Pigment epithelial detachment in polypoidal choroidal vasculopathy

PURPOSE: To study the morphological features of serosanguineous pigment epithelial detachments (PEDs) with accompanying polypoidal lesions in eyes with polypoidal choroidal vasculopathy (PCV). DESIGN: Retrospective observational case series. METHODS: For this observational case study, we retrospectively reviewed 93 consecutive eyes of 85 patients with PCV. The lesions in eyes with PCV were examined with indocyanine green angiography (IA) and optical coherence tomography (OCT). RESULTS: Of 93 eyes with PCV, 51 eyes (55%) had serous or hemorrhagic PEDs. Of these 51 eyes, a notch in the PED was found in 27 eyes (53%) by angiography, most of which showed polypoidal lesions by IA that corresponded in location to the notch observed by angiography. Polypoidal lesions were detected outside the PED in one eye (2%), at the margin of the PED in 33 eyes (65%), and inside the PED in 12 eyes (24%). OCT revealed that PED had a notch observed tomographically in 29 eyes (57%), most of which corresponded in location to polypoidal lesions seen by IA. In eight eyes, polypoidal lesions, which were adherent to the inner surface of the serous PED, appeared to be detached from the Bruch membrane and the choroid. CONCLUSIONS: Polypoidal lesions are located at the margin of PED and make a notch in the accompanying PED that is visible by angiography and tomographically. When the polypoidal lesions have increased exudate, the fluid from the lesions infiltrates under the polypoidal lesions themselves, which results in the lesions detaching from the Bruch membrane and appearing to be located inside the PED.     

Pigment epithelial proliferation in human retinal detachment with massive periretinal proliferation

Biopsy specimens from vitreous and preretinal membranes, obtained during vitreous surgery from 39 human eyes suffering from massive periretinal proliferation, were examined electron-microscopically. Analysis of the cellular membranes demonstrated mostly cells with epithelial characteristics: polarization of the cells, basal lamina formation, specialized cellular junctions, and microvilli formation. These epithelioid cells contained prominent rough endoplasmic reticulum, glycogen deposits, a multitude of cytoplasmic filaments, some resembling myofilaments, and nonmembrane bound, sometimes wedge-shaped pigment granules. Macrophages were interspersed in the membranes. There was a striking similarity of these findings to those of an experimental model of retinal detachment in owl monkeys, We concluded that most likely the described cells derived from cells of pigment epithelial origin.     

Pigment epithelial repair

We studied the repair of large, surgically induced retinal pigment epithelial defects in rabbit eyes for up to 28 days. Ophthalmoscopically, the pigment epithelium surrounding the defect became less pigmented and scattered pale foci appeared. The margin remained distinct for 28 days and the defect was subsequently covered by a variable lacework of pigmentation. Angiographically, the acute defect was hyperfluorescent and leaked heavily, but within 7 days fluorescein leakage had ceased. Histology, transmission and scanning electron microscopy, and autoradiography for the study of cells in division revealed that the pigment epithelium surrounding the defect became pleomorphic after 1 day, began to proliferate within 3 days, and covered the defect within 7 days. Subsequently, many cells became pigmented and some were fibrocyte-like. The cells within the healing defect appeared to have derived from the pigment epithelium. Our findings suggest that similar processes occur in large human defects such as pigment epithelial rips.Supported by a National Institutes of Health grant (EY02903), by Research to Prevent Blindness, Inc., New York, and by the Helena Rubinstein Foundation, New York Offprint requests to: R. Machemer     

Retinal pigment epithelial detachment

Detachment of the retinal pigment epithelium is a prominent feature of many chorio-retinal disease processes, the most prevalent of which is age-related macular degeneration (AMD). Detachment of the retinal pigment epithelium may or may not be associated with choroidal neovascularization and may be caused by different types of pathogenesis, each associated with distinct angiographic features, natural course, visual prognosis, and response to treatment. The phrase "detachment of the retinal pigment epithelium" is used quite often, not always in the correct association and with no clear differentiation between its various types. It is important to identify the specific nature of detachment of the retinal pigment epithelium, and to establish an accurate diagnosis and treatment plan. Therefore, we present a review of the existing types of detachment of the retinal pigment epithelium with what we propose as being appropriate nomenclature and classification, and potential treatment recommendations.     

