Risk factors for RPE tears after ranibizumab for RAP

This retrospective review confirms what I have suspected for years – anti-VEGF treatment should be performed cautiously in patients with retinal angiomatous proliferation (RAP). Researchers found that RAP patients with higher pigment epithelium detachment (PED) height and thinner subfoveal choroidal thickness were at higher risk for developing retinal pigment epithelium (RPE) tears after intravitreal ranibizumab injections.

The authors studied incidence and risk factors for retinal tearing in 86 treatment-naïve RAP patients who were treated with 3 monthly loading injections followed by further injections as needed at a single eye center in South Korea.

Among 98 eyes, 8 developed RPE tears by 12 months, with the majority (7) occurring during the loading injection phase. All 8 eyes had pigment epithelium detachment (PED) at baseline. The authors found that patients with higher PED (P = 0.011) and thinner choroid (P =0.023) were significantly more likely to develop RPE tearing. Additionally, patients with RPE tearing had significantly worse BCVA compared to patients without RPE tearing (20/72 vs. 20/109, P = 0.009). BCVA in the patients with RPE tears also did not significantly improve from baseline (P=0.672) unlike patients who did not develop RPE tears (P=0.012).

Considering the neovascular process and development of PED in RAP, the authors hypothesized that there may be some difference in the clinical features of RPE tearing in RAP patients compared with wet AMD patients. However, the rate of RPE tearing was similar in this cohort (8.2%) compared to reported incidence rates for patients with wet AMD (2.8-14%). They suggest that this is an indication that the underlying mechanism behind RPE tears in RAP may be similar to wet AMD. They also suggest that anti-VEGF therapy should be performed with caution in RAP patients with thin choroid or high PED height, considering that RPE tears are associated with poorer visual outcomes.