Brolucizumab for Choroidal Neovascular Membrane with Pigment Epithelial Tear and Subretinal Fluid

The aim of this study was to determine the utility of brolucizumab in the management of choroidal neovessels (CNV) with a retinal pigment epithelial (RPE) tear and subretinal fluid. We used a case series of patients with CNV who developed an RPE tear either spontaneously or following an intravitreal injection. All patients received intravitreal brolucizumab as primary or switch therapy. Appropriate data were collected. Follow-up was one year. The paired t-test was used to determine the significance of the results. The primary outcome measure was the change in best corrected visual acuity (BCVA). Secondary outcome measures were the change in subretinal fluid and complications, if any. A total of five patients were included in the analysis. The age range was 67−74 years and baseline BCVA was from 20/80 to 20/100. On average, all patients showed improvement in BCVA (p = 0.012) and also showed a significant anatomical improvement (p = 0.03). None of the patients had any complications, and all patients responded to additional anti-VEGF injections. In conclusion, all patients showed significant visual and anatomical improvement with brolucizumab; no complications were noted. All patients, including those who received switch, demonstrated a favorable anatomical and visual response to intravitreal brolucizumab without safety concerns.

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.

Retinal Pigment Epithelium Tears After Anti-Vascular Endothelial Growth Factor Therapy for Neovascular Age-Related Macular Degeneration

Purpose: To assess the visual prognostic factors of retinal pigment epithelium (RPE) tears and describe their clinical features. Methods: The medical records of treatment-naive neovascular age-related macular degeneration patients who received intravitreal anti-vascular endothelial growth factor (VEGF) injections were retrospectively reviewed. Results: The incidence of RPE tears was 1.36% (10 out of 733 eyes). The type of anti-VEGF agent administered did not affect the incidence (p = 0.985). The median best-corrected visual acuity (BCVA) of 10 patients decreased after an RPE tear (0.4 to 0.6 logMAR); however, subsequent injections restored the BCVA to a level similar to that before the RPE tear (0.4 logMAR, p = 0.436). Central macular thickness improved significantly during the study (794.4 to 491.9 μm, p = 0.013). The final BCVA was positively correlated with the BCVA before and immediately after the RPE tear (p = 0.025 and 0.002, respectively) and was weakly correlated with foveal involvement of the RPE tear (p = 0.061). Conclusion: The incidence of RPE tears did not differ according to the type of anti-VEGF agent. The final BCVA was proportional to the BCVA before and after RPE tears. Continuous treatment with anti-VEGF after the occurrence of RPE tears can benefit the final visual acuity and macular anatomy.

Systemic steroids for the management of choroidal neovascular membrane with pigment epithelial tear and recalcitrant subretinal fluid

A 67-year-old man was diagnosed to have dry age related macular degeneration in the right eye and a choroidalneovascular membrane (CNVM) with a large pigment epithelial detachment in the left eye, confirmed with clinical examination, angiography and optical coherence tomography scans. He received an intravitreal injection of bevacizumab in the right eye and developed a retinal pigment epithelial (RPE) tear 3 weeks later. 3 consecutive ranibizumab injections failed to clear the subretinal fluid (SRF). A course of systemic steroids was administered and this improved the vision. Subsequently, the patient received one more ranibizumab injection and the disease process resolved. The left eye corrected distance visual acuity (LE CDVA) was 20/30 at the final visit (1 year after the last injection). Systemic steroids may be a management option in patients with CNVM and RPE tear with recalcitrant SRF if there is no contraindication to their use.

