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PHOTO ESSAY
Year : 2021  |  Volume : 1  |  Issue : 1  |  Page : 75-76

Intravitreal Aflibercept in peripheral exudative hemorrhagic chorioretinopathy associated with large retinal pigment epithelial tear


1 Department of Vitreoretina, Grewal Eye Institute, Chandigarh, India
2 Duke Eye Center, Duke University Medical Center, Durham, North Carolina, USA, India

Date of Submission29-May-2020
Date of Acceptance27-Jul-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. Manpreet Brar
Grewal Eye Institute, SCO: 168-169, Sector 9C, Madhya Marg, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_584_20

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  Abstract 


Keywords: Intravitreal Aflibercept, Peripheral Exudative Hemorrhagic Chorioretinopathy, Retinal Pigment Epithelial tear


How to cite this article:
Brar M, Sharma M, Grewal S P, Grewal DS, Dogra MR. Intravitreal Aflibercept in peripheral exudative hemorrhagic chorioretinopathy associated with large retinal pigment epithelial tear. Indian J Ophthalmol Case Rep 2021;1:75-6

How to cite this URL:
Brar M, Sharma M, Grewal S P, Grewal DS, Dogra MR. Intravitreal Aflibercept in peripheral exudative hemorrhagic chorioretinopathy associated with large retinal pigment epithelial tear. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Feb 26];1:75-6. Available from: https://www.ijoreports.in/text.asp?2021/1/1/75/305530



An 85-year-old female came to our clinic for her regular eye visit. Best-corrected visual acuity (BCVA) was 20/20 in the right eye and 20/400 in the left eye. Examination of fundus right eye showed few soft drusens at the macula with peripheral retinal pigment epithelium (RPE) alterations in the nasal retina and abnormal raised sub RPE lesion (arrow) in the temporal retina suggestive of pigment epithelial detachment (PED) [Figure 1]a. Fundus examination of the left eye recorded a large fibrovascular macular scar secondary to age-related macular degeneration (ARMD). Baseline Swept Source Optical Coherence Tomography (SS-OCT) scan was done and it confirms the presence of drusen in the right eye and subfoveal scar in the left eye [[Figure 2]a and [Figure 2]b respectively].
Figure 1: (a) Baseline color fundus photograph of an 85-year-old lady with ARMD. Yellowish subretinal deposits of soft drusens are seen at the fovea, peripheral RPE irregularities are seen at the nasal periphery. Large PED is seen in the temporal retina (arrow). (b) One month later color fundus photograph shows darker and more elevated area in the temporal periphery due to enlargement of PED (arrow). (c) Color fundus photograph at three months shows that PED has increased in size and shape (arrow). (d) Color fundus photograph at five months shows development of large RPE tear (arrow) with subretinal hemorrhage adjacent to the PED

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Figure 2: (a) Swept-source OCT scan of the right eye shows the presence of RPE irregularities suggestive of drusen in a case of Dry ARMD. (b) Swept-source OCT scan of the left eye demonstrating PED with subfoveal scar

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She was kept under observation. Follow-ups at 1 month [Figure 1]b and at 3 months [Figure 1]c showed a gradual increase in size of PED (arrow). Her VA was maintained at 20/20; therefore, no active intervention was planned. Five months later she developed sudden onset of floaters and BCVA dropped to 20/40 in the right eye. Fundus examination showed a large crescent-shaped RPE tear (arrow) in the temporal retina adjacent to a large vascularized PED and subretinal hemorrhage in the inferior retina and the macula [Figure 1]d.

