Color fundus photograph of a patient who developed RPE tear after intravitreal anti-VEGF therapy reveals well-defined hyperpigmented line at the site of the rolled RPE (arrow), and a depigmented area corresponding to the exposed choroid (star).
Vertical and horizontal OCT scans show the rolled RPE which causes a hyperreflectivity and an intense back-shadowing (arrows) and the missing RPE band causing an increased depth signal due to the absent RPE (star).
In FAF imaging, areas of RPE tears exhibit a markedly reduced autofluorescent signal since RPE cells with fluorescent lipofuscin are lost
Tears of the retinal pigment epithelium (RPE) are most commonly associated with vascularized pigment epithelium detachment (PED) due to age-related macular degeneration (AMD). RPE tears might occur in the natural course of a PED with underlying macular neovascularization or polypoidal choroidal vasculopathy. Risk factors for RPE tears have been established in patients with AMD receiving anti-VEGF injections, and include larger lesion linear diameter, vertical PED dimension, and duration of PED formation.
The diagnosis of RPE tears is clinical, and can be assisted by different imaging modalities. In a classical RPE tear from a vascularized PED, the hallmark on OCT is a discontinuity of the hyperreflective RPE band, with a free edge of RPE usually wavy and scrolled up overlying the PED, contracted back towards the macular neovascularization. The area where the RPE is missing will demonstrate marked a window defect where there is increased depth signal. Moreover, in fundus autofluorescence, areas of RPE tears reveal marked hypoautofluorescence, since the RPE accounts for the signal; while the area of “scrolled” or bunched up RPE adjacent to the tear area can demonstrate hyperautofluorescence.
Credit: Kemal Tekin, M.D., from Ulucanlar Eye Training and Research Hospital
Instagram accounts: @retina.academy and @dr.kemaltekin