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Classic features of non-neovascular age-related macular degeneration (AMD) include drusen, drusenoid retinal pigment epithelial (RPE) detachment, and RPE atrophy. More recent studies have shown that intra- and subretinal fluid also may complicate the non-neovascular form of AMD.
studied 5 cases of RPE defect all associated with drusenoid PED.
In this correspondence, we describe 7 cases of RPE aperture that developed in eyes with acquired vitelliform lesions and subretinal fluid in the absence of drusenoid PED at the time of presentation. In this retrospective case series, eyes with RPE aperture associated with subretinal fluid (SRF) secondary to non-neovascular AMD were captured. The study was approved by the institutional ethics committee and adhered to the tenets of Declaration of Helsinki. Inclusion criteria were age greater than 55 years, presence of classic features of non-neovascular AMD including macular drusen and/or outer retina and RPE atrophy associated with an RPE aperture, and the absence of macular neovascularization (MNV) with multimodal imaging including optical coherence tomography (OCT; Spectralis, Heidelberg Engineering, Heidelberg, Germany, or Avanti, Optovue, Calif.), OCT angiography (Spectralis, Heidelberg Engineering or Avanti), and fluorescein angiography (Heidelberg Retina Angiograph, Heidelberg Engineering). Eyes with retinochoroidal disorders other than AMD were excluded. RPE aperture was defined as an abrupt discontinuity of the RPE with a preserved overlying ellipsoid zone and external limiting membrane in the absence of retracted or scrolled RPE suggestive of an RPE tear.
Seven eyes of 7 patients including 3 males and 4 females with an age range of 64–87 years were included. Table 1 summarizes the demographics and imaging findings. Best-corrected (Snellen) visual acuity was 20/32–20/100. Follow-up visits were available for 5 eyes. The visual acuity decreased in 3 eyes and remained stable in 2 other eyes. MNV was not detected at any of the baseline or follow-up visits.
Table 1Patient Demographics and Imaging Characteristics of Eyes with RPE Defect Secondary to Non-neovascular AMD
All 7 eyes presented with RPE aperture associated with SRF and an intact overlying ellipsoid zone and external limiting membrane (Fig. 1, Fig. 2). None of the eyes displayed evidence of macular hemorrhage or MNV with clinical examination or with OCT or OCTA imaging. All eyes displayed macular drusen and evidence of intraretinal hyper-reflective foci with OCT. Six of the 7 eyes showed evidence of associated acquired vitelliform lesions. Choroidal thickness ranged from 150 to 352 µm. Typical features of non-neovascular AMD were identified in 6 fellow eyes.
Three patients presented with a history of prior intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections. OCT and FA images were available for these 3 eyes before injections and before the development of an RPE aperture. Two of these 3 eyes displayed drusenoid PED with vitelliform material, and the other eye exhibited an acquired vitelliform lesion. None of these eyes had evidence of MNV before anti-VEGF injections.
In this correspondence, we describe 7 eyes with RPE aperture associated with SRF and acquired vitelliform lesion (AVLs) in the setting of non-neovascular AMD. Drusenoid PED is an invariable association of aperture formation in prior studies
but was not observed at the time of baseline presentation in this study and was noted in 2 of 7 cases with prior images. MNV was absent in all eyes using multimodal imaging. From a total of 22 reported cases of RPE aperture in the literature, 19 were associated with drusenoid PED.
suggested that drusen regression in the context of drusenoid PED results in a sharply demarcated area of round RPE atrophy. In this study, AVL, not drusenoid PED, was the typical lesion type associated with the development of RPE aperture, although it is possible that drusenoid PED was present in these eyes predating patient baseline visits. AVL is a known risk factor for the development of RPE atrophy, similar to drusenoid PED, and is an indicator or biomarker of RPE impairment and disruption.
Subsequent development of RPE dehiscence therefore is not a surprising finding.
RPE apertures should be differentiated from an RPE tear. RPE tears occur most commonly in eyes with neovascular AMD and large PEDs (>500 µm in height) after anti-VEGF therapy as a result of a combination of contractile and hydrostatic forces in the vascularized PED.
Unlike apertures that typically develop near the apex of the PED, tears develop near the base of the PED, where the contractile forces are greatest. Non-neovascular fluid, acquired vitelliform lesions, and RPE apertures are all the result of RPE dysfunction and disruption. The greatest risk of decompensation of the RPE may relate to its separation distance from the underlying choroid that supports and nourishes the overlying pigmented layer. This may explain the propensity for non-neovascular fluid, AVLs, and apertures to develop at the apex of a large drusenoid PED. The presence of AVL alone, however, is a sign of RPE impairment and a risk factor for the development of RPE aperture and/or atrophy.
Footnotes and Disclosure
None of the authors has any conflict of interest in the subject matter of this paper. David Sarraf has received research grants from Amgen, Boehringer, Genentech, Heidelberg, Optovue, Regeneron, and Topcon and is a consultant for Amgen, Bayer, Genentech, Iveric Bio, Novartis, and Optovue and a paid speaker for Optovue.
Non-neovascular age-related macular degeneration with subretinal fluid.