Double retinal pigment epithelial tears following intravitreal ranibizumab injection for neovascular age-related macular degeneration

Case Description Intravitreal ranibizumab (Razumab®, Intas Pharmaceuticals) was given to a 74-year-old man with type 1 choroidal neovascular membrane (CNVM) in his left eye. One month later, the fundus showed a large area of absent retinal pigment epithelium (RPE), exposing the choroid with scrolled margins in the lesion’s center. An acute RPE tear was diagnosed. Two similar-looking opposite RPE tears were confirmed on fundus autofluorescence, one from the superonasal edge and the other from the inferotemporal edge. Scrolled RPE margins on either side at the pigment epithelial detachment (PED) center created the impression of two identical RPE tears [Fig. 1].Figure 1: Imaging findings in a case of double symmetrical RPE tear. (a) A color fundus photograph of the left eye taken before treatment revealed fine drusens and a well-defined, elevated, deep, circular grayish lesion, indicating a PED (white arrows). (b) An OCT scan of the left eye before injection revealed a type 1 subretinal pigment epithelium CNVM (orange and yellow arrows) occupying the entire extent of PED (white arrows) on the inner aspect of RPE, as well as a prechoroidal cleft (red arrow) and a small pocket of subretinal fluid (SRF) (blue arrow). (c and d) A large area of bare RPE exposing the choroid, with scrolled RPE margins (blue arrow on (c) and orange arrow on (d)) occupying the central portion of the bare RPE, indicating two distinct, similar-looking RPE tears (white arrows on (c) and (d)). (e) A blue-wavelength fundus autofluorescent image of the left eye revealed two well-defined patches of hypoautofluorescence, indicating two similar-looking RPE tears (white arrows) and an intervening scrolled RPE (blue arrow) in the center. Hyperautofluorescent dots were noted as well, suggestive of drusens. (f) Two months after the tear, the last OCT scan showed the bare RPE (white arrow), scrolled RPE within it (orange arrow), and reduced neovascular membrane activity. CNVM = choroidal neovascular membrane, OCT = optical coherence tomography, PED = pigment epithelial detachment, RPE = retinal pigment epitheliumDiscussion Multiple RPE tears occurring either simultaneously or sequentially are rare. Mouallem et al.[1] reported 12 cases of double RPE tears in type 1 CNVM – six occurred simultaneously and the remaining six occurred sequentially after treatment. The authors found that the initial RPE tear developed after 4.5 injections and the second after 7.1 injections. Another recent case report showed three RPE tears immediately after each anti-vascular endothelial growth factor (anti-VEGF) injection.[2] Mouallem et al.[1] believe that double RPE tears are caused by a type 1 CNVM complex contraction that is adherent to the RPE’s posterior surface and spans a significant portion of the PED area on the opposite sides of the vascularized PED. After treatment, CNVM in the current case contracted from diagrammatically opposite points of the vascularized PED, exactly as described by Mouallem et al. In contrast to Mouallem et al.,[1] who reported that most simultaneous RPE tears occurred after 5.5 intravitreal anti-VEGF injections, in our case, the double, identical RPE tears developed after the first intravitreal injection itself. No prechoroidal cleft–RPE tear association has been found. A highly vascularized PED and its rapid contraction after treatment could be the likely causes. The RPE tears spared the foveal center, and hence, the visual acuity remained unaffected. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.