Hemorrhagic retinal arterial macroaneurysm combined with branch retinal artery occlusion treated with intravitreal conbercept injection: A case report.

RATIONALE: Branch retinal artery occlusion (BRAO) is a rare complication of retinal arterial macroaneurysm (RAM), a low-incidence ocular disease. PATIENT CONCERNS: A 75-year-old woman presented with a chief complaint of blurred vision. DIAGNOSES: The patient for 4 days received a diagnosis of RAM combined with BRAO. INTERVENTIONS: The patient was treated with two successive intravitreal conbercept injections. OUTCOMES: The patient's best-corrected visual acuity improved, and the RAM diminished. LESSONS: Administration of conbercept injection might be an effective treatment for complex RAM with BRAO.

[Diagnostic and treatment options for retinal arterial macroaneurysms in relation to our cases]. / Retinalis artéria macroaneurysmák diagnosztikai és kezelési lehetoségei eseteink kapcsán.

In our report, we present the history of four patients diagnosed with retinal arterial macroaneurysm associated with complications. Our aim is to present the varied appearance of the disease and to present the various therapeutic options. Retinal artery macroaneurysm is a rare, but potentially vision-threatening ophthalmic condition. Macroaneurysm develops from the arteriosclerotic transformation of the artery caused by high blood pressure. Macroaneurysms can be asymptomatic, or they can be associated with exudative or hemorrhagic complication which causes visual impairment. Depending on the symptoms, they can be treated with laser photocoagulation, intravitreal injections, or with vitrectomy. Our presented cases also illustrate that each case requires individual consideration because a uniform therapeutic recommendation is still yet to be developed. In addition to the ophthalmic treatment, it is extremely important to refer the patient to internal medicine. Orv Hetil. 2023; 164(42): 1673-1677.

Effect of Laser Panretinal Photocoagulation Combined with Lucentis on Long-Term Visual Acuity of Patients with Retinal Arterial Macroaneurysm.

Objective: To analyze the efficacy of laser panretinal photocoagulation in combination with Lucentis treatment on patients with retinal arterial macroaneurysm and investigate more effective novel therapy options to treat retinal arterial macroaneurysm. Method: This study was conducted in the Pediatric department of Chongqing Aier Hospital between October 2016 and October 2020, and a total of 62 inpatients were enrolled for the study. Patients were randomly organized into two groups, an 'observation group' with patients receiving combinational treatment of laser panretinal photocoagulation and Lucentis, and a 'control group' with patients treated by only laser panretinal photocoagulation, were allotted. Though a comparative statistical analysis, the clinical outcomes and adverse effects on both groups, including their best corrected visual acuity, central macular thickness, intraocular pressure, and required number of laser treatments before and after treatments, were investigated. Also prognosis associated factors for patient's visual function, were analyzed. Results: The clinical efficacy of the combinational treatment of laser panretinal photocoagulation and Lucentis was better than single laser panretinal photocoagulation treatment, accompanied by decreased incidence of adverse reactions (P < .05). For a combinational treatment, the observation group showed improved best corrected visual acuity and reduced central macular thickness and intraocular pressure, including fewer laser treatments (P < .05). Also, a better prognostic quality of life score; (measured as physical function, mental state, visual function, and social activity ability of patients), was observed for a combinational treatment than that of laser panretinal photocoagulation treatment (P < .05). Conclusion: Laser panretinal photocoagulation combined with lucentis can deliver with reduced incidence of adverse effects compared to laser panretinal photocoagulation treatment and hence can more effectively contribute to retinal rehabilitation of patients with retinal arterial macroaneurysm.

Appearance of retinal arterial macroaneurysms in patients using swept-source optical coherence tomographic angiography.

BACKGROUND: Retinal arterial macroaneurysm (RAM) is a common clinical disease leading to vision loss in elderly individuals. The appropriate interpretation of swept-source optical coherence tomographic angiography (SS-OCTA), a noninvasive examination, is easy and convenient for detecting the status of RAMs and guiding treatment. METHODS: The objectives of this study were to describe the morphologic characteristics of RAMs using SS-OCTA and to observe whether there are differences in the morphologies of RAMs between SS-OCTA and fundus fluorescein angiography (FFA), before and after treatment. We retrospectively evaluated twenty-two eyes of 22 patients who were diagnosed with RAMs. All patients underwent a complete ophthalmologic examination, including a review of medical records, best-corrected visual acuity (BCVA), fundus photography, FFA and SS-OCTA. RAMs were recorded by SS-OCTA before any treatment or observation decisions were made. The morphologic findings of the RAMs on SS-OCTA were investigated. RESULTS: On SS-OCTA, RAMs can show local dilatation or an irregular linear blood flow signal, and the dilated cystic lumen may show thrombosis with a low reflection signal. After treatment, the shape of the RAMs will show reactive changes. The findings on SS-OCTA are not very consistent with those on FFA. CONCLUSIONS: The same RAM may have different manifestations on OCTA and FFA, and OCTA can more conveniently reflect the changes in blood flow signals and treatment response of RAMs.

