Graefe's Arch Clin Exp Ophthalmol (1987)225:308-310 Graefe's Archive

for Clinical and Expedmental

Ophthalmology
© Springer-Verlag 1987

Tearing of retinal pigment epithelium after glaucoma surgery

L. Laatikainen 1 and P. Syrdalen 2
i Department of Ophthalmology, Helsinki University Central Hospital, Haartmaninkatu 4 C, SF-00290 Helsinki, Finland
2 University of Oslo, Rikshospitalet, Oslo, Norway

Abstract. Tearing of the retinal pigment epithelium follow-
ing trabeculectomy for chronic open-angle glaucoma in two
patients is reported. In one patient, the tear was diagnosed
on the 4th postoperative day. It started a few disc diameters
above the temporal vascular arcade, crossed the temporal
part of the macula and extended to the equator in the lower
temporal periphery. At the acute stage, hypotonia and exu-
dative retinal detachment were found. In the other patient,
the tear was equatorial extending from the upper nasal to
the lower nasal quadrant. At the acute stage, hypotonia
and choroidal detachment, but no exudative retinal detach-
ment, were present. After 1 year, the retina was flat in both
eyes and no further complications were noted.
Introduction
Tears of the pigment epithelium of the retina have been
described as a complication of pigment epithelial detach-
ment in senile macular degeneration (Hoskin et al. 1981;
Laatikainen 1983; Decker et al. 1983). In these eyes tearing
occurs along the edge of the pigment epithelial detachment.
Following severe contusion injury, tears in the pigment epi-
thelium may be seen in association with a rupture of Bruch's
membrane, but there seem to be no reports on pigment
epithelial tears following glaucoma surgery.
lium temporal to the fovea was noticed (Fig. 1). Tearing
started a few disc diameters above the macula as a narrow
slit, broadening downward and extending down to the
equator in the lower temporal quadrant. An exudative de-
tachment of the inferior retina peripheral to the inferior
temporal arcade was also present. Two weeks later, the
intraocular pressure was 11 13 mmHg, the eye was quiet
and the visual acuity was 0.25.
A follow-up examination 12 months later showed that
visual acuity was unchanged (0.25 with correction in both
eyes), intraocular pressure was 6 m m H g in the fight and
13 m m H g in the left eye, and both eyes had some cataract.
Ophthalmoscopy and contact lens examination of the left
eye showed that the pigment epithelial rupture was almost
unchanged except that in some areas the margin of the
pigment epithelium had slightly rolled up (Fig. 2a-c). There
were no signs of retinal detachment or subretinal neovascu-
larization.
Case 2
A 53-year-old man with bilateral ectopia lentis had been
on medication for glaucoma since 1961 and both lenses
were extracted in 1973-74. Laser trabeculoplasty was per-

Case reports

Case 1
A 77-year-old women had been on medication for chronic
open-angle glaucoma since 1970. In February 1985, trabe-
culoplasty using argon laser was performed on both eyes,
followed by trabeculectomy on the right eye in August 1985
and on the left eye in September 1985.
Before trabeculectomy of the left eye, the medication
consisted of pilocarpin lamellae combined with timolol ma-
leate 0.5% and dipivalylepinephrine 0.1% twice a day. The
pressure level varied between 25 and 40 mmHg. The proce-
dure of trabeculectomy was uneventful. Postoperatively, the
intraocular pressure was low (1-3 mmHg) and the anterior
chamber was shallow. On the 4th postoperative day the
patient complained of decrease in vision. On indirect oph- Fig. 1. Case 1. Copy of color photograph of the left fundus showing
thalmoscopy, a large vertical rupture of the pigment epithe- a long vertical rupture of the pigment epithelium temporal to the
fovea. In the inferior temporal quadrant the rupture extended down
Offprint requests to." L. Laatikainen to the equator (outside the photograph)

Fig. 2a-c. Case 1. Copies of color photographs of the left fundus
at 12-month follow-up examination, showing that the configura-
tion of the tear was unchanged. In some areas, edges of the tear
were rolled up (e), but no other complications were noticed
309
Fig. 3. Case 2. Copy of color photograph of the right fundus show-
ing a long vertical rupture of the pigment epithelium in the two
nasal quadrants along the equatorial region
Fig. 4. Case 2. Fluorescein angiographic picture showing the
uprolled posterior border of the pigment epithelium masking the
fluorescence and the uncovered choroidal vessels. Retinal vessels
are crossing the rupture
formed on both eyes in January 1984, and cyclocryotherapy
was applied to the right eye in the upper two quadrants
in April 1984. However, the intraocular pressure was not
controlled (medication: timolol maleate 0.5 %, ecothiophate
iodide 0.1%, acetazolamide 500 mg), and trabeculectomy
was performed on the right eye in February 1985. The pro-
cedure was uneventful. Postoperatively, the intraocular
pressure was low and there was peripheral choroidal detach-
ment. After 1 week, the choroidal detachment had disap-
peared and the intraocular pressure was 25 mmHg. The
intraocular pressure was later controlled on medication.
The patient was referred to our department for Y A G
laser treatment of the pupil of the left eye in January 1986.
In his right fundus a large pigment epithelial rupture was
seen. The rupture started in the equatorial region at
1 o'clock and extended along the equator to the 5 o'clock
position. The posterior border of the pigment epithelium
310
was rolled up at 2 o'clock (Fig. 3). There was no bleeding
or any other reaction around the rupture, and there was
no retinal detachment. Fluorescein angiography showed no
dye leakage and no neovascularization (Fig. 4). Follow-up
examination in May 1986 showed no change of the pigment
epithelial rupture. Visual acuity was 0.3.
Discussion
In cases of pigment epithelial detachment or severe contu-
sion injury, tearing of the pigment epithelium could be ex-
plained by mechanical stretch or traction of the intercellular
junctions of the pigment epithelial cells, in the present cases
the mechanism of pigment epithelial tearing is not clear.
The junctions of the pigment epithelial cells were probably
abnormally weak because a lot of peripheral drusen were
present in case 1, and case 2 had ectopia lentis and as such
was not a normal eye. Both eyes were hypotonic, and there
may have been at least some edema in the choroid in case 1
and choroidal detachment was seen in case 2. Thus stretch-
ing of the pigment epithelium may also be the cause of
these ruptures.
At the acute stage, an exudative detachment of the reti-
na was observed in case 1, but it healed spontaneously.
In case 2, no such detachment was noticed, but this patient
was operated on in another clinic and was not seen in our
clinic (2) until 1 year after the operation. The exact time
of the pigment epithelial rupture in this eye is therefore
not known, but there has been no surgery to this eye since
the trabeculectomy, and the patient has had no acute symp-
toms. It is therefore very likely that the rupture happened
during surgery or in the immediate postoperative period.
After 1 year of follow-up the retina was attached in both
eyes. Some retraction at the margins of the pigment epitheli-
al tear had occurred in both eyes, but no signs of subretinal
neovascularization or other complications related to the
tearing were observed.
References
Decker WL, Sanborn GE, Ridley M, Annesley WH, Sorr EM
(1983) Retinal pigment epithelial tears. Ophthalmology (Roch-
ester) 90: 507-512
Hoskin A, Bird AC, Sehmi K (1981) Tears of detached retinal
pigment epithelium. Br J Ophthalmol 65:417422
Laatikainen L (1983) Rupture of retinal pigment epithelial detach-
ment in senile macular disease. Acta Ophthalmol (Copenh)
61:1-8
Received January 6, 1987 / Accepted March 18, 1987