Intravitreal gas injection with prone positioning for giant retinal pigment epithelial tear.

We report a 78 year old male with acute RPE tear with sudden vision loss, who underwent intravitreal C3F8 injection for reattaching the RPE. The impact of gas on detached RPE was studied by serial OCTs and Fundus pictures.

Introduction

Giant retinal pigment epithelium (RPE) tear has been associated with profound vision loss. RPE tear has been found to develop spontaneously, following laser, photodynamic therapy, and intravitreal injections.[1234] Incidence of RPE tear has been reported to be variable from 1.6% to 12%.[13] Natural course of giant RPE tear is not favorable and vision loss from loss of photoreceptors unsupported by RPE is inevitable.[3] Very few interventions for giant RPE tear have been reported.[5] We report a 78-year-old male with acute RPE tear with sudden vision loss, who underwent intravitreal C3F8 injection. The impact of intravitreal gas on detached RPE was studied by serial optical coherence tomographies (OCTs) and fundus pictures.

Case Report

A 78-year-old male patient presented with sudden painless vision loss OS for the last 3 days. His best-corrected visual acuity (BCVA) was 20/400 OD and 20/80 in OS. Anterior segment examination was unremarkable OU. Fundus examination revealed large disciform scar OD and giant RPE tear with subretinal hemorrhage OS [Figure 1a and b]. RPE tear was >6 DD extending across the posterior pole. Imaging with Heidelberg Spectralis OCT (Heidelberg Engineering, Heidelberg Germany) for OS confirmed a large RPE tear with detached RPE along with serous retinal detachment (RD) [Figure 2]. Very minimal folding and wrinkling of RPE were also noted. Prognosis and treatment options were discussed with the patient in detail. Intravitreal C3F8 injection with prone positioning was advised. With informed consent, patient underwent intravitreal C3F8 injection in OS. The patient maintained prone position for 2 weeks. The patient was followed up weekly with Fundus pictures and OCT scans to analyze the impact of intravitreal gas and prone positioning on RPE tear and associated serous RD [Figure 1c and d]. At 2 weeks follow-up, comparison of OCT scans revealed reduced height and extent of serous RD, but no change in the position of detached RPE and BCVA was reduced to 20/120 OS. The patient received monthly 3 bevacizumab injections at 4-week intervals. His final BCVA in OS remained stable at 20/120 at 4 months follow-up. We fail to demonstrate any impact of intravitreal C3F8 gas injection with prone positioning on fresh giant RPE tear associated with age-related macular degeneration.

Figure 1

Serial fundus pictures showing giant retinal pigment epithelial tear OS at presentation and at 5 days, 2 weeks, and 3 months after intravitreal gas injection. (a) Fundus picture showing giant RPE tear with subretinal hemorrhage (black arrows) OS. The edge of retinal pigment epithelial tear >6 DD in size is seen as sharply demarcated border between rolled retinal pigment epithelial and bare area temporal to hemorrhage (White arrow). Serial fundus pictures showing no change in the position of retinal pigment epithelial tear at 5 days (b), 2 weeks (c), and 3 months (d) follow-up

Figure 2

Optical coherence tomography pictures showing comparison optical coherence tomography scans at presentation (upper half) and at 2 weeks follow-up (Lower half). Heidelberg Spectralis optical coherence tomography (Heidelberg Engineering, Heidelberg Germany) for OS showing a large RPE tear with floating edge of detached retinal pigment epithelial (White solid arrow) along with serous retinal detachment (Vertical unfilled arrows) at presentation (upper half) and the optical coherence tomography scan at 2 weeks follow-up (Lower half) showing reduced serous retinal detachment (Vertical unfilled arrows) but no change in position of the edge of retinal pigment epithelial tear (White solid arrow)

Discussion

While pneumatic displacement of subretinal and sub-RPE blood has been well described, very few interventions for RPE tear have been described in literature. Factors affecting displacement of subretinal blood were analyzed by Stopa et al. who pointed out role of gravitation force on displacement.[5] Intravitreal gas injection with prone positioning displaces the blood in subretinal space and changes its natural course. Hence, authors hypothesized that intravitreal gas bubble along with prone positioning might impact a fresh giant RPE tear also and the same was attempted for this patient. However, we failed to demonstrate any impact of intravitreal gas injection with prone positioning on RPE tear. Although a single case may not be sufficient to conclude the ineffectiveness of this technique, the failure does provide insight into the mechanisms involved in RPE tear and also calls for more, possibly surgical, interventions for this visually devastating complication.

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.