OPTIMAL MANAGEMENT OF PIGMENT EPITHELIAL DETACHMENTS IN EYES WITH NEOVASCULAR AGE-RELATED MACULAR DEGENERATION

Abstract

Purpose: This review aimed to determine the optimal management of retinal pigment epithelial detachments (PEDs) in neovascular age-related macular degeneration (nAMD) based on review of available evidence in the literature.

Methods: A comprehensive literature review evaluates previous retrospective and prospective studies that assessed the treatment of PEDs in nAMD.

Results: Studies illustrated that anti-vascular endothelial growth factor (VEGF) therapy can be effective in eyes with PED secondary to nAMD. Similar visual outcomes are associated with different anti-VEGF treatments. Higher anti-VEGF doses may improve anatomical response, without correlation with vision improvement. Fibrovascular PEDs may be difficult to treat, but even these eyes can gain vision with anti-VEGF therapy. A retinal pigment epithelial tear may develop in 15% to 20% of eyes with PEDs after anti-VEGF therapy, especially in PEDs greater than 500 µm to 600 µm in height; however, vision may stabilize with continued therapy. Atrophy may complicate eyes with PED and nAMD after anti-VEGF therapy, especially in association with complete PED resolution.

Conclusion: Available literature suggests that anti-VEGF therapy is safe and efficacious for PED and nAMD. Treatment should focus on vision gains rather than PED resolution because there is no apparent correlation between anatomical and functional improvement in most eyes with PED and nAMD.

Fig. 1.

Vision outcomes across trials of eyes with PEDs.^,,,, AFL, aflibercept; ETDRS, Early Treatment Diabetic Retinopathy Study; LD, loading dose; PRN, as needed; q4w, every 4 weeks; q8w, every 8 weeks; 2q8, every 8 weeks; RBZ, ranibizumab; TR, treatment-resistant; V, vascular.

Fig. 2.

Development of RPE tear across trials of eyes with PEDs.^–,,,,,– AFL, aflibercept; BVZ, bevacizumab; F, fibrovascular; H, hemorrhagic; M, multilayered; RBZ, ranibizumab; S, serous; TN, treatment-naive; TR, treatment-resistant; V, vascular.

Fig. 3.

Sequential SD-OCT B-scans during the course of anti-VEGF therapy demonstrating the evolution of a multilayered fibrovascular PED with progressive vascularization and increasing evidence of traction as illustrated by the RPE folds.

Fig. 4.

A Grade 2 RPE tear developed after several anti-VEGF injections. A. The fundus autofluorescent image illustrates the characteristic crescentic shape and hypoautofluorescent nature (red arrow) that are typical features of a tear. B. The RPE tear is also visible with SD-OCT, where areas of choroidal hypertransmission denote the absence of RPE (red arrow).

Fig. 5.

Progressive reduction in the hypoautofluorescence of the RPE tear occurred over several years after many anti-VEGF injections. With continued anti-VEGF therapy, the patient has maintained a visual acuity of 20/40 in the affected right eye.

Fig. 6.

Development of atrophy across studies of eyes with PEDs.^,,