Retinal pigment epithelial tear with vitreomacular attachment: a novel pathogenic feature

Background: The development of tears of the retinal pigment epithelium (RPE) has classically been described with or without choroidal neovascularization (CNV) or after laser treatment. Tangential shear forces within the RPE or CNV are usually considered to cause the dehiscence. Methods: Three patients with CNV and spontaneous RPE tear and additional vitreomacular traction were examined by fluorescein angiography (FA), optical coherence tomography (OCT) and kinetic ultrasound. Results: From the pre-tear to the tear stage a sudden decrease in vision was observed. Fluorescein angiographic images demonstrated RPE-tear formation with blocked filling in the area of the contracted RPE and a well-demarcated hyperfluorescence in the bed of the torn RPE. OCT-scans demonstrated vitreomacular traction at the foveal area in all three cases. Kinetic ultrasound revealed vitreous attachments at the optic disc and fovea. Conclusion: Magnitude, variation of mechanical forces, and the continuous shear stress of the aged vitreous gel transmitted across vitreoretinal attachments may cause a chronic stimulus to retina and RPE. Vitreo-macular traction may contribute to the subsequent formation of RPE tears via mechanical or cell mediator pathways.