Retinal pigment epithelium rip following single intravitreal ziv-aflibercept injection.

A 40-year-old male presented with diminished vision (visual acuity 20/30) in the right eye for 4 years. Fundus examination revealed hard drusen with subretinal hemorrhage inferior to fovea [Fig. 1a]. Autofluorescence showed punctate hyperautofluorescence due to drusen and hypoautofluorescence due to subretinal hemorrhage [Fig. 1b]. Fluorescein angiography showed the presence of pooling in the area of retinal pigment epithelium detachment (PED) with temporal leakage suggestive of the occult choroidal neovascular membrane (CNVM). Swept-source optical coherence tomography (SS-OCT) showed the presence of large PED and irregular RPE folds (thick arrow) with the presence of hyperreflectivity (thin arrow) at sub-RPE level [Fig. 1c]. The patient was advised intravitreal ziv-aflibercept (IVZ) injection (1.25 mg/0.05 ml) under standard protocol. At 1 month, vision had dropped to 20/80. Fundus showed the increased area of subretinal hemorrhage with visible deeper choroidal vessels (arrows) [Fig. 2a]. Autofluorescence showed the presence of hypoautofluoresecence nasally and temporally (asterisk) with central hyperautofluorescence suggestive of double RPE rip [Fig. 2b]. SS-OCT showed the presence of irregular RPE folds with RPE rip (arrow) [Fig. 2c].

Figure 1

Fundus photograph (a) of the right eye showing the presence of small, hard drusen and presence of subretinal hemorrhage inferior to fovea and autofluorescence (b) showing punctate hyperautofluorescent areas due to drusen and blocked autofluorescence due to subretinal hemorrhage. Swept-source optical coherence tomography horizontal scan (c) showing the presence of pigment epithelium detachment, irregular retinal pigment epithelium folds (broad arrow), and linear hyperreflective signals under pigment epithelium detachment (arrow)

Figure 2

Fundus photograph (a) at 1-month follow-up postintravitreal ziv-aflibercept injection showing increased area of subretinal hemorrhage and increased visibility of choroidal vessel (arrows). Autofluorescence showed the presence of hypoautofluoresecent area nasally and temporally (asterisk) due to localized loss of retinal pigment epithelium with hyperautofluorescent area in the center due to scrolled edges of retinal pigment epithelium suggestive of double retinal pigment epithelium rip (b). Swept-source optical coherence tomography horizontal scan (c) showing the presence of tall pigment epithelium detachment, retinal pigment epithelium folds, and site of retinal pigment epithelium rip (arrow)

Discussion

RPE rip is a known complication seen with vascularized PED in various etiologies and has been reported following intravitreal injection of antivascular endothelial growth factor agents.[123] Here, we report the first case of double RPE rip[4] following single IVZ injection in a patient with occult CNVM.

RPE rip usually develops at the point of minimal strength, i.e., junction of elevated and flat RPE following contraction of vascularized PED. The presence of irregular RPE folds in PED is an indication of contractile CNV complex beneath the RPE surface which accentuates postintravitreal injection. We also noted RPE folds at baseline [broad arrow, Fig. 1c] along with linear hyperreflective signals under PED [arrow, Fig. 1c], which could be suggestive of angiofibrotic switch.[35]

Conclusion

Treating physicians need to be aware of the small risk of RPE rip in vascularized PED following IVZ injections.

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.

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Conflicts of interest

There are no conflicts of interest.