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 Epithelium Tear Following Aflibercept for Exudative Macular Degeneration Tachyphylactic to Anti-Vascular Endothelial Growth Factor A Agents

Purpose: To report two cases of retinal pigment epithelium (RPE) tears following treatment with aflibercept of exudative macula degeneration associated with pigment epithelial detachment (PED) tachyphylactic to antivascular endothelial growth factor (VEGF) A agents such as bevacizumab or ranibizumab.Methods: Retrospective case series of patients with exudative macular degeneration with PED who were managed with anti-VEGF A agents that developed RPE tear following the first aflibercept injection. The patients were followed with optical coherence tomography and fluorescein angiography.Results: In our two cases, RPE tear developed after being switched from bevacizumab or ranibizumab to treatment with aflibercept. Both cases were rescued with monthly ranibizumab injections. In each case vision and macular edema improved with continued treatment.Conclusion: RPE tears may occur following injection with aflibercept for treatment of exudative AMD tachyphylactic to bevacizumab or ranibizumab. Continued anti-VEGF treatment can be effective rescue therapy.

Prechoroidal Cleft in Type 3 Neovascularization: Incidence, Timing, and Its Association with Visual Outcome

Purpose. To investigate the incidence and timing of prechoroidal cleft development and its association with visual prognosis in type 3 neovascularization. Methods. This retrospective study included 166 eyes that were diagnosed with type 3 neovascularization. All eyes were treated with antivascular endothelial growth factor therapy. The incidence and timing of prechoroidal cleft development were evaluated. Best-corrected visual acuity (BCVA) at diagnosis and at final follow-up was compared between eyes with (cleft group) and without (no-cleft group) prechoroidal cleft. The incidence of retinal pigment epithelium (RPE) tear and subretinal hemorrhage was also compared between the two groups. Results. During the mean 39.7 ± 18.5 months of follow-up, prechoroidal cleft developed in 37 eyes (22.3%) at an average of 14.6 ± 10.4 months. The BCVA at final follow-up was significantly worse in the cleft group than in the no-cleft group (P=0.024), whereas the difference was not significant at diagnosis (P=0.969). The incidence of RPE tear (P=0.002) and subretinal hemorrhage (P<0.001) was significantly higher in the cleft group. Conclusions. Prechoroidal cleft is a frequently observed finding during the treatment course of type 3 neovascularization. Eyes with prechoroidal cleft are at high risk of RPE tear or subretinal hemorrhage and subsequently associated with poor prognosis.

Retinal Pigment Epithelium Tear Following Aflibercept for Exudative Macular Degeneration Tachyphylactic to Anti-Vascular Endothelial Growth Factor A Agents

Purpose: To report two cases of retinal pigment epithelium (RPE) tears following treatment with aflibercept of exudative macula degeneration associated with pigment epithelial detachment (PED) tachyphylactic to antivascularendothelial growth factor (VEGF) A agents such as bevacizumab or ranibizumab.Methods: Retrospective case series of patients with exudative macular degeneration with PED who were managed with anti-VEGF A agents that developed RPE tear following the first aflibercept injection. The patients were followed with optical coherence tomography and fluorescein angiography.Results: In our two cases, RPE tear developed after being switched from bevacizumab or ranibizumab to treatment with aflibercept. Both cases were rescued with monthly ranibizumab injections. In each case vision and macular edema improved with continued treatment.Conclusion: RPE tears may occur following injection with aflibercept for treatment of exudative AMD tachyphylactic to bevacizumab or ranibizumab. Continued anti-VEGF treatment can be effective rescue therapy.

Retinal Pigment Epithelium Tears: Risk Factors, Mechanism and Therapeutic Monitoring

Tears of the retinal pigment epithelium (RPE) are most commonly associated with vascularised RPE detachment due to age-related macular degeneration (AMD), and they usually involve a deleterious loss in visual acuity. Recent studies suggest an increase in RPE tear incidences since the introduction of anti-vascular endothelial growth factor (anti-VEGF) therapies as well as a temporal association between the tear event and the intravitreal injection. As the number of AMD patients and the number of administered anti-VEGF injections increase, both the challenge of RPE tear prevention and the treatment after RPE tear formation have become more important. At the same time, the evolution of retinal imaging has significantly contributed to a better understanding of RPE tear development in recent years. This review summarises the current knowledge on RPE tear development, predictive factors, and treatment strategies before and after RPE tear formation.