This 64YO male presented with recent central vision loss in his right eye. Vision was 20/40.
Color imaging shows a large central macular retinal pigment epithelial detachment (PED). Triton swept-source OCT through the central portion of the PED shows underlying hyporeflectivity. Scanning through the inferior portion shows a hyperreflective type 1 macular neovascularization (MNV) with a thin underlying prechoroidal cleft.
Optos fluorescein angiography shows an inferior linear filling defect within the MNV. The PED also shows late uneven pooling.
Learning Points:
Originally described by Gass (Retina 1984;4:205-220), a notched PED is a sign of an occult MNV. The notch represents a type 1 MNV, which tethers the overlying RPE from the surrounding more highly elevated PED. Hydrostatic leakage from the MNV may contribute to the larger PED.
Although now considered a classic clinical and angiographic finding, in 1984 this was evidently not the case, as the reviewers for this article advised against publication.
Based solely on who the contributing author was, the journal’s editor overruled his reviewers, published Dr. Gass’ manuscript, and the rest was literally history! The uneven angiographic pooling is also suggestive of an occult MNV.
A prechoroidal cleft is a hyporeflective space between the RPE and Bruch’s membrane. These are seen in up to about 20% of treated eyes with nAMD, particularly with type 3 neovascularization (intraretinal MNV) and polypoidal choroidal vasculopathy.
They are usually associated with worse visual acuity due to potential complications, including RPE tears and subretinal hemorrhage (Kim et al, Retina 2017;37:2047-2055).
Anti-VEGF therapy was recommended, and the patient was warned of the possibility of RPE development with or without treatment (Ersoz et al., Surv Ophthalmology 2017;62:493-505).
