Advances in the diagnosis and treatment of retinal artery macroaneurysms / 国际眼科杂志(Guoji Yanke Zazhi)

Retinal arterial macroaneurysm(RAM)is a kind of acquired retinal vascular disorder. The pathogenesis of RAM is not yet clear, and it is associated with some systemic conditions, including hypertension, arteriosclerosis and hyperlipidemia. RAM is prone to exudation or bleeding, leading to some other complications in the condition of hypertension due to the weak tube wall, and its clinical manifestations are complex and diverse, which makes it difficult to diagnose. RAM itself has a tendency of self-degeneration, and the prognosis of visual acuity is good if the lesion doesn't involve the macular area. However, when the macula is affected by exudation and/or bleeding, the vision is severely affected and some feasible treatments are needed. Understanding the typical imaging manifestations of RAM is helpful to make a definite diagnosis and give corresponding treatment measures. In this paper, the manifestations of RAM by various examination methods are reviewed and the corresponding treatments of different types of RAM are summarized, aiming to provide reference for the early diagnosis and treatment of RAM in the future.

Retinal arterial macroaneurysms in patients recovered from COVID-19 / Macroaneurismas arteriais retinianos em pacientes recuperados da COVID-19

ABSTRACT This is a case series about retinal arterial macroaneurysms in three patients recovered from COVID-19. None of them had previous past ocular and systemic history. The first patient was a 47-year-old man, with best-corrected visual acuity of 20/20 in both eyes. He presented a cotton wool spot in the right eye and two peripheral exudative retinal arterial macroaneurysms in the left eye. Laser photocoagulation was performed and best-corrected visual acuity remained stable. The second one was a 62-year-old-woman with acute visual loss in the right eye (best-corrected visual acuity of 20/400). There was vitreous hemorrhage and a peripheral retinal arterial macroaneurysm in the right eye. Laser photocoagulation was performed and best-corrected visual acuity improved to 20/20. The third patient was a 54-year-old woman, with best-corrected visual acuity of 20/20 in the right eye and 20/600 in the left eye. Fundus examination showed multiple layer hemorrhage in the macular region and retinal arterial macroaneurysms in the superior temporal branch. The cases underwent fluorescein angiography, which confirmed the diagnosis of retinal arterial macroaneurysms.

RESUMO Esta é uma série de casos sobre macroaneurismas arteriais da retina em três pacientes recuperados da COVID-19. Nenhum tinha história ocular e sistêmica prévias. O primeiro era um homem de 47 anos, com melhor acuidade visual corrigida de 20/20 em ambos os olhos. Apresentava mancha algodonosa em olho direito e dois macroaneurismas arteriais da retina exsudativos periféricos em olho esquerdo. Foi realizada fotocoagulação a laser, e a melhor acuidade visual corrigida permaneceu estável. A segunda era uma mulher de 62 anos com perda visual aguda em olho direito (melhor acuidade visual corrigida de 20/400). Havia hemorragia vítrea e um macroaneurisma periférico em olho direito. O laser foi realizado, e a melhor acuidade visual corrigida melhorou para 20/20. A terceira paciente era uma mulher de 54 anos, com melhor acuidade visual corrigida 20/20 em olho direito e 20/600 olho esquerdo. A fundoscopia mostrou hemorragia em múltiplas camadas na região macular e um macroaneurisma arterial da retina no ramo temporal superior. Os casos foram submetidos à angiofluoresceinografia, que confirmou o diagnóstico de macroaneurismas arteriais da retina.