Visual Recovery and Prognosis in the Treatment of Submacular Hemorrhage due to Polypoidal Choroidal Vasculopathy and Retinal Arterial Macroaneurysm: A Retrospective Study.

Purpose: This study was carried out to evaluate the visual acuity (VA), complications, and prognosis of patients diagnosed with submacular hemorrhage (SMH) from polypoidal choroidal vasculopathy (PCV) and retinal arterial macroaneurysm (RAM) treated by pars plana vitrectomy (PPV), subretinal tissue plasminogen activator (tPA), and air tamponade in vitreous cavity. It facilitates the development of generic treatment methods that can be widely used to improve vision and treat potential complications in patients with SMH, regardless of the underlying pathophysiological condition, such as PCV or RAM. Methods: In this retrospective study, SMH patients were divided into two groups based on their diagnosis: (1) polypoidal choroidal vasculopathy (PCV) and (2) retinal arterial macroaneurysm (RAM). The visual recovery and complications of patients with PCV and RAM after PPV + tPA (subretinal) surgery were analyzed. Results: A total of 36 eyes of 36 patients were included: PCV (47.22%, 17/36) and RAM (52.78%, 19/36). The mean age of the patients was 64 years, and 63.89% of the patients (23/36) were female. The median VA was 1.85 logMAR before surgery, 0.93 and 0.98 logMAR at 1 and 3 months after surgery, respectively, indicating that most patients' vision improved after surgery. At the 1 and 3 months postoperative follow-up, each patient was diagnosed with rhegmatogenous retinal detachment at 1 month and 3 months postoperatively, and four patients had vitreous hemorrhage at 3 months postoperatively. Preoperatively, patients exhibited macular subretinal hemorrhage, retinal bulge, and exudation around the blood clot. Postoperatively, most patients showed dispersal of subretinal hemorrhage. Optical coherence tomography results revealed retinal hemorrhage involving the macula and hemorrhagic bulges under both the neuroepithelium and the pigment epithelium under the fovea preoperatively. After surgery, the air injected into the vitreous cavity was completely absorbed and the subretinal hemorrhage was dispersed. Conclusion: PPV combined with subretinal tPA injection and air tamponade in the vitreous cavity can facilitate modest visual recovery in patients with SMH due to PCV and RAM. However, some complications may occur, and their management remains challenging.

Triple retinal arterial macroaneurysms in a hypertensive patient with hypothyroidism.

PURPOSE: To present the unique case of numerous, recurring retinal arterial macroaneurysms (RAMs) in a hypothyroid patient with hypertension. METHODS: 67-year-old woman's clinical findings, laboratory results, fundus fluorescein angiography, optical coherence tomography (OCT), and optical coherence tomography angiography (OCTA) are given. Over a two-year period, the patient was monitored. RESULTS: A 67-year-old woman presented to the outpatient clinic with vitreous and dense subretinal hemorrhages in her right eye. RAM rupture was discovered along the suprotemporal retinal arteriole. A diagnosis of systemic arterial hypertension was made. Two months later, the vitreous hemorrhage spontaneously resolved and the patient's vision improved. After nine months of initial presentation, the patient developed another RAM. Meanwhile the patient developed ichthyosis caused by hypothyroidism. Because fundus fluorescein angiography revealed that the first RAM was still active, an intravitreal injection of anti-VEGF was administered six months afterwards. More proximal RAM with macular edema developed after another six months necessitating laser photocoagulation. However macular edema didn't resolve and a second injection of intravitreal anti-VEGF was given. CONCLUSIONS: Patients with RAMs, particularly if multiple or recurring, should be thoroughly investigated and assessed, particularly for secondary causes of hypertension. OCT and OCTA are useful tools for RAM confirmation and follow-up. It is important to look into how RAM behavior interacts with coexisting macular edema, and other variables affecting hemodynamic status.

