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A43-year-old woman presented with blurry vision in her left eye following blunt trauma to the left side of her head. She had a history of mild amblyopia in her right eye. On examination, visual acuity (VA) was 20/60 in the right eye and 20/60–2 in the left. There was a mild subconjunctival haemorrhage with left-sided periorbital ecchymoses. Fundus examination of the left eye revealed a well demarcated, crescent-shaped lesion with a linear zone of hyperpigmentation along its nasal border, consistent with a retinal pigment epithelial (RPE) tear (Fig. 1). Superotemporally, there was a horseshoe retinal tear. Fundus examination of the right eye was notable for rare nodular drusen.

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Figure 1. Colour fundus photograph of the left eye showing a giant tear in the retinal pigment epithelium with retracted tissue at the nasal margin of the defect.

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Fluorescein angiography (FA) revealed a well circumscribed area of staining, corresponding with lost RPE, with a narrow portion of blocked fluorescence of the nasal margin, consistent with retracted RPE (Fig. 2).

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Figure 2. Fluorescein angiogram of the left eye revealing a well circumscribed area of staining with blocked fluorescence along the nasal margin.

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Optical coherence tomography (OCT) (OCT I; Humphrey/Zeiss, Dublin, Cali-fornia, USA) showed a serous retinal detachment beneath the fovea overlying an area devoid of the reflective RPE/choriocapillaris band. Nasal to fixation, there was a focal area of intense hyper-reflectivity corresponding to scrolled RPE (Fig. 3).

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Figure 3. OCT displaying serous retinal detachment, absence of the RPE/choriocapillaris band, and scrolled RPE.

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The patient underwent laser retinopexy for the horseshoe tear. At 6 months follow-up, the VA in the left eye had deteriorated to counting fingers at 3 feet and the crescent-shaped macular lesion in the left eye appeared dry.

Traumatic RPE tears are rare (Levin et al. 1991; Doi et al. 2000). Retinal pigment epithelial tears are most commonly seen with RPE detachment associated with exudative age-related macular degeneration (AMD) (Hoskin et al. 1981; Patel et al. 1992); they have also been associated with chorioretinal scarring, retinal detachments, laser photocoagulation and glaucoma surgery (Cantrill et al. 1983; Swanson et al. 1984; Laatikainen & Syrdalen 1987).

The aetiology of a traumatic tear is uncertain. An acute tangential force has been proposed as a mechanism; the force required for this to occur is below the threshold necessary to disrupt both the RPE and Bruch's membrane (BM), leading to choroidal rupture, yet enough to tear the RPE alone (Levin et al. 1991).

Regardless of aetiology, the torn edge of the elastic RPE retracts over an intact and more compliant BM, leading to the characteristic scrolled appearance of the RPE on OCT. Tearing of the RPE also disrupts the apical tight junctions that maintain the blood−retinal barrier. This results in choroidal leakage and a serous retinal detachment in the area of the tear. The eventual reabsorption of the subretinal fluid may stem from atrophy and/or fibrosis of the underlying choriocapillaris (Doi et al. 2000).

This case underscores both the vision-threatening nature of a large, traumatic RPE tear and the diagnostic role of OCT, which displays the scrolled and retracted RPE characteristic of this condition.

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