Research progress in the treatment of retinal arterial macroaneurysm / 国际眼科杂志(Guoji Yanke Zazhi)

@#The retinal arterial macroaneurysm, also known as isolated aneurysm, is an acquired retinal vascular abnormality, which is characterized by fusiform or circular dilatation of the posterior polar retinal arteries, forming one or more aneurysms. Most of aneurysms are located on the temporal vessels of the retina. There are no clinical symptoms in the early stage. If the tumor ruptures and hemorrhage involving the macula, may suddenly appear central dark spots and vision loss. The hemorrhage may be located in the vitreous cavity, under the posterior vitreous boundary membrane, under the retinal inner boundary membrane, and subretinal region. Treatments for RAM include retinal laser photocoagulation, vitrectomy, intravitreal or intraretinal injection of tissue plasminogen activator, and anti-VEGF agent. In this paper, the latest research progress in the treatment of RAM is discussed and prospected.

Clinical observation of treatments for retinal arterial macroaneurysm / 国际眼科杂志(Guoji Yanke Zazhi)

@#AIM: To analyze the treatment of retinal arterial macroaneurysm(RAM)and its efficacy. <p>METHODS:A total of 26 diagnoses of retinal arterial microaneurysm made in the Fourth People's Hospital of Shenyang between June 2016 and June 2018 were reviewed. Various treatment strategies for different types, and complications, of RAM were utilized, with the clinical, anatomical, and functional outcomes being analyzed retrospectively. <p>RESULTS: Visual prognosis and its efficacy were due to the scope and location of exudation or heamorrhage, disease duration and treatments employed. Hemorrhagic RAM, edema or hemorrhage affecting the macular region and long disease duration associated with poor prognosis. Vitrectomy with subretinal air tamponade had strong functional and anatomical effects on submacular haemorrhages within 3wk. <p>CONCLUSION: A suitable, individually adapted treatment of retinal arterial macroaneurysm should be chosen to achieve better prognosis.

Optical coherence tomography angiography of fleeting macroaneurysm in retinal racemose angioma

We present a rare case of retinal racemose angioma complicated with fleeting macroaneurysm (MA). A 50-year-old female presented with diminution of vision in her right eye for 6 years. Fundus examination showed a racemose angioma with hemorrhagic MA temporal to the fovea in the right eye. On subsequent follow-ups, spontaneous thrombosis of MA was noted with the development of new MA inferior to the fovea, with intraretinal hemorrhage extending into the fovea. Focal laser to MA resulted in resolution of MA with improvement in vision. We report optical coherence tomography angiographic features of the fleeting MA in a case of racemose angioma.

Multi-mode imaging features of retinal arterial macroaneurysms / 中华实验眼科杂志

Objective To observe the clinical characteristics of multi-mode images of retinal arterial macroaneurysms and provide reference for the accurate diagnostic.Methods The clinic data of 24 patients (25 eyes) with retinal arterial macroaneurysms who were diagnosed in the First Affiliated Hospital of Zhengzhou University from August 2012 to May 2016 were retrospectively analyzed.All patients received ophthalmologic examinations including visual acuity,fundus photography,and fundus fluorescein angiography (FFA).The patients who could not be diagnosed by fundus photography and FFA underwent indocyanine green angiography (ICGA) and spectral-domain optical coherence tomography (SD-OCT) examinations.The visual acuity of the three types of retinal arterial macroaneurysms and the diameters of retinal arterial macroaneurysms based on FFA images was analyzed.Results A single macroaneurysm appeared in all the 25 eyes.Retinal arterial macroaneurysms of 22 eyes were on temporal artery branches and those of 3 eyes were on the nasal artery branches.Sixteen retinal arterial macroaneurysms were determined as hemorrhagic type,2 were exudative type and the other 7 were quiescent type.The difference of vision acuity in the three types of retinal arterial macroaneurysms was significantly different (x2=15.117,P=0.001).Retinal arterial macroaneurysms of 20 eyes could be clearly exhibited by FFA,and the retinal arterial macroaneurysms in other 5 eyes which were concealed due to bleeding were displayed by ICGA and OCT.The average diameter of retinal arterial macroaneurysms and normal arteries were (330.65±43.09)μm and (134.70±10.74)μm,respectively,showing a significant difference (t =21.034,P =0.000) and a positive correlation between them (r =0.867,P=0.000).Conclusions Most retinal artcrial macroaneurysms can be diagnosed by FFA,moreover,both ICGA and OCT can provide necessary supplement for the concealed retinal arterial macroaneurysms.The larger the diameter of the normal artery is,the larger the diameter of the corresponding retinal arterial macroaneurysms is.The typing of retinal arterial macroaneurysms can offer basis for the evaluation of management.