IMPACT OF MACULAR INTRARETINAL HEMORRHAGE AND MACULAR HOLE ON THE VISUAL PROGNOSIS OF SUBMACULAR HEMORRHAGE DUE TO RETINAL ARTERIAL MACROANEURYSM RUPTURE.

PURPOSE: To compare the effects of macular intraretinal hemorrhage (IRH) and macular hole (MH) on best-corrected visual acuity (BCVA) after displacement of submacular hemorrhage (SMH) due to retinal arterial macroaneurysm (RAM) rupture. METHODS: This multicenter retrospective study included 48 eyes with SMH due to RAM rupture. Cases underwent vitrectomy to displace SMH and were followed up for 6 months. We classified cases according to the presence of IRH and MH and compared the postoperative BCVA among the groups. RESULTS: We classified the eyes into IRH(+)MH(+) group (10 eyes), IRH(+)MH(-) group (23 eyes), and IRH(-)MH(-) group (15 eyes). The postoperative BCVA was significantly worse in the IRH(+)MH(+) and IRH(+)MH(-) groups than in the IRH(-)MH(-) group (0.91 ± 0.41 in logarithm of the minimal angle of resolution units, Snellen equivalent 20/163, 0.87 ± 0.45, 20/148, and 0.18 ± 0.21, 20/30, respectively; P < 0.001). The postoperative central retinal thickness was significantly lower in the IRH(+) group (IRH(+)MH(+) and IRH(+)MH(-) groups combined) than in the IRH(-) group (IRH(-)MH(-) group) (121.4 ± 70.1 µ m and 174.3 ± 32.9 µ m, respectively, P = 0.008). The postoperative external limiting membrane and ellipsoid zone continuities were significantly discontinuous in the IRH(+) group ( P < 0.001, P = 0.001, respectively). The multiple linear regression analysis showed that both IRH(+)MH(+) and IRH(+)MH(-) were associated with the postoperative BCVA (regression coefficient, 0.799 and 0.711, respectively; P < 0.001 for both). CONCLUSION: Both IRH and MH were poor prognostic indicators in cases with SMH due to RAM rupture.

FEATURES OF VASCULATURE IN PATIENTS WITH RETINA ARTERIAL MACROANEURYSM USING OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY.

PURPOSE: To assess morphologic characteristics of retinal arterial macroaneurysm (RAM) and their vascular changes using optical coherence tomography angiography (OCTA). METHODS: This observational study included 31 eyes of 29 participants diagnosed with RAM based on fundus fluorescein angiography in Tianjin Medical University Eye Hospital. Multimodal imaging modalities, including fundus photography, fluorescein angiography, and OCTA, were used to examine RAMs. The demographic and clinical characteristics of the RAMs were recorded. RESULTS: Depending on the fundus fluorescein angiography examination, 40 cases of RAM were confirmed in 29 patients. Twenty-three patients were female (79%), and six patients were male (21%). Two patients had binocular RAM, and four eyes had more than one RAMs. Relying on the OCTA technology, RAMs have four different vascular morphology types (i.e., distended, meshed, malformed, and occult types). In the distended type, round or encircled thrombi caused asymmetrical or symmetrical distention of retinal arteriolar, leading to separate true lumen and false thrombus lumen in RAM. In the meshed type, the meshed or dendritic vascular network around the RAM was likely to be the neovascularization due to the ischemia and hypoxia of the arteriolar wall. Finally, in the malformed and occult type, the RAM usually regressed, and the retinal arterioles were remodeled to distorted or normal arterioles accompanied by capillary degradation. CONCLUSION: Relying on the OCTA technology, we found that the RAMs have four different types of vascular morphology. Each group of RAM has different vascular features. The application of OCTA in patients with RAM furthers our understanding of the vasculature of RAMs.

Retinal arterial macroaneurysm rupture by Valsalva maneuver: a case report and literature review.

