Giant retinal pigment epithelial tear associated with fluid overload due to end-stage diabetic kidney disease

Abstract

Purpose: To report a case of a giant retinal pigment epithelial (RPE) tear associated with fluid overload in a patient with diabetic macular edema (DME) and kidney disease.

Observations: A 60-year-old man with type 2 diabetes mellitus and end-stage diabetic kidney disease who had gained weight because of fluid overload complained of a visual disturbance in the left eye that had started a few days earlier. The left fundus showed a RPE defect in two temporal quadrants under an extensive serous retinal detachment (SRD) with exacerbation of the original DME. Seven days later, he was admitted for severe edema and pleural effusion. No overt signs of congestive heart failure were noted. On admission, the RPE defect had markedly widened to involve the macula. Spectral-domain optical coherence tomography images showed substantial intraretinal fluid and an extensive SRD with rolled edges of the retinal pigment epithelium, which led to the diagnosis of a RPE tear. The fluid under the SRD was absorbed on the fourth hospital day and the substantial intraretinal fluid resolved on the eleventh day after systemic management of fluid overload only without ophthalmic treatment. The change in the appearance of the RPE area was minimal and the visual field defect remained even after 6 months.

Conclusions and importance: A RPE tear may develop in association with fluid overload in patients with diabetes.

Keywords: Diabetic macular edema; Fluid overload; Retinal pigment epithelial tear; Serous retinal detachment.

Fig. 1

Composite fundus photography of the left fundus. Immediately (A), 7 days (B), 10 days (C), and 6 months (D) after the retinal pigment epithelial (RPE) tear developed.

Fig. 2

Images of horizontal spectral-domain optical coherence tomography (SD-OCT) scan in the left fovea. (A) Seven days after the RPE tear developed, SD-OCT showed the presence of substantial intraretinal fluid and marked serous retinal detachment (SRD) with rolled edges of the retinal pigment epithelium. (B) Ten days after the RPE tear developed, SD-OCT showed rapid absorption of fluid under the SRD. (C) Seventeen days after the RPE tear developed, SD-OCT showed almost complete resolution of the substantial intraretinal fluid, and the direct attachment of the outer retina to Bruch's membrane without the RPE line (white arrow).

Fig. 3

Goldmann perimetry of the left eye. Six months after the RPE tear developed, Goldmann perimetry revealed a visual field defect corresponding to the area where the retinal pigment epithelium was lost.