Ruptured Retinal Arterial Macroaneurysm after Panretinal Photocoagulation for Diabetic Retinopathy

PURPOSE: To report a case of deterioration of a retinal arterial macroaneurysm after panretinal photocoagulation (PRP) for diabetic retinopathy. CASE SUMMARY: A 70-year-old woman visited our clinic for evaluation of diabetic retinopathy. Fundus examination and fluorescein angiography showed severe non-proliferative diabetic retinopathy and PRP was planned for the patient. In addition, the patient was found to have a retinal arterial macroaneurysm on the superotemporal area of the retina on her right eye. However, the lesion was small and was located far from the macula, causing no symptoms; thus we decided to observe the patient over a period of time. Two months after PRP, the patient revisited the clinic complaining of acute visual loss. Fundus examination showed vitreous and retinal hemorrhage and optical coherence tomography revealed subretinal fluid in the corresponding area. This was considered to be due to aggravation of the pre-existing macroaneurysm. Intravitreal Bevacizumab injection, C₃F₈ gas injection, and pars plana vitrectomy were performed. After absorption of the hemorrhage, barrier photocoagulation was performed around the retinal macroanerysm. The visual acuity improved and the retina remained stable through the most recent follow-up. CONCLUSIONS: We experienced the rupture of a preexisting retinal arterial macroaneurysm in an asymptomatic patient after panretinal photocoagulation. PRP in diabetic patients could aggravate retinal arterial macroaneurysms. Therefore, it is necessary to carefully examine the patient for retinal macroaneurysms when planning a PRP for diabetic retinopathy.

Retina findings in intracranial aneurysm patients / 国际眼科杂志(Guoji Yanke Zazhi)

AIM: To evaluate fundus findings in patients with intracranial aneurysm (ICA) to determine the relation between ICA and distinguishable retinal features.METHODS: We analyzed the medical records and ocular images of 46 patients with previously diagnosed ICA referred from the Neurosurgical Department.All patients underwent ophthalmologic evaluation including fluorescein angiography (FAG).Furthermore, the presence of drusen, macular degeneration, cotton wool spot, hard exudates, retinal hemorrhage, arteriolar attenuation, A-V crossing signs, arm-to-retina time, and A-V transit time were evaluated.The results of ICA patients (Group 1) were compared with those of 22 idiopathic epiretinal membrane patients with unaffected eyes (Group 2).RESULTS: Mean ages were 60.02y (Group 1) and 60.68y (Group 2) respectively (P=0.70).The prevalence of hypertension was similar in both groups.No case with retinal macroaneurysm was found in either group.The presence of drusen, macular degeneration, cotton wool spot, hard exudates, retinal hemorrhage, arteriolar attenuation, and A-V crossing sign was not significantly different between the two groups.Mean arm-to-retina time was not significantly different in two groups, either.CONCLUSION: We cannot find any evidence that the patients with ICA shows specific changes in the FAG and fundus.

Submacular hemorrhage: A study amongst Indian eyes.