BACKGROUND: Retinal artery macroaneurysms (RAMs) are focal dilations of the large retinal arteries. Most RAMs are asymptomatic, however, when hemorrhage or exudation caused by a RAM involves the macula, patients can experience marked vision loss. This article reported a rare case of a ruptured RAM due to the Valsalva maneuver in an elderly female with constipation and offered a review of the relevant literature. CASE PRESENTATION: A 78-year-old woman with several risk factors presented with multi-level retinal hemorrhages following a Valsalva maneuver during constipation. Due to the poor coagulation and heavy bleeding in this case, the blood broke through the internal limiting membrane and drained "on its own" into the vitreous cavity. First, we observed the patient and controlled for her risk factors. After the blood was completely drained into the vitreous cavity, the root cause of the bleeding was found to be a RAM rupture. After laser photocoagulation, the patient's vision recovered significantly and remained stable for a long time despite the presence of an epiretinal membrane and a lamellar macular hole. CONCLUSIONS: This is the first reported case of a RAM rupture by Valsalva maneuver during constipation. For multi-level hemorrhages caused by RAM, measures should be taken to drain out the sub-internal limiting membrane hemorrhage and simultaneously control for risk factors. After the RAM is exposed, laser photocoagulation can be performed.

Observation, laser photocoagulation or anti-VEGF therapy in the management of retinal arterial macroaneurysms.

BACKGROUND: To explore the efficacy of observation, laser photocoagulation, and anti-VEGF in the management of retinal arterial macroaneurysm (RAM). METHODS: We retrospectively included patients diagnosed with RAM at the Peking Union Medical College Hospital (PUMCH) from 2003 to 2021, and comprehensively reviewed cases documented in the literature from multiple databases (PROSPERO protocol CRD42022310417). Patients were categorized into 3 groups: the observation group, anti-VEGF group, and laser photocoagulation group. LogMAR visual acuity (VA) and central retinal thickness (CMT) at the end of the follow-up were analyzed. RESULTS: A total of 14 patients from the PUMCH and 210 patients from the literature review were included. VA and CMT in patients who underwent observation, laser photocoagulation, and anti-VEGF therapies were significantly improved from baseline (p < 0.05), with changes in LogMAR VA improved by -0.34 ± 0.68, -0.17 ± 0.58, and -0.45 ± 0.62 and changes in CMT improved by -148.26 ± 138.99 µm, -185.61 ± 130.37 µm, and -287.45 ± 171.87 µm, respectively. Subgroup analysis revealed that anti-VEGF therapy was used in patients with worse VA than patients who underwent laser photocoagulation (p = 0.010), but achieved better improvement in VA than the laser photocoagulation group (p = 0.049). Patients treated with anti-VEGF also had thicker CMT than the observation group (p = 0.013), and experienced better changes in CMT than the observation, as well as laser photocoagulation groups (p = 0.005; p = 0.047). CONCLUSION: Observation, anti-VEGF, and laser photocoagulation are effective therapeutic methods for the management of RAM, and anti-VEGF therapy is intended to better improve patients with severe VA and CMT.

Differences in clinical characteristics and treatment outcomes of submacular hemorrhage caused by age-related macular degeneration and retinal macroaneurysms: A multicenter survey from the Japan Clinical Retina Study (J-CREST) group.

PURPOSE: To evaluate the clinical characteristics, treatment trends, and visual prognosis of submacular hemorrhage (SMH) secondary to neovascular age-related macular degeneration (nAMD) and retinal arterial macroaneurysm (RAM). METHODS: This retrospective study enrolled 187 Japanese patients with SMH at 10 institutions from 2015 to 2018. Medical records including SMH etiology, best-corrected visual acuity (BCVA), fundus photographs, optical coherence tomography images, and selected treatments were analyzed. RESULTS: Major causes of SMH were typical nAMD (tnAMD) (18%), polypoidal choroidal vasculopathy (PCV) (50%) and RAM (29%). Age, male/female ratio, baseline BCVA, central retinal thickness, and involved retinal layers were significantly different between etiologies (all P<0.0001). Treatment with anti-vascular endothelial growth factor drugs with and without intravitreal gas injection was chosen for half of eyes in the tnAMD and PCV groups, whereas vitrectomy was performed in 83.7% of eyes with RAM. The final BCVA improved significantly from baseline in the PCV and RAM groups (P = 0.0009, P<0.0001) and final BCVA was significantly better in the PCV group at a level similar to the other groups (P = 0.0007, P = 0.0008). BCVA improvement from baseline was significantly greater in the RAM group compared with the tnAMD (P = 0.0152) and PCV (P = 0.017) groups. Multivariate analysis revealed better final BCVA was significantly associated with younger age (P = 0.0054), better baseline BCVA (P = 0.0021), RAM subtype (P = 0.0446), and no tnAMD (P = 0.001). CONCLUSIONS: The characteristics of, and treatment strategy for, SMH were different between the underlying diseases. Anti-vascular endothelial growth factor treatment with or without expansile gas was mainly chosen for SMH in tnAMD and PCV, whereas vitrectomy with gas was the most common treatment for RAM, and the higher rate for vitrectomy might result in the greater BCVA improvement in the RAM group than in the other groups. Final BCVA was better in PCV, RAM, and tnAMD, in that order, because patients with PCV were younger and had better baseline BCVA.

