How to manage retinal pigment tear in course of Anti VEGF therapy?
Age-related macular degeneration is a chronic degenerative condition that can lead to irreversible loss of vision. Neovascular AMD (nAMD) is characterized by growth of abnormal blood vessels beneath the macula (choroidal neovascularization [CNV]), and is usually treated with anti–vascular endothelial growth factor (VEGF) agents.
Retinal pigment epithelium tears are a relatively frequent occurrence in patients with nAMD and associated pigment epithelial detachment (PED), with reported incidence rates of 10% to 12% of eyes. In the longer term, visual acuity is frequently poor for these patients, particularly in the case of larger tears and if the foveal center is affected.
Although a range of retinal imaging modalities are recommended for the diagnosis and monitoring of RPE tear, there are currently no officially recognized guidelines, and a multimodal approach provides the most complete information. These modalities include color fundus photography, optical coherence tomography (OCT), fluorescein angiography (FA), OCT-angiography (OCT-A), near-infrared reflectance imaging, and fundus autofluorescence.
In the longer term, RPE tears are often associated with poor visual outcomes, particularly for tears involving the fovea and in cases where subretinal hemorrhage and scar formation occur. Therefore, the assessment of several prognostic markers is recommended in patients with PED considered at high risk of developing RPE tear during anti-VEGF treatment, although validation by prospective studies is necessary.
A literature search was conducted by Paul et al to review current evidence on the development, diagnosis, and management of retinal pigment epithelium (RPE) tear during anti–vascular endothelial growth factor (VEGF) therapy.
Three key recommendations were made based on existing literature and clinical experience:
1) Multimodal imaging with color fundus photography, optical coherence tomography, near-infrared reflectance imaging, fundus autofluorescence imaging, optical coherence tomography-angiography, and/or fluorescein angiography are recommended to diagnose RPE tear and assess risk factors. Retinal pigment epithelium tears can be graded by size and foveal involvement.
2) Patients at high risk of developing RPE tear should be monitored after each anti-VEGF injection. If risk factors worsen, it is not yet definitively known whether anti-VEGF administration should be more frequent, or alternatively stopped in such patients. Prospective research into high-risk characteristics is needed.
3) After RPE tear develops, anti-VEGF treatment should be continued in patients with active disease (as indicated by presence of intraretinal or subretinal fluid), although cessation of therapy should be considered in eyes with multilobular tears.
Overall, the incidence of RPE tear during anti-VEGF therapy in patients with PED is similar to that reported for untreated PED, with no clear evidence of differing risk according to use or type of anti-VEGF agent.
Although evidence to support the assumption that anti-VEGF treatment contributes to development of RPE tear is not definitive, some data suggest this link.