Statistics from Altmetric.com
In 1981, Hoskin et al1 described retinal pigment epithelial tears as a newly recognised severe complication of pigment epithelial detachment. Retinal pigment epithelial tears, which may occur either spontaneously or after laser photocoagulation to treat pigment epithelial detachment and choroidal neovascularisation (CNV) in diseases such as age related macular degeneration (AMD), usually cause sudden visual loss at the time of tearing. We report a case of spontaneous bilateral giant tears of the retinal pigment epithelium (RPE).
A 79 year old woman was referred on 18 January 2002, because of sudden visual loss in the left eye of 2 weeks’ duration. In October 2001, the patient had undergone bilateral phacoemulsification and lens implantation by her local ophthalmologist. She had no apparent complications postoperatively, and the postoperative visual acuity (VA) was 20/250 in the right eye and 20/20 in the left eye; however, she noticed sudden decreased vision in the left eye on 3 January 2002, and visited the local ophthalmologist 5 days later.
When she presented to our hospital, her VA was 20/200 in right eye and hand movements in the left eye. The intraocular pressure was 18 mm Hg in the right eye and 19 mm Hg in the left eye. The external eye examination, pupillary responses, and results of slit lamp examinations were normal in both eyes except for poor mydriasis. Intraocular lenses were fixed in the capsular bag in both eyes. Results of fundus examination showed bilateral widespread pigment epithelial detachments overlying areas of bare choroid, which measured 7×8 disc diameters in the right eye and 9×10 disc diameters in the left eye, and adjacent sheets of retracted and rolled RPE (fig 1). A fluorescein angiogram of the right eye demonstrated hyperfluorescence of the denuded choroid in the early phase, which lightened slightly in the late phase, that blocked fluorescence corresponding to the retracted RPE, and appeared to have cystoid macular oedema (figs 2, 3). A fluorescein angiogram of the left eye disclosed persistent intense hyperfluorescence of the exposed choroid, blocked fluorescence consistent with the rolled RPE (figs 2, 3). An indocyanine green (ICG) angiogram of the left eye revealed fluorescence of the large choroidal vessels in the area of the bare choroid and no obvious evidence of CNV. Fundus examination using scanning laser ophthalmoscopy with a diode laser (780 nm) sharply defined the folded RPE (fig 4). From these findings, we diagnosed bilateral tears of the RPE.
In this case, the fluorescein angiogram showed ill defined light hyperfluorescence in the right eye and well defined intense hyperfluorescence in the left eye, corresponding to the region of the exposed choroid and pigment epithelial detachments. The ICG angiogram of the left eye demonstrated persistent light hyperfluorescence consistent with the bare choroid. On fluorescein angiogram, intense hyperfluorescence was reported in an area of exposed choroid when a RPE tear occurred, and over time the edges were not clearly defined and the fluorescence lightens because of proliferation and infiltration of the pigment epithelial cells on the bare choroid along the margin of the tear.2 In an ICG angiogram, it then was reported that hyperfluorescence of an area of exposed choroid in the late phase indicates that the tear may be fresh because of tissue staining in Bruch’s membrane by leakage from the choriocapillaris.3 Accordingly, we identified the RPE tears in our patient as an old tear in the right eye and a fresh one in the left eye.
Many reports have been published that a RPE tear is caused by photocoagulation to treat CNV and pigment epithelial detachment in diseases such as AMD because scarring and retraction of the RPE by photocoagulation may result in tangential tractional forces along the RPE that weaken it.1 Lois et al4 reported that low intraocular pressure after trabeculectomy causes a RPE tear because of mechanical stress between Bruch’s membrane and the RPE following increased subretinal fluids caused by leakage from the choriocapillaris. There have been no reports that cataract surgery causes a RPE tear, but the possibility that it caused the tear in the left eye in this case cannot be completely excluded. However, in our case, we thought that there was little relation between cataract surgery and the tear, because no complications occurred during surgery and intraocular inflammation after surgery was unremarkable. Although we considered that the RPE in our patient might be weak by nature, there was nothing in the family history or the presence of systematic diseases that affected the connective tissue.
In the present case, the tears measured 7×8 disc diameters in the right eye and 9×10 disc diameters in the left eye. Although the large size of the pigment epithelial detachment might be important in the pathogenesis of RPE tears,5 most tears in previous reports were no more than about 5 disc diameters. Accordingly, the tears in this case were much larger compared with previous reports and also bilateral.
In this case, fundus examination using scanning laser ophthalmoscopy with a diode laser defined the folded RPE more sharply than any other examination. It may be useful to observe the rolling shape of the RPE. In conclusion, the possibility that cataract surgery caused the RPE tear in the left eye cannot be completely excluded, but this case represented a rare report of spontaneous bilateral giant tears.