Tears of the Retinal Pigment Epithelium during Aflibercept Therapy: PED and Treatment Characteristics

Abstract

Background: Tears of the Retinal Pigment Epithelium (RPE) are associated with Age-Related Macular Degeneration (AMD) in the setting of a pigment epithelial detachment (PED). Methods: Chart review of patients treated with intravitreal (IV) Aflibercept for neovascular AMD (nvAMD). Clinical course and OCT images were analyzed to compare characteristics for patients who experienced RPE tears during treatment of symptomatic PED with IV Aflibercept. Results: 8 eyes of 8 patients were included in the study. All cases were being treated for nvAMD with IV aflibercept. The average maximal height of PED was 475 μm (172-874 μm), and the mean linear diameter was 3426 μm, (1004-5185 μm). All eyes had associated subretinal fluid; 4 had RPE folds and irregularities, and one had subretinal hemorrhage. Four eyes experienced an RPE tear after the first injection of Aflibercept. Two eyes had received more than 10 injections of aflibercept prior to the development of RPE tear. Two patient’s eyes were previously treated with other anti-VEGF agent (one bevacizumab, and one ranibizumab). The visual acuity improved by 2 or more lines in 3 eyes, and worsened by 2 or more lines in no eyes. The final BCVA was ≥ 20/40 in 2 eyes, 20/50-20/100 in 5 eyes, and </= 20/200 in 1 eye. Conclusion: IV Aflibercept has been recommended for treatment of PED in the setting of nvAMD. In our study, 8 patients with PED experienced a tear of the RPE during the early course of treatment with Aflibercept. Aflibercept’s mechanism of action is such that it binds to multiple targets with higher affinity than other anti-vascular-endothelialgrowth- factors. This proposed mechanism may increase its efficacy in the setting of PED. This mechanism, however, may also augment the risk for RPE tears. Therefore, consideration for RPE tear should be given in the setting of large PED in nvAMD.