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ReferencesErnest P, Rhem M, McDermott M, Lavery
K & Sensoli A (2001): Phacoemulsification
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Correspondence:
Takashi Kojima MD
Department of Ophthalmology
Social Insurance Chukyo Hospital
1-1-10 Sanjo
Minami-ku, Nagoya-shi
Aichi 457-0866
Japan
Tel: + 81 52 691 7151
Fax: + 81 52 692 1273
Email: [email protected]
Occult vitreo)macular
traction may cause
traumatic RPE tears
Carsten H. Meyer, Stefan Menneland Jorg C. Schmidt
Department of Ophthalmology, Philipps
University, Marburg, Germany
doi: 10.1111/j.1600-0420.2006.00703.x
Editor,
W ith great interest we read thearticle by Amiel et al. (2006),
which described a 43-year-old womanwith an acute tear of the retinal pig-ment epithelium (RPE) and a retinalhorseshoe tear in her left eye follow-ing blunt trauma. The retinal tear wastreated by laser retinopexy. Sixmonths later the subject’s visual acuitydeteriorated to counting fingers at1 metre and the crescent-shapedmacular lesion in the left eye appeareddry. We would like to make two com-ments on this observation.
Firstly, the authors proposed thatan acute tangential tractional stressbetween the relatively flexible RPElayer and the stiffer Bruch’s mem-brane might have caused the RPE
tear. However, there are other poss-ible explanations that have not beenaddressed by the authors. The edge ofmost RPE tears is frequently found inthe temporal aspect of the macula,while the RPE sheath contractstowards the optic nerve (Giovanniniet al. 1999). It is also known that thefirmest attachments of the posteriorvitreous are found at the optic nervehead and the fovea. In the partiallydetached vitreous, this vector mayexplain the frequent contractiontowards the optic nerve head. Unfor-tunately, we find no informationabout the status of the posterior vitre-ous in the paper by Amiel et al.(2006). However, the consecutive pres-ence of a retinal horseshoe tear indica-ted vigorous traction of the vitreousdue to the blunt trauma. On the pre-sented optical coherence tomography(OCT) scan there is no visible vitreoustraction; however, the authors do notgive any information regarding thelength, direction and location of thepresented OCT scan, thus an ‘occult’vitreo)macular traction may bemissed. We have previously obtainedmultiple scans by OCT in patientswith acute RPE tears and frequentlydetermined vitreous attachments (Me-yer & Toth 2001). This leads us tohypothesize that vitreous traction maytrigger RPE tears. Incomplete poster-ior vitreous detachments may triggerthe development of RPE tears afterblunt ocular trauma.
Secondly, the authors highlight thevision-threatening nature of traumaticRPE tear. Machemer and Heriotinvestigated the physiological repairof experimental RPE tears in rabbits(Machemer & Heriot 1991; Heriot &Machemer 1992). They determined aprofuse leakage of fluoresceinthrough the bare Bruch’s membraneduring the acute phase. However, thisleakage terminated in a well demarca-ted window defect during the follow-up because a thin layer of unpig-mented RPE cells cover the defect.These cells were clearly visible in his-topathological examinations. Heriot& Machemer (1992) postulated thatthe viability of these cells is essentialto seal the RPE defect and restorecentral vision.
Amiel et al. (2006) underscore thevision-threatening nature of the trau-matic RPE tear and the diagnosticrole of OCT, which displays the
scrolled RPE. Recently, we observedan acute RPE tear after an intravitrealAvastin injection, which also presentsa small iatrogenic trauma to the eye.Although we were unable to see vitre-ous attachment on multiple OCTscans, we clearly determined a firmlyattached vitreous at the posterior poleduring vitrectomy for consecutivesubretinal surgery (Meyer et al. 2006).The copresence of an RPE tear andretinal horseshoe tear after a bluntocular trauma may indicate that,rather than the stiffness of Bruch’smembrane, the tractional forces of thevitreous may have triggered the tear-ing of the RPE. Further studies aremandatory to determine the underly-ing preretinal and subretinal causesfor traumatic RPE tears.
ReferencesAmiel H, Greenberg PB, Kachadoorian H &
O’Brien M (2006): Optical coherence
tomography of a giant, traumatic tear in
the retinal pigment epithelium. Acta Oph-
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Giovannini A, Scassellati-Sforzlini B, Lafaut
B, Edeling J, D’Altobrando E & De Laey
JJ (1999): Indocyanine green angiography
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Heriot WJ & Machemer R (1992): Pigment
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Machemer R & Heriot W (1991): Retinal pig-
ment epithelial tears through the fovea
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Arch Ophthalmol 10: 1492–1493.
Meyer CH & Toth CA (2001): Retinal pig-
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Graefes Arch Clin Exp Ophthalmol 239:
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Meyer CH, Mennel S, Schmidt JC & Kroll P
(2006): Acute retinal pigment epithelial
tears following intravitreal bevacizumab
(Avastin) injection for occult choroidal
neovascularization secondary to age-related
macular degeneration. Br J Ophthalmol
(in press).
Correspondence:
Carsten H. Meyer MD
Department of Ophthalmology
Philipps University Marburg
Robert Koch Strasse 4
35037 Marburg
Germany
Tel: + 49 6421 286 2616
Fax: + 49 6421 286 5678
Email: [email protected]
Acta Ophthalmologica Scandinavica 2006
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