) was directly correlated with the presence of choroidal neovascularizations (P = 0.002). There was also a direct correlation between the presence of choroidal neovascularization and size of the PED (P = 0.03). The number of retinal vascular findings was not significantly correlated with serous elevation of the retina. CONCLUSIONS: Retinal vasculopathies may be observed in eyes with PED and are detectable by indocyanine green and fluorescein angiography.     

RPE-rip after intravitreal bevacizumab (Avastin) treatment for vascularised PED secondary to AMD.

BACKGROUND: Retinal pigment epithelial (RPE)-rips in age-related macular degeneration (AMD)-associated pigment epithelial detachment (PED) occur in the natural course of the disease but also after therapy (e.g. laser photocoagulation, photodynamic therapy), possibly triggered by the specific therapy. We report here on four patients that received intravitreal bevacizumab (Avastin) for AMD-associated vascularised PED and developed RPE-rips during the follow-up. METHODS: The case reports of four consecutive patients that developed RPE-rips after intravitreal injection of bevacizumab at 1 mg/0.1 ml were reviewed. RESULTS: The RPE-rips occurred in all patients between 1 week and 1 month following intravitreal injection. Two of the four patients improved in vision despite the rip, but 3 months after the initial intervention, three patients suffered deterioration in visual acuity and had to be re-injected. CONCLUSION: Improvement in visual acuity may occur following intravitreal bevacizumab despite RPE-rips, but the patients need close follow-up and eventual re-treatment in the case of deterioration.     

Retinal pigment epithelial tear following intravitreal pegaptanib sodium

PURPOSE: To report two cases of a retinal pigment epithelial tear after intravitreal injection of pegaptanib sodium. To our knowledge, this is the first report of this finding after intraocular antivascular endothelial growth factor therapy. DESIGN: Observational case reports. METHODS: Two patients presented with occult choroidal neovascularization and associated serous pigment epithelial detachment that was a result of age-related macular degeneration. Both patients were treated with an intravitreal injection of pegaptanib sodium. RESULTS: One patient developed a retinal pigment epithelium tear one week after the intravitreal injection. The second patient developed a retinal pigment epithelium tear eight weeks after treatment. CONCLUSIONS: Although these cases may represent natural history, there should be a high index of suspicion for retinal pigment epithelium tears in patients who report significant visual deterioration after intravitreal injection of pegaptanib sodium. Further studies are needed to determine whether angiographic subtypes of choroidal neovascular membranes are more susceptible to developing retinal pigment epithelium tears after treatment with antivascular endothelial growth factor agents.     

Intravitreal triamcinolone in the treatment of serous pigment epithelial detachment and occult choroidal neovascularization secondary to age-related macular degeneration

PURPOSE: To report two cases of occult choroidal neovascularization (CNV) and serous pigment epithelial detachment (PED) treated with intravitreal triamcinolone (IVT) injections. METHODS: Interventional case reports. RESULTS: Both patients showed an increase in visual acuity and a complete flattening of the PED at 10 months (Case 1) and 4 months (Case 2) after IVT injections. No complications or adverse effects are reported. CONCLUSIONS: Future studies should be designed to investigate if IVT can effectively influence the clinical and functional outcome of eyes with serous PED and occult CNV secondary to age-related macular degeneration, for which at the moment no treatment has been shown to be effective.     

Idiopathic polypoidal choroidal vasculopathy (IPCV) presenting with simultaneous choroidal neovascular membrane (CNM).

Idiopathic polypoidal choroidal vasculopathy (IPCV), a rare retinal condition initially described in 1982, is characterized by retinal pigment epithelial (RPE) detachments associated with choroidal polypoidals. Although it is recognized as a unique entity, many consider it a peculiar representation of choroidal neovascular membrane (CNM), commonly associated with age-related macular degeneration (ARMD). We report a case of IPCV with simultaneous presentation of CNM. Dilated examination and fluorescein angiography (FA) revealed RPE detachments associated with choroidal polypoidals. FA also revealed a lacy hyperfluorescent vascular lesion. Ocular manifestations, differential diagnoses, and treatment options are discussed, with emphasis on similarities and differences between IPCV and CNM. It is imperative to consider IPCV in the differential diagnosis of RPE detachments, including those associated with CNM. Careful funduscopic evaluation, FA, and/or indocyanine green videoangiography analysis helps confirm the diagnosis.     

Pigmentepithelabhebungen bei AMD und “polypoidal choroidal vasculopathy”Eine fluoreszein- und indozyaningrünangiographische Studie

Aims. A prospective analysis to differentiate the angiographic appearance of pigment epithelial detachments (PED) in age-related macular degeneration (AMD) was performed. The aim was to verify if characteristics of polypoidal choroidal vasculopathy (PCV) can be observed in elderly patients with Central European background. Patients and methods. Fluorescein and indocyanine green angiography was performed in101 consecutive patients (53–87 years, 63 females, 38 males) with clinical signs of PED and drusen. Results. Different types of PED could be differentiated: PCV-associated PED in 14 patients (13.9%), vascularized PED in 72 patients (71.2%), and nonvascularized PED in 15 patients (14.9%). Conclusions. The clinical diagnosis of PED in AMD can be differentiated by angiography into PCV-associated PED, vascularized PED, and nonvascularized PED. This differentiation is important because PCV-associated PED may have a pathogenetic and genetic background other than age-related changes in Bruch's membrane. These patients also may share a natural course and treatment options different from PED in AMD.     

