A simple and informative presentation on PED & IRF with pathophysiology, clinical examination, diagnostic imaging and one case study each for both PED & IRF

1. By,
Loknath Goswami
B. Optom 4th year

2. Introduction
• Retinal pigment epithelial
detachments (PEDs) are
characterized by separation between
the RPE and the inner most aspect of
Bruch's membrane.

3. Introduction

4. Introduction

5. Introduction
• The space created by this separation is
occupied by blood, serous exudate, drusenoid
material, fibrovascular tissue or a
combination.

6. Types
Drusenoid
SerousVascularsied

7. Types
• Drusenoid PEDs are seen mostly in dry AMD
• Serous PEDs are typically associated with the
wet form of AMD
• Vascularized PEDs associated with Type 1
(sub-RPE) neovascularization

9. Ocular Diseases
• PEDs are present in several chorioretinal
diseases including:
– Vogt-Koyanagi-Harada (VKH) Syndrome
– Central Serous Chorioretinopathy (CSC)
– Polypoidal Choroidal Vasculopathy (PCV)
– Exudative/Non-Exudative Age-Related Macular
Degeneration (AMD).

10. Systemic Diseases
• PEDs have also been associated with certain
systemic conditions including:
– Sarcoidosis
– Neurosyphilis
– Cryoglobulinemia
– Large cell non–Hodgkin lymphoma

11. Pathophysiology
• The retinal pigment epithelium (RPE) monolayer,
extending from the optic disk margin uninterrupted
through to the ciliary body epithelium, is bounded
apically by the apical surface of the retina and on its
basal surface by the collagenous layer of Bruch’s
membrane.

12. Pathophysiology
• Proper anatomical apposition between the retina, the
RPE, and Bruch’s membrane is crucial for nutritional
support of the photoreceptors, retinol metabolism,
phagocytosis of the photoreceptors outer segments,
and formation of the outer blood-retinal barrier.

13. Pathophysiology
• Under normal conditions, there exists a net
bulk flow of fluid towards the choroid from
the vitreous, with its generation dependent
upon hydrostatic and osmotic forces within
the two bodies. Both the RPE and the retina
produce resistance to this fluid flow.
• The RPE has greater resistance due to its
limited hydraulic conductivity, subsequently, a
vector force is generated pushing it against
Bruch’s membrane.

14. Pathophysiology
• The attachment of the RPE basement membrane
to Bruch’s membrane is possibly supplemented
by regions of hemidesmosomes containing fine
filaments of laminin, proteoglycans and collagen
types IV and V.
• Age-related deposition of lipids, such as
cholesterol esters, triglycerides, and fatty acids,
in Bruch membrane may change its permeability
altering retinochoroidal flow.
• Fluid may accumulate in the sub- RPE space,
unable to pass through Bruch membrane,
resulting in RPE elevation.

15. Diagnosing

16. Diagnosis
History
Physical
examination
Imaging tests
Diagnosing
Diagnosing PEDs relies on careful history and
physical exam with further information provided
by various imaging modalities.
Treatment

17. History
• Patients will typically present with painless
blurred vision or partial vision loss.
• Others have described a dark shadowing
effect or sensation that a curtain has been
pulled in front of their vision.

18. Physical Exam
• Often PEDs will transilluminate if they are filled
predominantly with serous fluid when observed
at the slit lamp. Pigment figures can also indicate
chronicity of disease.
• Examination reveals a reticulated pattern of
increased pigmentation extending radially over
the PED, likely due to migration of RPE cells into
the outer retinal space however it is unclear
whether these carry a prognostic significance.

19. Drusenoid PED
• Drusenoid PEDs appear as well-circumscribed
yellow or yellow–white elevations of the RPE
that are usually found within the macula. They
may have scalloped borders and a slightly
irregular surface. It is not uncommon to
observe a speckled or stellate pattern of
brown or gray pigmentation on their surface.

20. Drusenoid PED
Yellow or yellow–white elevations
Scalloped borders
Stellate pattern of brown or gray pigmentation on their surface

21. Serous PED
• Serous PED appears as a distinct circular or
oval-like detachment of the RPE. Clear or
yellowish–orange in color, this dome-shaped
elevation of the RPE has a sharply demarcated
border.

