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Case Reports and Small Case Series
April 2000

Tear of the Retinal Pigment Epithelium and Serous Retinal Detachment in a Case of IgA Nephropathy After Renal Transplantation

Arch Ophthalmol. 2000;118(4):572-575. doi:

Central serous chorioretinopathy has been reported to be independently associated with a retinal pigment epithelial (RPE) tear1 and renal transplantation.2 To our knowledge, the association of an RPE tear, central serous chorioretinopathy, and renal transplantation, however, has not been reported in the English-language literature. Additionally, RPE tear usually occurs at one side of the RPE detachment. We report a case in which the RPE tear occurred at the center of the RPE detachment and is associated with central serous chorioretinopathy in a patient with IgA nephropathy after renal transplantation.

Report of a Case

A 39-year-old Chinese man was initially seen by us with a 2-month history of flashes in his right eye. He had a history of IgA nephropathy requiring renal transplantation 6 months earlier. A combined regimen of oral cyclosporine and prednisolone was given to prevent graft rejection. On ophthalmic examination,the patient's best-corrected visual acuities were 20/50 OD and 20/30 OS. Intraocular pressure in both eyes was normal. Slitlamp examination showed no abnormalities. Funduscopic examination of his right eye revealed a crescent-shaped RPE tear with rolls of RPE along both edges, along the inferotemporal arcade (Figure 1). Additionally, there was exudative retinal detachment inferior to the macula when the patient was sitting upright; and the macula was involved when the patient was supine. A few small RPE detachments outside the macular region were also found in his left eye. Fluorescein angiography of the right eye demonstrated a hyperfluorescent lesion measuring about 7 × 5 disc diameters, lined by 2 almost parallel hypofluorescent bands (Figure 2, left). There was a point of leakage located at the inferonasal margin of the RPE tear during the early phase, which leaked profusely during the later stage (Figure 2, right). Electroretinography and electro-oculography of the right eye were abnormal. Amplitudes of the b-wave were 30.5 µV in the right eye and 133.1 µV in the left eye. The Arden ratios were 1.29 OD and 2.24 OS. Focal diode laser photocoagulation to the point of leakage was performed that subsquently resulted in complete resolution of the exudative retinal detachment. The best-corrected visual acuity improved to 20/30 OU 4 months later.

Figure 1.
The right fundus photograph shows a large retinal pigment epithelium tear along the inferotemporal arcade.

The right fundus photograph shows a large retinal pigment epithelium tear along the inferotemporal arcade.

Figure 2.
Left, Composite photograph of early-phase fluorescein angiography of the right fundus demonstrates a hyperfluorescent lesion representing the denuded Bruch's membrane. It is lined by 2 almost parallel hypofluorescent bands, which represent the rolled retinal pigment epithelium on each side. Right, A late-phase fluorescein angiogram of the right fundus shows a large hyperfluorescent lesion representing the denuded Bruch's membrane. It is lined by 2 almost parallel hypofluorescent bands, which represent the rolled retinal pigment epithelium on each side. At the nasal tip of the retinal pigment epithelium tear, a leakage point with profuse leakage is evident.

Left, Composite photograph of early-phase fluorescein angiography of the right fundus demonstrates a hyperfluorescent lesion representing the denuded Bruch's membrane. It is lined by 2 almost parallel hypofluorescent bands, which represent the rolled retinal pigment epithelium on each side. Right, A late-phase fluorescein angiogram of the right fundus shows a large hyperfluorescent lesion representing the denuded Bruch's membrane. It is lined by 2 almost parallel hypofluorescent bands, which represent the rolled retinal pigment epithelium on each side. At the nasal tip of the retinal pigment epithelium tear, a leakage point with profuse leakage is evident.

Comment

Krishan et al,3 using a metal plate model, demonstrated that the bending stress along the RPE detachment was inversely proportional to the radius of curvature. The radius of curvature at the margin of the detachment was much smaller than that at the center. Hence, the bending stress at the edge was greater than that at the center of the RPE detachment, which explained why tears occurred mostly at the margin of the RPE detachment. However, in cases of age-related macular degeneration, the subretinal neovascular membrane may exert a tangential tractional force on one side of the RPE detachment causing an RPE tear at one side. In our patient, the RPE tear occurred at the center of the detachment. This might be due to uneven thickness or strength of the RPE layer. Gradual weakening or thinning of the RPE layer at the center of the detachment might have rendered it unable to sustain high mechanical stresses. Whether a steroid administered for systemic effect or IgA nephropathy itself predisposes the RPE weakness remains speculative.

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Article Information

This investigation was supported in part by the Mr W. K. Lee Eye Foundation, Hong Kong, China.

We have no proprietary interest in any material relating to this article.

Reprints: Alvin K. H. Kwok, FRCS, Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China (e-mail: alvinkhk@netvigator.com).

References
1.
Sunakawa  MTsukahara  I Tear of the retinal pigment epithelium and serous retinal detachment. Am J Ophthalmol. 1985;100488- 489
2.
Friberg  TREller  AW Serous retinal detachment resembling central serous chorioretinopathy following organ transplantation. Graefes Arch Clin Exp Ophthalmol. 1990;228305- 309Article
3.
Krishan  NRChandra  SRStevens  TS Diagnosis and pathogenesis of retinal pigment epithelial tear. Am J Ophthalmol. 1985;100698- 707
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