CASE REPORT

A 55-year-old female visited an eye hospital for her routine eye checkup with a complaint of decreased near vision. On history taking, she was found diabetic as well as hypertensive.

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Pigment Epithelial detachment(PED)

Her best corrected visual acuity was 6/6 in both eyes. Adnexa was normal in both eyes. Bilateral Pupil reaction was Round Regular Reactive (RRR). Bilateral media was clear.

On slit lamp examination, the optic disc, retinal vasculature and macula were found normal but an extramacular discoloured area temporal to the macula was noted.

The patient was kept on follow-up to observe fundus changes and visual outcomes after some time. Followup reports also confirm the diagnosis of Pigment Epithelial detachment (PED).

Pigment Epithelial detachment (PED) entity

Pigment Epithelial detachment (PED) refers to a detachment of Retinal Pigment Epithelium from the Bruch’s membrane. This detachment creates a space between RPE and Bruch’s membrane which is occupied by blood, drusenoid materials and exudates.

PEDs can be caused by chorioretinal diseases such as Age-related macular degeneration (ARMD), Central serous Chorioretinopathy(CSC), and polypoidal choroidal vasculopathy (PCV).

Pigment Epithelial detachment(PED)

Types of PED:

In AMD, PED can be categorized into the following main types:

1. Serous PED

2. Drusenoid PED

3. Fibrovascular PED

4. Haemorrhagic PED

 

1. Serous PED:

  • Patients of serous PED present with the symptoms of painless blurring of vision, micropsia, Metamorphopsia and distortion of objects. They might have developed induced hyperopia.
  • On slit lamp, it is characterized by yellow, orange, dome-shaped elevations of RPE having distinct margins.
  • Fluid present in subretinal space shows transillumination when examined through a slit lamp.
  • On OCT, PEDs are seen as elevations of RPE with hyporeflective sub-retinal space.
  • OCT is performed to differentiate whether PED is caused by AMD or CSC. If it’s due to AMD, subfoveal Choroidal thickness appears normal. Subfoveal Choroidal thickness will be increased in case of CSC.
  • On FA, this type of PED shows early hyperfluorescence and pooling without showing leakage.

 

2. Drusenoid PED:

  • It is characterized by irregular surface yellow white Elevations of RPE with scalloped borders present within the macular region.
  • It is mostly bilateral.
  • FA indicates early mild hyperfluorescence with late staining without showing any leakage.

Pigment Epithelial detachment(PED)

  1. Fibrovascular PED:
  • It occurs due to the presence of CNV. Due to breaks in Bruch’s membrane, abnormal blood vessels from the choroid enter into subretinal space. These abnormal blood vessels lack an inner blood-retinal barrier due to which they are leaky and bleed in subretinal space thus separating Bruch’s membrane from retinal pigment epithelium and leading to Fibrovascular PED.
  • It is characterized by irregular surface RPE elevations with haemorrhages, intra-retinal fluid and subretinal fluid etc
  • FA shows stippled hyperfluorescence with late leakage.

 

  1. Haemorrhagic PED:
  • This type of PED is associated with CNV or Polypoidal Choroidal Vasculopathy (PCV).
  • Patients with Haemorrhagic PED present with sudden Impairment of central vision.
  • On examination, dark red dome-shaped elevated lesions with sharp borders are noted.
  • FA shows masking of background fluorescence, but overlying vessels are visible.

MANAGEMENT of Pigment Epithelial detachment (PED)

  • For serous PED, no treatment option is available.
  • For Vascularized PED, Laser photocoagulation, anti-VEGF therapy, photodynamic therapy and intravitreal steroids can be given as a treatment.

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REFERENCES

  1.  American Academy of Ophthalmology. Pigment epithelial detachment.
  2.  Khochtali S, Ksiaa I, Megzari K, Khairallah M. Retinal Pigment Epithelium Detachment in Acute Vogt-Koyanagi-Harada Disease: An Unusual Finding at Presentation. Ocul Immunol Inflamm. 2019;27(4):591–594.
  3.  Mrejen, S. (2013). Multimodal imaging of pigment epithelial detachment: a guide to evaluation. Retina, 33(9), 1735-1762.
  4.  Gass JD, Norton EW, Justice J., Jr Serous detachment of the retinal pigment epithelium. Trans Am Acad Ophthalmol Otolaryngol. 1966;70:990–1015.
  5.  Gass JD. Drusen and disciform macular detachment and degeneration. Trans Am Ophthalmol Soc. 1972;70:409–436.
  6.  Casswell AG, Kohen D, Bird AC. Retinal pigment epithelial detachments in the elderly: classification and outcome. Br J Ophthalmol. 1985;69:397–403.

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