- Design
- Systematic review and random-effects meta-analysis, PROSPERO-registered
- Population
- 16 studies, 4,043 eyes with neovascular AMD
- Primary outcome
- Risk factors for retinal pigment epithelium tear
- Effect
- Baseline PED height mean difference 212.4 µm (95% CI 133.9 to 290.9)
A registered systematic review and meta-analysis pooled 16 studies of 4,043 eyes with neovascular age-related macular degeneration to identify risk factors for retinal pigment epithelium tears, which often occur soon after anti-VEGF treatment begins.
Eyes that developed tears had taller pigment epithelial detachments at baseline, by about 212 µm on average (95% CI 134 to 291), and larger ones, by about 5.8 mm². Fibrovascular detachments, larger basal diameter and volume, subretinal fluid, sub-RPE clefts, radial hyperreflective lines and occult or haemorrhagic neovascularisation were also associated. The choice of anti-VEGF agent was not consistently associated.
Most studies were retrospective with moderate to serious risk of bias, and certainty was very low. These are associations, not a validated prediction rule.
In clinic, the findings support measuring detachment height and noting high-risk features before the first injection, so that the risk can be explained to the patient.
- Measure pigment epithelial detachment height and area on OCT before starting anti-VEGF.
- Look for sub-RPE clefts and radial hyperreflective lines as warning features.
- Counsel patients with tall or large detachments about the risk of a tear.
- Do not switch anti-VEGF agent solely to avoid a tear; agent choice was not consistently linked.
Why it matters
RPE tears can cause sudden loss of central vision, and patients are better prepared if warned beforehand.
Don't overread it
The evidence is very low certainty and largely unadjusted; it does not provide a validated threshold.
The statistics, in plain English
A mean difference of 212 µm in height is large and consistent across studies (I² about 25%), but rests on only 55 eyes with tears. Very low certainty means the true relationship could differ substantially.
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