Severe choroidal ischemia following Photodynamic Therapy for pigment epithelial detachment and chronic central serous chorioretinopathy

Background  Photodynamic therapy (PDT) has proven beneficial in the treatment of central serous chorioretinopathy (CSC). Cases  Two patients with serous pigment epithelial detachments (PEDs) and one patient with chronic CSC developed an abrupt visual loss caused by severe choroidal ischemia following PDT. Serous PEDs in the two patients were regarded as a latent variant of CSC. PDT was performed in accordance with the Treatment of Age-Related Macular Degeneration with Photodynamic Therapy guidelines. Observations  Although following PDT, PEDs and serous sensory retinal detachments resolved in all patients, the laser-treated areas of the patients revealed severe choroidal ischemia and their visual acuity decreased. Only in case 1 did visual acuity recover to the pretreatment level 2 months after treatment. In case 2, visual acuity was still reduced 7 months after treatment. In case 3, secondary choroidal neovascularization developed in the treatment area 1 month after treatment. Conclusions  In the CSC variant associated with PED only or in chronic CSC, PDT performed by the standard procedure can increase the risk of severe choroidal ischemia. Further studies are needed to find safe and optimal PDT parameters.     

RPE-rip after intravitreal bevacizumab (Avastin) treatment for vascularised PED secondary to AMD

Background Retinal pigment epithelial (RPE)-rips in age-related macular degeneration (AMD)-associated pigment epithelial detachment (PED) occur in the natural course of the disease but also after therapy (e.g. laser photocoagulation, photodynamic therapy), possibly triggered by the specific therapy. We report here on four patients that received intravitreal bevacizumab (Avastin) for AMD-associated vascularised PED and developed RPE-rips during the follow-up. Methods The case reports of four consecutive patients that developed RPE-rips after intravitreal injection of bevacizumab at 1 mg/0.1 ml were reviewed. Results The RPE-rips occurred in all patients between 1 week and 1 month following intravitreal injection. Two of the four patients improved in vision despite the rip, but 3 months after the initial intervention, three patients suffered deterioration in visual acuity and had to be re-injected. Conclusion Improvement in visual acuity may occur following intravitreal bevacizumab despite RPE-rips, but the patients need close follow-up and eventual re-treatment in the case of deterioration. None of the authors has a propietary interest in the presented cases.     

Prospective evaluation of aflibercept in pigment epithelial detachments secondary to neovascular age related macular degeneration

ObjectiveTo assess the efficacy of intravitreal aflibercept in treating visual loss and structural changes in patients with pigment epithelial detachments (PED) secondary to neovascular age-related macular degeneration (nAMD).MethodsProspective, exploratory, open-label study (ClinicalTrials.gov Identifier: NCT02142296). Participants with PED secondary to nAMD were enrolled and received intravitreal aflibercept injection on a monthly basis for 3 months, followed by injections on a bimonthly basis for another 9 months. Best-corrected visual acuity (BCVA), ophthalmic examinations, optical coherence tomography (OCT) imaging, and fluorescein angiography were performed based on a predetermined schedule.ResultsThirty-six participants (37 eyes) were enrolled. At the end of study, 74.3% eyes demonstrated PED height reduction of 25% or more and 34.3% demonstrated complete resolution. The average reduction in retinal thickness was 128.4 μm. Participant eyes who had at least a 25% reduction in PED height at month 4 were labelled as “responders” (73.0%, n = 27), and those who had less than 25% reduction in PED height were labelled as “partial-responders” (27.0%, n = 10). Responders demonstrated more significant reduction in PED height than partial-responders (p <0.0001). The average gain in BCVA was 10.1 Early Treatment Diabetic Retinopathy Study (ETDRS) letters. Responders demonstrated more gain in BCVA than partial-responders (p = 0.0018). Among the responders, 57.7% demonstrated disease recurrences with increase in PED height during bimonthly dosing.ConclusionsIntravitreal aflibercept injection for patients with PEDs secondary to nAMD has high response rate with few adverse events. Responders demonstrated BCVA gains, as well as structural improvements. However, high recurrence rate was found on bimonthly maintenance dosing.     

Angiographic lesion of polypoidal choroidal vasculopathy on indocyanine green and fluorescein angiography

BACKGROUND: Before treating polypoidal choroidal vasculopathy (PCV), the extent of the lesion should be determined, but the angiographic lesion size of PCV is sometimes different when comparing indocyanine green angiography (ICGA) and fluorescein angiography (FA). The purpose of this study was to evaluate angiographic findings and compare the lesion sizes of PCV on ICGA and FA using confocal scanning laser ophthalmoscopy (SLO) and fundus camera. METHODS: Thirty-seven eyes of 37 patients with PCV were examined by ICGA and FA using confocal SLO and a fundus camera, and the findings and the lesion sizes were compared during the early, mid, and late-phases of ICGA and FA. RESULTS: The polyps with abnormal vessel networks were depicted on ICGA in all eyes and the lesion showed classic-type leakage on FA in 15 eyes. Ten eyes with a pigment epithelial detachment (PED) had the maximal lesion size on FA because hyperfluorescent areas involving PED were determined as the lesions; although on ICGA, a PED distinguished from abnormal vessels was not included in the lesion. In 27 eyes without a PED, the early-phase of ICGA using confocal SLO showed the maximal lesion size in 24 eyes (89%) and the late-phase in three eyes (11%), and the maximal size on ICGA agreed on FA. While FA depicted the maximal lesion sizes in 24 eyes (89%), another three eyes showed the maximal lesion size on early-phase ICGA on confocal SLO. The maximal lesion size on ICGA using a fundus camera was smaller than when using confocal SLO in seven eyes (19%). CONCLUSIONS: The ICGA on confocal SLO could visualize the more detailed findings of the abnormal vasculature of PCV and the FA showed hyperfluorescent regions overlaying the lesions. To determine the maximal lesion size on angiograms, early-phase ICGA using confocal SLO and FA should be referred.