Retinal pigment epithelial detachment

The vast majority of cases of AMD involve widespread disease with visible neovascularization, "occult" neovascularization, and serous as well as hemorrhagic detachments of the RPE. Accurate interpretation of the clinical and fluorescein angiographic findings in PEDs is difficult. The most noteworthy problem is the recognition of the presence and extent of associated neovascularization. Definitive guidelines for laser photocoagulation treatment of these PEDs have not yet been established. Large-scale, sophisticated clinical trials are needed to assess the efficacy and safety of laser treatment for this important manifestation of exudative AMD. Until these investigations are completed, certain cases of PEDs may be selected for laser treatment by one of three treatment techniques. A grid pattern photocoagulation to a serous PED may be carried out when there is no demonstrable or suspected underlying SRN and there is persistence and progression of the detachment with associated visual decline. Total photocoagulation of the PED which is suspected of having neovascularization can also be carried out if the fovea can be spared. Finally, photocoagulation of extrafoveal neovascularization beneath or at the margin of a PED can be performed in an attempt to obliterate the neovascularization, resolve the exudative manifestations, and stabilize or improve the vision. Only experienced retinal specialists who are well trained in the recognition of the complex clinical and fluorescein angiographic features of PEDs should attempt to treat these unusual and complicated cases.     

Retinal pigment epithelial detachment in sarcoidosis

PURPOSE: To report primary retinal pigment epithelial (RPE) detachments in sarcoidosis. DESIGN: Case report. METHODS: Clinical findings, fluorescence angiography and optical coherence tomography (OCT) results are presented and discussed. RESULTS: A 54-year-old Hispanic male with biopsy proved sarcoidosis presented with multiple RPE detachment in both eyes. Except for acute iritis, there were no other ocular manifestations of sarcoidosis. CONCLUSIONS: Detachments of the RPE may be a rare manifestation of ocular sarcoidosis.     

Intravitreal aflibercept in treatment-resistant pigment epithelial detachment

The purpose of the study was to assess the efficacy and safety of transition from ranibizumab to aflibercept intravitreal injections in treatment-resistant retinal pigment epithelial detachment (PED). The data of intravitreal ranibizumab treatment-resistant patients who have been switched to aflibercept treatment were reviewed retrospectively. After three monthly injections, bimonthly regimen was performed. The changes of PED height and radius, and the best-corrected visual acuity (BCVA) were analyzed retrospectively. Mean baseline PED height decreased from 297 ± 151 to 122 ± 42 µm at month 12 (P = 0.0007). Mean baseline PED radius decreased from 2371 ± 882 to 1859 ± 779 µm at month 12 (P = 0.0007). No complete PED resolution occurred in any of the patients at the end of the 12 months. Baseline BCVA improved from 0.63 ± 0.21 to 0.43 ± 0.17 logMar at month 12 (P = 0.0049). Mean BCVA gain was 1.4 decimal chart lines (7 letters) at month 12. Switching to aflibercept seems to have promising functional and anatomical outcomes with a reasonable complication rate in treatment-resistant PED.     

Occult retinal pigment epithelial detachment in hyperviscosity syndrome

We document and evaluate a serous retinal detachment in a patient with hyperviscocity syndrome. Optical coherence tomographic images of the serous retinal detachment in a patient with hyperviscocity syndrome were correlated with slit-lamp biomicroscopic findings, fundus photographs, fluorescein angiograms, and indocyanine green angiograms. Fluorescein angiography demonstrated venous and capillary bed abnormalities but no leakage or pooling of fluorescein corresponding to the retinal pigment epithelial detachment (PED) beneath the serous retinal detachment. Indocyanine green angiogram disclosed a delay of intrachoroidal circulation. Optical coherence tomography (OCT) revealed a large retinal pigment epithelial detachment beneath the serous retinal detachment. The occult retinal PED beneath the neurosensory retinal detachment was detected only by OCT in a patient with hyperviscosity syndrome. We suggest that gamma globulin, which is the hyperviscosity material, accumulated in the subretinal pigment epithelial space and blocked the leakage or pooling of fluorescein corresponding to the retinal pigment epithelial detachment.     

