Abstract
Retinal pigment epithelial (RPE) tears are now a documented potential complication following the intravitreal injection of anti-vascular endothelial growth factor (VEGF) treatments for neovascular age-related macular degeneration. Patients are often not well consented regarding this risk and thus we retrospectively analyzed the data from all of our patients undergoing this treatment over a six month period. Our findings highlighted the fact that the three patients (out of thirty) who had developed this RPE tear complication were initially all diagnosed with a pigment epithelial detachment (which is a type of macular degeneration in question). Therefore, we have adjusted our informed consent procedure such that all patients with “wet” macular degeneration and especially those with pigment epithelial detachments are now fully consented regarding the risks of the intravitreal treatment, which could potentially damage their vision further.
Introduction
Treatment of neovascular age-related macular degeneration (ARMD) with intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) drugs such as pegaptanib, bevacizumab and ranibizumab has revolutionized the prognosis of this sight-threatening condition. This has understandably led to increased patient hopes and expectations. This attitude is reflected in the patient's reaction towards consenting to intravitreal treatment. Commonly, family members counsel their relative by questioning rhetorically ‘what do you have to lose?’
Retinal pigment epithelial (RPE) tears are a known complication of pigment epithelial detachments in the elderly, which can occur either spontaneously or secondary to laser photocoagulation. Recent case reports have raised the potential link between RPE tears and intravitreal injections.1–3
Methods
We retrospectively reviewed our initial six months experience of using intravitreal ranibizumab (Lucentis) for ARMD, in order to identify any issues that should be raised during the informed consent procedure for patients.
Results
Thirty patients had photographic and angiographic evidence of ARMD suitable for intravitreal therapy. Three patients had a clinical diagnosis of pigment epithelial detachment (PED) and subsequently developed RPE tears.
Two patients developed RPE tears after treatment with Lucentis. The third patient developed her tear prior to starting any intravitreal treatment.
This latter patient presented to the eye clinic with a visual acuity of 6/18 at time of diagnosis with a PED. She was not immediately keen to undergo any intravitreal treatment and therefore was to be reviewed in clinic one month later. Unfortunately, at this visit, her vision had dropped to 6/60 (6/24 with pinhole) and an RPE rip was evident.
Of the two patients who developed RPE tears after treatment with Lucentis, the first had a diagnosis of PED and his vision was 6/12. He underwent one intravitreal injection with Macugen but his vision decreased further to 6/18. Two further injections with Lucentis stabilized his vision at 6/18; however, one month after his second injection with Lucentis, he developed an RPE rip, further deteriorating his vision to counting fingers (see Figure 1).
Retinal pigment epithelial rip
The second patient had a visual acuity of 6/18 at the time of diagnosis with her PED. She underwent two intravitreal Lucentis injections, which stabilized her vision at 6/18; however, on the day of her planned final third injection (one month after the second), her vision was 6/36 and she was seen to have developed an RPE rip.
Conclusions
All three patients in our series who developed RPE tears had been diagnosed with pigment epithelial detachments. Two developed their tears following intravitreal injection with ranibizumab. A similar study had also found that the serous pigment epithelial detachments were the most vulnerable. 4 The third patient developed her tear spontaneously, prior to embarking on any treatment. Lee et al. 5 emphasized in their study that RPE tears may occur even with previous uneventful intravitreal injections.
Another study, which retrospectively analysed 920 eyes, found that the risk of developing RPE tears was 1.6% and those involving the fovea had a very poor visual prognosis – those eyes in which the tear was extrafoveal tended to have a much better outcome. 6
Other research has quoted the risk of RPE tears of 3% of all wet ARMD and 7% in eyes with pre-existing PED. 7 The risk of RPE tear is also thought to increase with the height of PED on ocular coherence tomography. 8
This information, enhanced by imaging, should be incorporated into a structured discussion with patients and relatives about the real risks of intravitreal therapy. By providing such informed consent, patients can have realistic expectations about this exciting developing treatment.
We believe that it is important to explain the risk of RPE tears to patients undergoing intravitreal anti-VEGF treatment, particularly those diagnosed with pigment epithelial detachments.