Coughing-induced retinal pigment epithelial tear after trabeculectomy combined with pars plana vitrectomy

Purpose: To report a case of retinal pigment epithelial (RPE) tear after trabeculectomy combined with pars plana vitrectomy (PPV). Observations: A 65-year-old man with neovascular glaucoma due to proliferative diabetic retinopathy presented with visual impairment and elevated intraocular pressure (IOP) in the right eye and underwent trabeculectomy combined with PPV. Three weeks after surgery, the best-corrected visual acuity (logarithm of minimal angle of resolution) improved from 3.0 to 0.30, and the IOP was controlled within normal limits. Four weeks after the surgery, he noticed visual impairment and ocular pain in the right eye after continuous coughing associated with asthma. Fundus examination revealed bullous retinal detachment, choroidal detachment, and submacular hemorrhage (SMH) due to a giant RPE tear at the posterior pole. Visual acuity worsened considerably to 1.7, while IOP was not elevated (6 mmHg). The patient received PPV with recombinant tissue plasminogen activator (rt-PA) and fluid/air exchange for internal tamponade and achieved anatomic retinal and choroidal attachments. Conclusions and importance: The acute increase in hydrostatic pressure in the choroidal interstitium due to continuous coughing induces an RPE tear. Vitrectomy with rt-PA and fluid/air exchange may be a favorable treatment for exudative retinal detachment and SMH due to RPE tears.