中心性浆液性脉络膜视网膜病变的微小色素上皮脱离

目的 应用共聚焦眼底血管造影联合光学相干断层成像技术(HRA+频域OCT系统)观察中心性浆液性脉络膜视网膜病变(central serous chorioretinopathy,CSC)荧光素渗漏点,评估渗漏点频域OCT图像特征.方法 临床确诊为CSC患者18例(21眼)接受HRA+频域OCT检查,其中男13例(13眼),女5例(8眼);年龄31～71岁,平均44.9岁,分析33处荧光素渗漏点的同步眼底血管造影及频域OCT图像.结果 应用HRA中荧光素血管造影同步定位急性CSC 12眼的14处荧光素渗漏点,频域OCT显示13处荧光素渗漏点(92.9%)伴有微小色素上皮脱离(pigment epithelium detachment,PED)及视网膜色素上皮(retinal pigment rpitelium,RPE)层光带异常改变,1处渗漏点可见较大PED(7.1%),其中3处渗漏点可见RPE光带断裂(21.4%).在复发性CSC 7处渗漏点中,频域OCT显示5处荧光素渗漏点显示PED(71.4%),较大的PED可以在其他2处荧光素渗漏点被观察到(28.6%);6处渗漏点可以看到RPE结节状突起(85.7%).在慢性CSC 6眼的12处荧光素渗漏点中,频域OCT显示7处渗漏点有微小PED,2处渗漏点可见中等程度的PED,而3处荧光素渗漏点可见高度隆起的PED(25.0%).结论 应用HRA+频域OCT系统可以对CSC的荧光素渗漏点进行准确定位,并对RPE层病理组织结构进行精确分析,大大提高了渗漏点处微小PED的检出率.研究发现微小PED、RPE形态学改变和RPE的断裂是CSC荧光素渗漏点中普遍存在的病理特征.     

Flicker perimetry and retinal pigment epithelial detachment

We report a case of a 71-year-old man with a retinal pigment epithelial detachment (PED) and occult subretinal neovascularisation. Automatic perimetry was performed with a non-flickering stimulus and an 18 Hz flickering stimulus (flicker perimetry). The addition of flicker to the perimetric task enhanced the detection of the PED. It appears that testing the ability of the visual system to process temporally encoded information can enable detection of a deficit in visual function where there is a minimal defect for conventional increment thresholds. Furthermore, given the known athophysiology of PED, it appears that flicker perimetry can enable detection of a defect of photoreceptor function. Flicker perimetry may prove December to be a useful tool for assessing retinal disease.     

Retinal pigment epithelial folds associated with retinal pigment epithelial detachment in macular degeneration

The authors reviewed six eyes that had a shallow retinal pigment epithelial detachment with the retinal pigment epithelium (RPE) thrown into folds. A contraction of subpigment epithelial fibrovascular tissue causes a folding of the overlying, intimately adherent RPE. Retinal pigment epithelial folds are a sign of subretinal neovascularization and are another manifestation of age-related macular degeneration.     

Vascularized pigment epithelial detachment in adult-onset foveomacular vitelliform dystrophy

PURPOSE: To report a case showing adult-onset foveomacular vitelliform dystrophy (AOFVD), associated with vascularized pigment epithelial detachment. CASE REPORT: A 72-year-old female affected by AOFVD complained with blurred vision and metamorphopsia in her right eye, seven months after a routinary clinical examination. Visual acuity in right eye dropped from 0.6 to 0.3, and biomicroscopic fundus examination revealed a serous pigment epithelial detachment arising from the temporal margin of the pseudovitelliform lesion. Fluorescein angiography showed an uneven filling of the pigment epithelial detachment, suggesting the presence of a subfoveal choroidal neovascularisation, which was confirmed by indocyanine green angiography. DISCUSSION: The association between AOFVD and vascularized pigment epithelial detachment, supports the hypothesis that AOFVD may be a different subgroup of age-related macular degeneration with specific genetic predisposition.     

Traumatic epithelial flap detachment after laser subepithelial keratomileusis

PURPOSE: To report a case of corneal epithelial flap detachment 20 days after laser subepithelial keratomileusis (LASEK). METHODS: A 30-year-old man underwent LASEK for correction of myopia. On postoperative day 8, he was comfortable and the corneal epithelium healed completely with uncorrected visual acuity (UCVA) of 20/20. On postoperative day 20, the corneal epithelial flap on the right eye detached and was lost during pressure patching after puncture of the hordeolum. RESULTS: The corneal defect was treated with a bandage contact lens, levofloxacin, and hyaluronic acid eye drops. Ten days after detachment, UCVA had improved to 20/20 and the epithelium had closed completely. CONCLUSIONS: Mild trauma can cause epithelial flap detachment during the early postoperative period of LASEK.     

High-dose ranibizumab therapy for vascularized pigment epithelial detachment

Purpose

The conventional dose of anti-vascular endothelial growth factor treatment may slowly reduce the subretinal fluid and height of a vascularized pigment epithelial detachment (vPED), but rarely leads to its complete resolution. We report a dramatic outcome involving a high dose (2 mg) of ranibizumab for treating vPED.