Aim: To evaluate the management outcomes amongst various treatment modalities for submacular hemorrhage (SMH) in Indian subjects. Settings and Design: Retrospective, single-center study. Materials and Methods: Patients presenting with SMH between 1999 and 2006 were included. Treatment modalities included: vitrectomy with subretinal recombinant tissue plasminogen activator (r-tPA) assisted SMH evacuation (group 1, n = 14); pneumatic displacement with intravitreal r-tPA and gas (group 2, n = 25); and pneumatic displacement with intraocular gas (group 3, n = 7). Favorable anatomical outcome was defined as complete displacement of SMH from fovea and favorable functional outcome was defined as a gain of >2 Snellen lines from the baseline. Kruskal–Wallis, analysis of variance (ANOVA), and Chi-square tests were used to compare the three groups, while Mann–Whitney and independent t-test were used to evaluate the influence of duration and size of SMH on outcomes. Results: There was no difference amongst groups in terms of favorable anatomical (P = 0.121) or functional outcomes (P = 0.611). Eyes with median duration of SMH less than 7.5 days had a significantly higher probability of achieving favorable anatomical outcome compared to eyes with SMH >14.5 days (P = 0.042). However, duration of SMH did not influence functional outcome (P = 0.595). Similarly, size of SMH did not affect anatomical (P = 0.578) or functional (P = 0.381) outcome. Median follow-up was 31.5, 6.5, and 2.5 months in the three groups, respectively. Conclusions: Co- existing posterior segment conditions and duration of SMH may influence the choice of treatment modality and treatment outcomes. Pneumatic displacement with r-tPA and r-tPA assisted vitrectomy appear to be favorable options for the management of SMH.

Intravitreal Bevacizumab for Macular Edema Secondary to Ruptured Retinal Arterial Macroaneurysm

PURPOSE: To study the short-term effect of intravitreal injection of bevacizumab in the treatment of macular edema secondary to retinal macroaneurysm. METHODS: Eight eyes of 9 patients who underwent consecutive intravitreal bevacizumab injections for macular edema secondary to retinal macroaneurysm were prospectively evaluated. Complete eye examination including the best corrected visual acuity (BCVA), fundus examination and optical coherence tomography (OCT) were performed at baseline and follow-up visits at 2, 4 and 6 months. RESULTS: The mean age was 73.6 +/- 6.9 years, and the mean study period was 7.3 +/- 2.6 months. At the final visit, BCVA improved from log MAR 1.92 +/- 0.67 to log MAR 0.87 +/- 0.57. The mean central macular thickness on OCT image decreased from 388 +/- 168 microm at the initial visit to 200 +/- 39 microm at the final visit. Three eyes without subretinal hemorrhage presented better visual outcome than eyes with subretinal hemorrhage. All eyes showed some decrease in angiographic leakage. No adverse side effects were observed following the injections. CONCLUSIONS: Intravitreal bevacizumab injection can be used as a selective alternative treatment modality for macular edema secondary to retinal macroaneurysm.

The Recurrent Submacular Hemorrhage after Removal of Sub-Internal Limiting Membrane Hemorrhage with Retinal Arterial Macroaneurysm

PURPOSE: To report a case of a recurrent macular hemorrhage that developed after surgical removal of the internal limiting membrane (ILM) for subintimal hemorrhage due to retinal macroaneurysm. CASE SUMMARY: A 75-year-old female was admitted to the hospital complaining of decreased vision in the left eye which had started 3 weeks previously. The best corrected visual acuity (BCVA) of the right and left eye was 0.7 and 0.03, respectively. The intraocular pressure (IOP) of the right and left eye was 10 mm Hg and 12 mm Hg, respectively. On the fundus examination, macular preretinal and subretinal hemorrhage was observed and a diagnosis of retinal arterial macroaneurym of the inferonasal major artery was made. Vitrectomy was performed. After indocyanine green dye staining, the sub-ILM hemorrhage was treated with removal of the ILM. At postoperative day 3, the annular chorioretinal folds were observed due to the hypotony (4 mm Hg). However, the absence of leakage was confirmed through the sclerotomy site. At postoperative day 8, recurrent submacular hemorrhage occurred and the hemorrhage was observed to have spread after intravitreal C3F8 gas injection and when the patient was placed in the prone position. At postoperative 4 months, the hemorrhage that had invaded the macular area was completely resolved. The BCVA was 0.3, respectively. CONCLUSIONS: When removing a sub-ILM hemorrhage due to retinal macroaneurysm, recurrent hemorrhage can occur especially in a patient with ocular hypotony, as in the present case report. Physicians should be aware of this possibility and the proper treatment the condition requires.