Fundus fluorescein angiography (FFA) revealed hyperfluorescent signal in the tear area and staining in the area of PED was seen in the late phase of the angiogram and blocked fluorescence in the area of retinal bleed [Figure 3]a. Optical Coherence tomography angiography (OCTA) did not reveal any polyps at the choriocapillaris slab [Figure 3]b. SS-OCT showed subretinal fluid (SRF) involving the fovea and RPE tear [Figure 4]a. In view of drop in vision in her good eye, intravitreal Aflibercept injection 2 mg (0.05 ml) was administered. Four weeks after injection, SS-OCT showed resolution of SRF [Figure 4]b and her VA improved to 20/20. She has not shown any signs of recurrence till her last 9 month follow up.
Figure 3: (a) FFA montage shows blocked patchy hypofluorescence from retinal hemorrhage and a large hyperfluorescent crescent-shaped patch of RPE tear and hyperfluorescent staining in the area of PED. (b) OCTA at the level of choriocapillaris slab demonstrates a large crescent-shaped hyper intense RPE tear and hypointense large patch at the temporal edge of the RPE tear due to a shadowing effect from a large PED

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Figure 4: (a) Swept source OCT shows an elevated RPE layer at the temporal edge with a clear cut area of RPE disruption, backscattering effect at the site of RPE tear (arrow). Subretinal fluid is present in the temporal macula trickling down to the fovea. Few drusens are seen in the subfoveal area. (b) Swept-source OCT one month after intravitreal Aflibercept injection shows complete resolution of subretinal fluid with flattening of the RPE layer

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  Discussion Top


This case presented with a giant RPE tear that developed as a result of large vascularized PED in a case of peripheral exudative hemorrhagic chorioretinopathy (PEHCR). This is reported by other authors in the past.[1] Presence of such giant RPE tear in the periphery points towards a coexistence of large PEDs with the underlying choroidal neovascular membrane (CNVM)/Retinal Angiomatous Proliferation (RAP)/Polypoidal choroidal vasculopathy (PCV). This case demonstrates the development of RPE tear during the natural course of PED. Rapid enlargement of the PED was observed over the course of few months that ultimately resulted in a large RPE tear [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d. The sub-PED fluid applies hydrostatic pressure and stretches the RPE. The PED enlarges as the hydrostatic pressure increases. Contraction of the choroidal neovascular membrane adds tractional forces to the RPE monolayer that results in development of RPE tears.[2]

Various studies have supported the role of anti-vascular endothelial growth factor (antiVEGF) treatment in spontaneous RPE tears due to vascularized PED. AntiVEGF treatment promotes rapid resolution of sub PED fluid, helps in RPE repair, and limits the extent of scarring.[3],[4],[5]

This case shows rapid restoration of vision and successful resolution of SRF following the use of single Aflibercept injection.

To summarize, this case highlights an unusual finding of large RPE tear in PEHCR that responded well to Aflibercept injection.

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.



 
  References Top

1.
Kumar V, Tewari R. Giant retinal pigment epithelium rip in a patient with peripheral exudative hemorrhagic chorioretinopathy. Indian J Ophthalmol 2019;67:1164-5.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Ersoz MG, Karacorlu M, Arf S, Sayman Muslubas I, Hocaoglu M. Retinal pigment epithelium tears: Classification, pathogenesis, predictors, and management. Surv Ophthalmol 2017;62:493-505.  Back to cited text no. 2
    
3.
Mukai R, Sato T, Kishi S. Repair mechanism of retinal pigment epithelial tears in age-related macular degeneration. Retina 2015;35:473-80.  Back to cited text no. 3
    
4.
Invernizzi A, Nguyen V, Arnold J, Young S, Barthelmes D, Gillies MC. Early and late retinal pigment epithelium tears after anti-vascular endothelial growth factor therapy for neovascular age-related macular degeneration. Ophthalmology 2018;125:237-44.  Back to cited text no. 4
    
5.
Casalino G, Bandello F, Chakravarthy U. Changes in neovascular lesion hyperreflectivity after anti-VEGF treatment in age-related macular degeneration: An integrated multimodal imaging analysis. Invest Ophthalmol Vis Sci 2016;57:288-98.  Back to cited text no. 5
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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