22. Serous PED
Yellowish–orange in colour
A sharply demarcated border

23. Vascular PED
• Fibrovascular PED’s indicate the growth of a
choroidal neovascular membrane (CNVM) in
the sub-RPE space; this is also known as occult
choroidal neovascularisation.
• Gass reported that a flattened or notched
border of the PED is a frequent and important
sign of hidden associated CNV

24. Vascular PED

26. Fluorescein angiography

27. Drusenoid PED
• Drusenoid PEDs demonstrate faint
hyperfluorescence in the early phase that
increases throughout the transit stage of the
study without late leakage.
• The correlation of FA findings with SD-OCT
and occasionally ICGA may help differentiate
drusenoid from vascularized PEDs.

28. Drusenoid PED

29. Serous PED
• Serous PEDs demonstrate intense early
hyperfluorescence and brisk, progressive
pooling within the PED in a homogeneous and
well-demarcated manner
• Late staining of serous PEDs is typical and may
make it difficult to differentiate these PEDs
from those that are vascularized based on FA
alone

30. Serous PED

31. Vascular PED
• From the analysis of fundus photographs of
the macula and FA, the Macular
Photocoagulation Study identified two main
patterns of CNV:
Classic
Occult

32. Vascular PED
• Classic CNV is characterized by a well-defined
area of early typically lacy hyperfluorescence
with progressive leakage in the late stages of
the study.

34. Vascular PED
• The term “occult” refers to a type of CNV that
is difficult to visualize, analyse and localize on
FA

35. Vascular PED

37. Drusenoid PED
• Using a confocal scanning laser
ophthalmoscope (SLO) system and ICGA, the
content of the drusenoid PED will block the
fluorescence emitted from the underlying
choroidal vasculature and, therefore, the PED
will appear as a homogeneous
hypofluorescent lesion during the early phase
and remain hypofluorescent throughout the
transit.

38. Drusenoid PED

39. Serous PED
• With an infrared fundus camera, the ICGA
reveals only variable, minimal blockage of
normal choroidal vessels by the serous PEDs in
the late phase. Using a confocal SLO system,
the ICGA reveals hypofluorescence in both the
early and the late phases of the ICGA study
with complete blockage of the normal
choroidal vasculature.

40. Serous PED

41. Vascular PED
• ICGA is very useful for diagnosing and
classifying CNV associated to serous PED, due
to its capacity to distinguish between the
serous and the vascular component

42. Vascular PED
The cases involve OCNV, where ICGA can show hot spots on the black image of the PED
associated to RAP (yellow arrows) or polyps (red arrows).

44. Drusenoid PED
• Drusenoid PEDs usually show a smooth
contour of the detached hyperreflective RPE
band that may demonstrate an undulating
appearance.
• The material beneath the RPE band typically
exhibits a dense homogeneous appearance
with moderate or high hyperreflectivity.
• Drusenoid PEDs are typically not associated
with overlying subretinal or intraretinal fluid.

45. Drusenoid PED

46. Drusenoid PED

47. Serous PED
• On OCT, serous PEDs appear as well-
demarcated, abrupt elevations of the RPE with
a homogenously hyporeflective sub-RPE
space.
• Enhanced depth imaging (EDI) OCT is useful to
determine whether serous PED is caused by
AMD (normal subfoveal choroidal thickness)
or by CSC (increased subfoveal choroidal
thickness).

48. Serous PED

49. Serous PED

50. Vascular PED
• Optical coherence tomography allows better
visualization of the exact relationship between
neovascular membranes and PEDs.
• Enhanced depth imaging OCT enables better
visualization of the contents of PEDs.
Untreated PEDs demonstrate evidence of
fibrovascular proliferation, often coursing
along the back surface of the detached RPE.

51. Vascular PED

52. Vascular PED

53. Management
• Depending on the etiology of the PED,
different treatment modalities have been
explored to prevent vision loss.

54. Treatment
• Several strategies, have being used to treat
vascularized PEDs, including laser
photocoagulation, photodynamic therapy
(PDT), intravitreal steroids and anti-VEGF
therapy.
• The results from the trial indicated that PDT
could significantly reduce the risk of moderate
and severe vision loss among patients with
subfoveal occult CNV.

55. Treatment
• Another treatment modality, described
recently by Costa et al as a pilot trial, is
photothrombosis at the neovascular ingrowth
site using ICG injection followed by laser
application. Occlusion of the feeder vessel
with cessation of leakage, restoration of
macular architecture and visual improvement
were induced in two patients with CNV
associated with PEDs.

56. Treatment
• Currently no treatment for serous PED is
proven effective, nor are recommendations
for treatment guidelines established.