Clinical Results of Vitrectomy in Macular Hemorrhage From a Ruptured Retinal Artery Macroaneurysm

PURPOSE: To evaluate the relationship between postoperative optical coherence tomography (OCT) findings and visual acuity in patients who underwent vitrectomy for macular hemorrhage related to the rupture of a retinal artery macroaneurysm. METHODS: A retrospective case review was conducted for patients who underwent vitrectomy for macular hemorrhage caused by a retinal arterial macroaneurysm. The relationship between postoperative OCT findings and visual acuity was analyzed. RESULTS: This study included 12 patients whose preoperative mean best corrected visual acuity (BCVA) (logMAR) was 1.7+/-0.8 and whose mean final BCVA was 0.6+/-0.5. These values were statistically different (p=0.004). Mean foveal thickness by OCT was 437.5+/-161.5 micrometer at the preoperative period and 252.8+/-84.9 micrometer three months postoperative, and this difference was statistically significant (p=0.017). As the foveal thickness decreased after removal of the remnant organized retinal hemorrhage in the postoperative period, BCVA improved at the final follow-up (p=0.048). According to the postoperative OCT, the photoreceptor disruption group presented a lower BCVA than that of the photoreceptor preservation group at the final follow-up (logMAR: 1.4+/-0.4 vs. 0.3+/-0.2, p=0.009). CONCLUSIONS: Photoreceptor preservation as observed by OCT was significantly associated with better visual outcome after vitrectomy in patients with macular hemorrhage caused by rupture of a retinal arterial macroaneurysm.

Full Thickness Macular Hole formation following Rupture of Retinal Arterial Macoraneur

PURPOSE: To report a case of a macular hole formation following rupture of retinal arterial macroaneurysm. METHODS: A 75-year-old female visited our clinic with a chief complaint of decreased vision in her left eye. We completed full ocular examinations, including fluorescein angiography (FAG), and optical coherence tomography (OCT). RESULTS: The best corrected visual acuity was 0.6 in the right eye and 0.04 in the left. Fundus examination showed a retinal arterial macroaneurysm in supratemporal artery of the left eye. Fluorescein angiography showed hyperfluorescence in the macroaneurysm site. The optical coherence tomography showed macular and submacular hemorrhage. We performed intravitreal gas injection to treat the submacular hemorrhage. One month after the intravitreal gas injection, a full-thickness macular hole developed.

Treatment of Retinal Arterial Macroaneurysm

PURPOSE: To evaluate the visual prognosis of retinal arterial macroaneurysm with various treatment. METHODS: We did retrospective study in 16 patients(16 eyes) of retinal arterial macroaneurysm diagnosed at our hospital from March 1996 to January 2003. RESULTS: The range of patient's age was from 26 to 92 year-old, and 10 patients were female and 6 patients were male. In 6 eyes without treatment, spontaneous absorption of hemorrhage or edema occurred in 4 eyes. In 2 eyes with preretinal hemorrhage involving the macular area, vision was improved 2 lines or more as hemorrhage was subsided. Two eyes with Nd: YAG laser photodisruption obtained visual improvement of 4 lines or more. In 2 eyes misdiagnosed as CNV, argon laser photocoagulation was performed. In 6 eyes treated surgically with tPA injection or pars plana vitrectomy, 5 eyes showed visual improvement of 4 lines or more. CONCLUSIONS: Laser therapy or vitrectomy seems to be an effective method for the treatment of retinal arterial macroaneurysm involving the macular area.

