Retinal Pigment Epithelial Detachment by Maria Andreea Gamulescu Horst Helbig & Joachim Wachtlin

Author:Maria Andreea Gamulescu, Horst Helbig & Joachim Wachtlin
Language: eng
Format: epub
Publisher: Springer International Publishing, Cham

5.7 Therapy

Because of their retinal–retinal or retinal–choroidal anastomosis, RAP lesions show a high blood flow and often have been refractory to many conventional therapies such as conventional laser photocoagulation, monotherapy with verteporfin photodynamic therapy, or even surgical ablation [3, 4, 31]. Recurrent edema, evolving geographic atrophy and associated serous PED with high imminent risk for RPE-tears limited the visual outcome [42]. However, early detection and small lesion size seem to be associated with better outcomes [31, 43].

Nowadays, intravitreal anti-VEGF substances are the gold standard of therapy in exudative age-related macular degeneration, as VEGF-driven edema and exudations respond well to anti-VEGF monotherapy. Under the presumption that RAP lesions are the sequel of increased intraretinal VEGF-levels [17, 18], this type of exudative AMD should also respond well to anti-VEGF (mono)therapy. Indeed, RAP lesions usually show fast and oftentimes complete resolution of intraretinal edema as well as of the accompanying serous PED after treatment with intravitreal anti-VEGF-substances [44]—only rarely seen in typical serous PEDs. However, anti-VEGF does not seem to occlude the retinal–retinal anastomosis completely, and the remaining flow may cause frequent recurrences (Fig. 5.12). In a paper by Cho et al, anti-VEGF injections showed favorable visual outcome with significant visual improvement during the first year, but this gain could not be maintained after the second year [45]. Therefore, combination treatment of PDT and intravitreal anti-VEGF injections has been proposed. In a paper by Saito et al, combination treatment resulted in a significantly improved visual acuity, significantly decreased central retinal thickness and occlusion of the retinal–retinal anastomosis in 33 of 35 patients with a mean of 2.5 PDT and 5.5 IVT during 24 months [27]. However, subgroup analysis of RAP lesions in the CATT trial with anti-VEGF monotherapy also showed that eyes with RAP were less likely to have fluid on OCT, leakage on FA, and scarring at 1 and 2 years compared to eyes with typical exudative AMD. Visual acuity in RAP eyes had greater improvement from baseline at year 1, but was similar to non-RAP eyes at year 2. Overall, RAP lesions required slightly less intravitreal injections than non-RAP lesion during the 2 years [50]. The same trial, however, showed that RAP eyes were more likely to have geographic atrophy over the follow-up period than non-RAP eyes. The development of geographic atrophy is reported with incidence rates as high as 37–86% [35, 36, 45] especially in eyes with coexistent RPD, here a more cautious anti-VEGF therapy was discussed [33, 34] (Fig. 5.13).

Fig. 5.13RAP lesion in the right eye (a) and reticular pseudodrusen showing a honeycomb pattern in the left eye (b) of a patient, demonstrated on blue-light autofluorescence (c), infrared fundus reflectance (d), FA (e), ICGA (f), and SD-OCT (g)

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