57. Prognosis
• The location of the PED is important in
determining prognosis.
• Patients with extrafoveal PEDs tend to
preserve good visual acuity, whereas patients
with subfoveal PEDs can have worse visual
outcomes.
• The course of PEDs also varies in CSC versus
AMD.

58. Prognosis
• Mudvari et al demonstrated with a mean
follow-up of 49 months that 65% of PEDs in
CSC completely resolved and the other 35%
PEDs remained persistent.
• Retinal pigment epithelium atrophy was
evident in 86% of patients over the area of the
resolved PED.

59. Prognosis
• The natural course of Type 1 or occult CNV can
vary considerably. Type 1 CNV patients can
appear relatively asymptomatic and may never
experience vision loss despite continued growth
of the neovascular lesion.
• On the other hand, large vascularized or
hemorrhagic PEDs are typically associated with
significant vision loss. Additionally, Type 1 CNV
can erode through the RPE, becoming Type 2 CNV
and follow a more aggressive course with more
progressive and severe vision loss.

60. Case study
• An 81-year-old female patient presented for a routine
eye examination with no ocular complaints.
• There were no general health concerns and no family
general or ocular health history.
• Refraction showed no change and visual acuity (VA) in
both eyes was stable at 6/7.5
• Binocular indirect examination of the right fundus
showed extensive exudates between the macula and
disc
• OCT examination revealed the presence of a large
pigment epithelial detachment (PED)

61. Case study

62. Case study
• In this case, the PED displays OCT
characteristics consistent with a fibrovascular
PED
• The RPE is broadly and irregularly elevated
with the PED appearing to be filled with solid
layers of medium reflective material,
separated by hyporeflective clefts.

63. Case study
• While vision remained stable in this patient –
likely due to the absence of sub-retinal and
intraretinal fluid and the maintained integrity of
the photoreceptor complex – as wet AMD was
suspected the patient was referred via a fast track
macular service.
• Fluorescein angiography examination, which was
performed within 10 days of the original referral,
confirmed OCT findings of a right occult CNVM.

64. Case study
• However, with VA of 6/7.5, the patient fell
outside NICE guidance for treatment with the
anti-VEGF therapy, Lucentis (ranibuzumab),
which states that VA must be between 6/12
and 6/96.
• The patient was advised to self-monitor with
an Amsler grid and would be reassessed on a
monthly basis with OCT.

65. Case study
• As this patient has wet AMD in her right eye and
dry AMD in the left eye, it would be advisable to
offer nutritional supplementation.
• In a patient with these characteristics,
supplementation with the AREDS 2 formula
(10mg lutein, 25mg zinc, 2mg copper, 500mg
vitamin C and 400IU vitamin E) could reduce risk
of progression to advanced AMD by 18–25%,
depending on dietary intake of nutrients.

66. Case study
• Nutritional supplementation with antioxidants
is believed to reduce the risk of AMD
progression by reducing the level of oxidative
stress at the retina, one of the most popular
hypotheses regarding AMD development and
progression.

67. Intraretinal fluid

68. Introduction
• It normally appears above outer plexiform
layer
• Intraretinal fluid either can occur diffusely and
cause increased retinal thickness and reduced
retinal reflectivity or be localized or non-
reflective cysts (cystic edema)
• It is mainly seen in cystoid macular edema

69. Cystoid macular edema
• Cystoid Macular Edema (CME) is retinal
thickening of the macula due to a disruption of
the normal blood-retinal barrier; this causes
leakage from the perifoveal retinal capillaries and
accumulation of fluid within the intracellular
spaces of the retina, primarily in the outer
plexiform layer.
• Visual loss occurs from retinal thickening and
fluid collection that distorts the architecture of
the photoreceptors.

70. Pathophysiology
• A delicate exchange of homeostatic mechanisms is in
place with the vitreous, retina, retinal pigment
epithelium (RPE), and choroid receiving their circulation
through the retinal and choroidal vasculature.

71. Pathophysiology
• There is an intrinsic balance amongst the
osmotic force, hydrostatic force, capillary
permeability, and tissue compliance that occur
within the vasculature. Specifically, the
capillary filtration rate should equal the rate of
fluid removal from extracellular retinal tissue,
such as glial and RPE cells.

72. Pathophysiology
• Once these forces are disrupted an imbalance
occurs, accumulation of fluid is seen in cystoid
spaces within the inner layers of the retina,
most commonly the outer plexiform layer
(OPL).
• Accumulation of the fluid commonly occurs in
the Henle’s fiber layer causing the classic
petaloid pattern.