Clinical Characteristics of Retinal Arterial Macroaneurysms

PURPOSE: To determine the clinical features of retinal arterial macroaneurysm (RAM). METHODS: Clinical characteristics of RAM, and its managements and results were evaluated. RESULTS: Of a total of 17 patients (17 eyes), 11 patients were women and 12 were over seventh decade. Mean follow-up period was 9.2 months. Hypertension was associated in 6 patients. Single aneurysm was temporally located in 15 eyes, which was along the temporal vascular arcade. It was on the arteriovenous crossing site in 8 eyes and followed retinal branch vein occlusion in 4 eyes. Aneurysms were located nasally in 2 eyes. Type was hemorrhagic in 15 eyes and exudative in 2 eyes. Pars plana vitrectomy was performed in 5 eyes and intraocular gas was injected in 2 eyes. Photocoagulation was performed directly in 2 eyes and indirectly in 3 eyes. Five eyes received no special managements. Visual acuity was less than 0.1 in 11 eyes and 0.3 or better in 4 on the initial visit, and less than 0.1 in 1 eyes and 0.3 or better in 10 on the final visit. Twelve eyes showed visual improvement of 2 lines or more. CONCLUSIONS: RAM usually develops along the temporal vascular arcade and induces visual disturbance due to hemorrhage and exudate. However, visual prognosis is relatively good.

Natural Visual Outcome of Submacular Hemorrhage Associated with Retinal Arterial Macroaneurysm

The authors retrospectively analysed epidemiologic characteristics, natural history and visual prognostic factors of submacular hemorrhage 2ndary to retinal arterial macroaneurysm in consecutive 10 patients. All the patients were female with mean age of 64.8 years and with hypertension in most cases.Typically, preretinal hemorrhage over submacular hemorrhage was the usual initial presentation.It took an average 2.9 months for the absorption of submacular hemorrhage.Average visual acuity was counting finger on initial visit and 0.3 on final visit. The initial visual acuity, the extent of submacular hemorrhage and the duration required for the absorption of it were statistically correlated with the final visual acuity[p<0.05]. But it was not the case with the extent of preretinal hemorrhage and the laser photocoagulation to macroaneurysm. As a conclusion, conservative treatment should be considered for the patient with tolerable initial visual acuity and with small extent of submacular hemorrhage 2ndary to retinal arterial macroaneurysm.

Retinal Arterial Macroaneurysms

Retinal arterial macroaneurysm may be presented with diverse clinical manifestations, such as various types of hemorrhage, exudate, edema or serous detachment especially in the elderly patients. Correct diagnosis can sometimes be difficult. A high index of suspicion is always required, and the characteristic findings of fluorescein angiography are useful for the correct diagnosis. Especially it is inevitably revealed as extrafoveal round hyperfluorescence on indocyanine green angiography(ICGA) which has recently become a useful tool in hemorrhagic and exudative disease, and can be misinterpreted as hot spot in choroidal neovascularization(CNV). So it may be misdiagnosed and treated as CNV associated with age-related macular degeneration(AMD), and the risk of branch retinal artery occlusion will be increased. We experienced four cases of retinal arterial macroaneurysms that showed various types of hemorrhagic and exudative change, and one case with serous retinal detachment. Two of these cases were misdiagnosed and treated as CNV associated with AMD, and branch retinal artery occlusion was developed in one of them. In the case presented with serous retinal detachment, it revealed as mass like lesion adjacent to the optic disc, and differential diagnosis with vascualr tumors was necessary. Our purpose is calling attention to the possibility of retinal arterial macroaneurysm in the diagnosis of various hemorrhagic and exudative lesions, especially in the elderly patients with hypertension.

Macroaneurysms of Retinal Arteries

Two patients with spontaneous intraretinal or subretinal hemorrhages were found, on evaluation by fluorescein angiography, to have macroaneurysms involving the major retinal arteries. Both patients were male in their seventies. One patient had a history of systemic hypertension. In the other patient, hypertension was discovered at the time of consultation. With absorption of the hemorrhage and the macular star, two patients experienced appreciable improvement in vision. Laser thrapy was not applied to both patients. The aneurysms diminished in size after 6 to 8 months as a result of fibrous changes within the arterial walls.