Retinal Arterial Macroaneurysm

Retinal Imaging Conference
Brooke LW Nesmith, M.D.
University of Louisville
Department of Ophthalmology and Visual Sciences
8/7/2014
Patient Presentation
CC:
Routine yearly diabetic eye exam
HPI: 59yo female presents for her yearly diabetic eye exam.
She has no visual complaints, although does state she has
noticed a new floater OS in the past month.
Medical History
POHx:
None
PMH:
NIDDM x 2 years (HA1C 6.2%), HTN, Graves
Disease, Pacemaker, Valve replacement
Meds:
Warfarin, Furosemide, Levothyroxine,
Atorvastatin, Spironolactone, Lisinopril
Allergies:
NKDA
Exam
20/20
P
BCVA
20/20
EOM:
CVF:
Full OU
Full OU
19
3mm
(-) RAPD
3mm
TTP
19
Exam
Ext/L/L
Conj
K
AC
Iris/Lens
OD
OS
wnl
wnl
wnl
wnl
+NS
wnl
wnl
wnl
wnl
+NS
Color Fundus Photo OU
OD: ON pink and sharp; MVP WNL
OS: Area of pre-, intra-, and sub-retinal hemorrhage along inferotemporal arcade
Autofluorescence OD
OD: WNL
Autofluorescence OS
OS: Areas of hypoautofluorescence along the inferior arcade corresponding to areas of
hemorrhage seen clinically
FA Photo OD
Mid AV phase: WNL
FA Photo OS
Early phase: Areas of hypofluorescence along inferotemporal arcade
FA Photo OS
Mid AV phase: Areas of hypofluorescence along inferotemporal arcade
Assessment and Plan

A: 59yo female with diabetes and hypertension
presents with retinal arterial macroaneurysm associated
with multilevel retinal hemorrhages inferiorly without
leakage on FA.

P: Observation
Retinal Arterial Macroaneurysm

Acquired large arteriolar dilation
Usually within first 3 orders of vasculature bifurcations, at
branch points

Women, ages 50 to 80, HTN
10% bilateral, 20% multiple



Natural course usually favorable
Vision loss secondary to macular
edema or hemorrhage
Retinal Arterial Macroaneurysm
Treatment

Laser treatment
 direct – studies vary as to benefit
complications – BRAO,
CNV, subretinal fibrosis

Retinal Arterial Macroaneurysm
Treatment

Pneumatic displacement with tissue plasminogen activator for
submacular hemorrhage

Surgical removal of associated hemorrhage with vitrectomy

Photodisruption of the internal limiting membrane or the
posterior hyaloid using Nd:YAG or argon laser to release the
hemorrhage
Retinal Arterial Macroaneurysm
Treatment




23 patients with symptomatic retinal arterial macroaneurysm
Retrospective case series
As needed monthly injections of bevacizumab vs observation
Quicker resolution of macular edema and hemorrhage in
bevacizumab group, but no statistically significant difference in
BCVA improvement or central macular thickness improvement
at final visit.
Retinal Arterial Macroaneurysm
Treatment




38 patients with foveal complications from macroaneurysms
Prospective nonrandomized study
All patients received 3 monthly injections of bevacizumab
Closure of macroaneursym in 36 cases, complete resolution of
macular edema and regression of hard exudates in 100%
Retinal Arterial
MacroaneurysmTreatment
References
Rabb M, Gagliano DA, Teske, MP. Retinal Arteriolar Macroaneurysms. Surv Ophthalmol 1988;33:73-96.
Hudomel J, Imre. Photocoagulation treatment of solitary aneurysm near the macula lutea: Report of a case.
Acta Ophthalmol 1973;Sl:633-638.
Brown DM, Sobol WM, Folk JC, Weingeist TA. Retinal arteriolar macroaneurysms: long-term visual outcome.
Br J Ophthalmol 1994;78(7(:534-538.
Battaglia P M, Iacono P, Pierro L, Papayannis A, Kontadakis S, Bandello FM. Subthreshold laser treatment
versus threshold laser treatment for symptomatic retinal arterial macroaneurysm. Invest Ophthalmol Vis Sci 2012
Apr 2;53(4):1783-6.
Hillenkamp J, Surguch V, Framme C, et al. Management of submacular hemorrhage with intravitreal versus
subretinal injection of recombinant tissue plasminogen activator. Graefes Arch Clin Exp Ophthalmol 2010
Jan;248(1):5-11
Zhao P, Hayashi H, Oshima K, Nakagawa N, Ohsato M. Vitrectomy for macular hemorrhage associated with
retinal arterial macroaneurysm. Ophthalmology 2000;107(3):613-617.
Iijima H, Satoh S, Tsukahara S. Nd:YAG laser photodisruption for preretinal hemorrhage due to retinal
macroaneurysm. Acta Ophthalmol 2005;83(2):240-241.
Thank You