73. Pathophysiology
• A common factor that can cause CME is
vitreomacular traction (VMT)

74. Signs
• Using slit lamp or direct/indirect ophthalmoscopy,
clinically significant foveal edema and retinal
thickening more than 300 μm can be seen as a loss
of foveal reflex; this is better visualized using
green light to outline the cystic spaces.
• Subclinical foveal edema is described as edema
less than 300 μm and is better seen through
retinal imaging.
• Vitritis and optic nerve head swelling can also be
seen in clinical examination.

75. Symptoms
• Decrease in visual acuity that is associated
with retinal edema
• Loss of contrast sensitivity and color vision
• Metamorphopsia that can be demonstrated
on Amsler grid, micropsia, and central
scotoma

76. Risk Factors
• Diabetes
• Epinephrine
• Pars Planitis/Uveitis
• Retinitis Pigmentosa (RP)
• Vein Occlusion
• Nicotinic acid and Niacin
• Surgery

78. Color Fundus Photography (CFP)
• It depicts intraretinal cysts within the foveal region of the
macula in Henle's layer in a honey comb pattern

79. Fluorescein Angiography (FA)
• It studies the circulation of the retina and choroid. In the
early phase of FA, capillary dilation in the perifoveal region is
appreciated

80. Fluorescein Angiography (FA)
• In the late phase (may take 5-15 minutes) of FA, leakage into
the cystoid spaces is distributed radially in Henle’s layer
forming the classic petaloid leakage pattern or expansile dot
appearance

81. Optical coherence tomography (OCT)
• OCT can depict the mechanical forces induced by
vitreomacular interface abnormalities, such as VMT or
epiretinal membrane (ERM), via a hyperreflective band on the
inner surface of the retina

82. Management
Surgery
Medical
therapy
General
treatment

83. General treatment
• Therapeutic approaches, whether medical or
surgical, in treating CME are dependent on the
underlying etiology.
• Most cases are self-limiting within 3-4
months.
• If CME persists then medical or surgical
therapy is warranted.

84. Medical therapy
• NSAIDS
• Corticosteroids
• Carbonic anhydrase inhibitors (CAIs)
• Anti-VEGF agents
• Pharmacologic vitreolysis agents

85. Surgery
• Pars plana vitrectomy can help to relieve
macula edema due to tractional or
nontractional components
• Side effects of vitrectomy include cataract,
retinal detachment, vitreous hemorrhage, and
a rise in intraocular pressure.

86. Case study
• MRD No : 152337
• Gender : Male
• Age : 70 Years
• Main complaints : OD – Floaters since 2Year
• No h/o ocular or head injury
• Past ocular history : Nil

87. Case study
• Past medical history:
– Diabetes mellitus - not using Rx.
– Hypertension systemic - take tablets
• Family history: Nil
• Allergy: Not aware of
• Current medication: Nil

88. Case study
• Vision (aided) :
– OD = Dist. 6/12 Near N6
– OS = Dist. 6/7.5 Near N6

89. Oct report

90. Case study
• Diagnosis:
– Occlusion branch retinal vein (BRVO) OD
– OU – Cataract immature
• Medications :
– OD- Extragat eyedrops-4times/day x 1 week
Remarks :- start one day before inj.
• Advice – Avastin (OD)

91. Review after 26 days
• Vision remained constant
• OD – Macular edema reduced

92. OCT report after Avastin inj.

93. Comparison
Pre op Post op

94. Review after 26 days
• Medications – Gatilox Hx eye drops –
3times/day x 1 week
Remarks: Start one day before inj.
• Advice :- OD (Avastin)

95. References
• http://www.amdbook.org/content/serous-ped-0
• http://eyewiki.aao.org/Pigment_Epithelial_Detachment
• http://eyewiki.aao.org/Cystoid_Macular_Edema
• http://www.amdbook.org/book/export/html/484
• Mudvari, S. S., Goff, M. J., Fu, A. D., McDONALD, H. R., Johnson, R. N., Ai,
E., & Jumper, J. M. (2007). The natural history of pigment epithelial
detachment associated with central serous
chorioretinopathy. Retina, 27(9), 1168-1173.
• Costa, R. A., Rocha, K. M., Calucci, D., Cardillo, J. A., & Farah, M. E. (2003).
Neovascular ingrowth site photothrombosis in choroidal
neovascularization associated with retinal pigment epithelial
detachment. Graefe's archive for clinical and experimental
ophthalmology, 241(3), 245-250