Retinal Pigment Epithelium Tear after Vitrectomy for Vitreomacular Traction Syndrome in an Eye with Retinal Angiomatous Proliferation
An 87-year-old Japanese man complained of a gradually progressive vision decrease in his right eye. He reported that he was being treated for mild hypertension. His ocular history revealed that he had untreated neovascular AMD in his left eye and open-angle glaucoma in both eyes. His best-corrected visual acuity was 0.15 in both eyes, and the intraocular pressure was 14 mm Hg in both eyes with latanoprost eye drops. Slit-lamp examination showed no abnormalities except for moderate cataracts in both eyes.\nOphthalmoscopy showed a shallow RPE detachment and macular edema accompanied by multiple drusen in his right eye (fig. ). His left eye had advanced AMD with a subretinal scar and severe macular edema. Optical coherence tomography (OCT) showed an RPE detachment, intraretinal hyperreflectivity and edema (fig. ). Vitreoretinal traction was also evident (fig. ). Fluorescein angiography showed a pooling of dye corresponding to the RPE detachment (fig. ). A hyperfluorescent spot suggesting a retinal choroidal anastomosis was observed by indocyanine green angiography (fig. ). He was diagnosed with RAP in the right eye.\nAfter 3 monthly injections of intravitreal ranibizumab, the RPE detachment was resolved (fig. ), and his visual acuity slightly improved to 0.2. Macular traction still remained, and we believed that vitreomacular traction limited the visual recovery.\nAfter discussing the rationale for vitreous surgery to remove vitreous traction and possible complications, the patient agreed to undergo surgery. Pars plana vitrectomy was performed using a 23-gauge system with cataract extraction and implantation of an intraocular lens. The posterior vitreous was separated from the retina using triamcinolone acetonide to make the vitreous more visible. We noted that the posterior hyaloid was firmly attached to the macular area of the retina, and it was carefully separated by aspiration with the vitreous cutter. The internal limiting membrane was not removed during surgery. No intraoperative complications were noted.\nOne month after the surgery, his visual acuity was 0.1 with normal foveal depression and no intraretinal fluid. Two months after the surgery, a large tear of the RPE was found over the entire macula (fig. ). The detached RPE contracted toward the angiomatous lesion. Although the patient did not notice any decrease in his vision, there was significant recurrence of the sub- and intraretinal fluid. Visual acuity in the right eye decreased slightly to 0.06 and then remained unchanged for more than 1 year.