Sir,

Retinal pigment epithelium (RPE) tears are a major complication in patients with pigment epithelial detachments (PED) secondary to exudative age-related macular degeneration (ARMD).1 They also occur following treatment of PEDs with photocoagulation, photodynamic therapy, and intraocular injections of bevacizumab (Avastin, Genentech) and pegabtanib sodium (Macugen, Eyetech Pharmaceutical).2

In this report, we describe a patient who developed an RPE tear following an intravitreal injection of ranibizumab (Lucentis, Genentech).

Case report

A 71-year-old man with ARMD had gradually decreased vision in his right eye. Best-corrected visual acuity (BCVA) was 20/50 in the right eye, and hand movements in the left eye. Three years earlier, he had been treated with photodynamic therapy (PDT) for exudative ARMD in his left eye and had subsequently developed a large disciform scar in that eye. Fundus evaluation, fluorescein angiography (FA), and optical coherence tomography (OCT) (Figure 1) now showed an occult choroidal neovascular membrane (CNV) with a fibrovascular PED in his right eye and a disciform scar in his left eye.

Figure 1
figure 1

Colour fundus photograph, fluorescein angiography, and OCT showing occult choroidal neovascularization with a fibrovascular retinal PED under the fovea of the right eye before the intravitreal injection.

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Three weeks after uneventful intravitreal injection of ranibizumab (0.5 mg), BCVA suddenly decreased to 20/60-2. Fundus evaluation including a repeat FA and OCT revealed a large RPE tear (Figure 2).

Figure 2
figure 2

Optical coherence tomography after the intravitreal injection showing the classical retraction of the RPE.

Full size image

Comment

The development of an RPE tear associated with CNV may occur as a spontaneous process or as a result of the contractile forces of regressing choroidal vessels after laser, photodynamic therapy, or anti-vascular endothelial growth factor agents (VEGF) therapy. RPE tears after intravitreal injections of pegaptanib sodium3 and bevacizumab4 have been reported.

Expanding PEDs and those with nonhomogenous filling filling may represent high-risk lesions because they may eventually exert sufficient tangential stress to result in a spontaneous tear.5 In retinal angiomatous proliferation (RAP), RPE tears are more common when the PED exceeds 50% of the lesion.6

Visual recovery after RPE tear is uncommon but possible in some instances, especially when the fovea is spared and conserves the RPE.

RPE tears can also follow intravitreal injections of ranibizumab presumably for similar reasons as with the other anti-VEGF agents.