Zacks and Johnson1 report an elderly woman with serous retinal pigment epithelial detachment (RPED) associated with a focal red neovascular complex (RNC) that appears with optical coherence tomography (OCT) to be confined within the outer half of the sensory retina near the dome of the RPED. A dilated right-angle retinal vein and artery dip into the RNC. They interpret these findings as retinal angiomatous proliferation arising in the sensory retina and causing a large underlying avascular RPED. The yellowish-gray color of the RPED and partial obstruction of fluorescence involving the nasal half of the RPED in fluorescein angiograms, however, suggest the presence of occult sub-RPE neovascularization beneath the RPED. Fluorescein angiogram and indocyanine green angiogram show evidence of 2 foci of subretinal neovascularization, one corresponding with the RNC and the other straddling the superior border of the RPED. Foci of nonfluorescence surrounding the lesions suggest the presence of intraretinal, subretinal, or sub-RPE blood pigment. Posterior to the hyperreflective RNC, OCT shows a sharply defined zone of decreased reflectivity of the outer retina and focal absence of RPE reflectivity. Optical coherence tomography shows complete shadowing by the RPE of the space beneath the RPED and elsewhere peripheral to the RPED. Interpretation of OCT in lesions posterior to hyperreflective intraretinal lesions or of lesions posterior to the normally hyperreflective RPE is unreliable because of the phenomena of shadowing or reduction of the reflectivity of tissues posterior to hyperreflective lesions. I believe that the authors’ interpretation of these findings as evidence of confinement of the RNC within the retina overlying an avascular RPED is incorrect. Optical coherence tomography shows evidence of 2 foci of serous detachment of the retina, one adjacent to the RNC and the other at the margin of the RPED. Optical coherence tomography shows no intraretinal cystoid spaces that would be expected if the leaky RNC, capable of causing exudative RPED, was within rather than beneath a focal area of atrophic retina.
Gass JDM. Optical Coherence Tomography and an Intraretinal Lesion. Arch Ophthalmol. 2005;123(4):580-581. doi:10.1001/archopht.123.4.580-b