Optical coherence tomography findings after surgery for sub-inner limiting membrane hemorrhage due to ruptured retinal arterial macroaneurysm.

Ruptured retinal arterial macroaneurysm (RAM) can cause sub-inner limiting membrane (ILM) hemorrhage, leading to acute vision loss in the elderly. Vitrectomy has been established as an effective treatment to remove hemorrhage and facilitate visual recovery. Although optical coherence tomography (OCT) is useful for the diagnosis of sub-ILM hemorrhage before surgery, little is known about the postoperative OCT findings. Here, we retrospectively investigated the records of nine eyes of nine patients who underwent surgery for sub-ILM hemorrhage due to RAM rupture. On postoperative OCT, hyperreflectivity throughout the full thickness of the central fovea was observed in eight eyes (88.9%), and disruption of the ellipsoid/interdigitation zone (EZ/IZ) was observed in seven out of eight eyes (87.5%). The widths of the hyperreflectivity and EZ disruption gradually decreased. Visual recovery was least favorable in two eyes, in which the EZ line continuation did not recover until the final follow-up. The OCT findings corresponded to the hemorrhagic staining identified on fundus photographs in at least four eyes; as per the fundus photographs the findings persisted even after the hemorrhage was absorbed. In contrast, the OCT findings resembled the appearance before the development of a full-thickness macular hole, suggesting fragility caused by the RAM rupture.

DETECTION AND CHARACTERISTICS OF UNRUPTURED RETINAL ARTERIAL MACROANEURYSMS.

PURPOSE: To determine the presence of unruptured retinal arterial macroaneurysms (RAMs) and to examine the characteristics of the detected lesions. METHODS: This retrospective observational study included the affected and contralateral eyes of 50 patients (100 eyes) with symptomatic, unilateral, ruptured RAMs who visited the Department of Ophthalmology at the Kyoto University Hospital (April 2014-April 2020) and were followed up for at least 6 months after the onset. The presence and characteristics of unruptured RAMs were examined by reviewing the findings of color fundus photography and infrared scanning laser ophthalmoscopy performed before the onset or during the follow-up period. RESULTS: Unruptured RAMs were detected in six of the 50 patients. Some patients had bilateral or multiple unruptured RAMs, and a total of 12 unruptured RAMs were detected in eight eyes of the six patients. Among the detected lesions, eight exhibited a longitudinal increase in their diameter during the follow-up period, whereas six exhibited ruptures. CONCLUSION: Unruptured RAM is not an uncommon retinal vascular abnormality and can enlarge and progress to ruptured RAM.

Three-dimensional locations of ruptured retinal arterial macroaneurysms and their associations with the visual prognosis.

The aim of this retrospective, observational study was to examine the intraretinal locations of ruptured retinal arterial macroaneurysms (RMAs) and investigate the associations with the visual prognosis. Fifty patients (50 eyes) with untreated RMA rupture who visited the Department of Ophthalmology at Kyoto University Hospital (April 2014-July 2019) were included. The intraretinal position of the ruptured RMAs relative to the affected retinal artery was examined using optical coherence tomography (OCT) and color fundus photography (CFP). The relative RMA positions were anterior to (anterior type, 44%), at the same level as (lateral type, 20%), or posterior to (posterior type, 34%) the affected artery. At the initial visit, the posterior type showed greater subretinal hemorrhage thickness than did the lateral and anterior types (P = 0.016 and 0.006, respectively), and poorer visual acuity (VA) than did the anterior type (P = 0.005). At the final visit, the length of the foveal ellipsoid zone band defect was longer (P = 0.005) and VA was poorer (P < 0.001) for the posterior type than for the anterior type. The intraretinal positions of ruptured RMAs vary, affect the thickness of foveal subretinal hemorrhage and predict future damage to the foveal photoreceptors. The visual prognosis may be poor for posteriorly ruptured RMAs.