Methods

This report describes three eyes with vPED that received 2 mg in 0.05 ml of ranibizumab injections on a monthly basis and were followed prospectively. Each patient received a complete ocular examination, including best-corrected standardized ETDRS testing, fundus photography (FP), fluorescein angiography (FA), optical coherent tomography (OCT), and indocyanine-green angiography at baseline. ETDRS and OCT testing were repeated monthly, while FP and FA were performed every 3 months.

Results

Following a single intravitreal injection of 2 mg ranibizumab, there was rapid resolution of the subretinal fluid, haemorrhage, exudates, and flattening of the vPED within 10 days for Case 1, and within 1 month for Case 2 and Case 3.

Conclusion

Rapid and dramatic decrease in the exudative changes and collapse of the vPED may develop after a single injection of high-dose (2 mg) ranibizumab in certain eyes with a vPED. The improvement was maintained with additional monthly injections to 12 months.     

色素上皮细胞移植治疗视网膜变性疾病:问题与展望

近年来对色素上皮细胞移植如PRE移植、自体虹膜色素上皮细胞移植以及干细胞移植等作为视网膜变性疾病的再生性疗法进行了许多研究,为视网膜变性疾病开辟新的治疗途径。色素上皮细胞移植治疗更能直接地解决视网膜的局部问题。然而,多数方法尚处在实验和试验阶段及存在不足与风险,其手术适应证、手术方法、供体细胞来源、伦理问题、移植后细胞存活、免疫、生理功能等多种问题均亟待深入研究。     

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.     

Pigment epithelium-derived factor in the vitreous is low in diabetic retinopathy and high in rhegmatogenous retinal detachment

PURPOSE: To report the levels of pigment epithelium-derived factor in the vitreous of patients with diabetic retinopathy, rhegmatogenous retinal detachment, and idiopathic macular hole. METHODS: Using enzyme-linked immunosorbent assay, we measured the levels of pigment epithelium-derived factor in the vitreous of 34 eyes of 33 patients who underwent vitrectomy for the treatment of diabetic retinopathy (17 eyes of 16 patients), rhegmatogenous retinal detachment (10 eyes), and idiopathic macular hole (seven eyes). RESULTS: The vitreal concentration of pigment epithelium-derived factor was 1.15 +/- 0.23 microg/ml (mean +/- standard error) in eyes with diabetic retinopathy, 3.28 +/- 0.69 microg/ml in rhegmatogenous retinal detachment, and 1.71 +/- 0.39 microg/ml in idiopathic macular hole. The pigment epithelium-derived factor level in rhegmatogenous retinal detachment was significantly higher than that in diabetic retinopathy (P =.0008) and idiopathic macular hole (P =.034). For eyes with diabetic retinopathy, the pigment epithelium-derived factor level was 0.88 +/- 0.21 microg/ml in proliferative diabetic retinopathy and 2.43 +/- 0.37 microg/ml in nonproliferative diabetic retinopathy (P =.0083). Additionally, the pigment epithelium-derived factor level in active diabetic retinopathy (0.70 +/- 0.22 microg/ml) was significantly lower than the level in inactive diabetic retinopathy (1.79 +/- 0.35 microg/ml; P =.018). CONCLUSIONS: These results suggest that pigment epithelium-derived factor inhibits angiogenesis and that lower levels of pigment epithelium-derived factor may be related to the angiogenesis in diabetic retinopathy and result in active proliferative diabetic retinopathy. The results also suggest that higher levels of pigment epithelium-derived factor in the eyes with rhegmatogenous retinal detachment may act as a neuroprotective agent for the detached retina.     

Retinal pigment epithelial tear after ranibizumab therapy for subfoveal fibrovascular pigment epithelial detachment

PURPOSE: To describe the unusual complication of retinal pigment epithelial (RPE) tear after intravitreal ranibizumab (Lucentis) for subfoveal fibrovascular pigment epithelial detachment (PED) and its effective management. METHODS: Chart review for case report of RPE tear after ranibizumab. RESULTS: An inferior RPE tear was documented by fluorescein angiography, fundus photography, and optical coherence tomography (OCT) 1 month after receiving repeat ranibizumab injection in the right eye of a patient with bilateral subfoveal fibrovascular PED. He had undergone multiple bevacizumab followed by ranibizumab injections for neovascular age-related macular degeneration (AMD) in both eyes, starting 6 months previously. Subsequent antivascular endothelial growth factor (VEGF) therapy improved vision of right eye from 20/200 to 20/40, despite RPE tear. CONCLUSIONS: RPE tear may form after anti-VEGF therapy, including ranibizumab injection. Further anti-VEGF therapy may preserve or improve vision. To the authors' knowledge, this is first case report of effective suppression of neovascular activity with bevacizumab after an RPE tear following ranibizumab therapy.