Case of the Month | January 2022

Case of the Month
January 25, 2022

The Case

The patient was a 79-year-old white woman who complained of blurred vision in the right eye for one week. Her past medical history was remarkable for hypertension and a remote history of cervical cancer. Her visual acuity was finger counting OD and 20/25 OS. Her anterior segment examination was remarkable for a posterior chamber intraocular lens with a clear posterior capsule in each eye. On posterior segment examination, both eyes had a posterior vitreous separation, the right macula had hemorrhages and edema, and the left macula had fine drusen.

What is the most likely diagnosis? What treatment, if any, would you recommend?

This patient had a retinal artery macroaneurysm presenting as a fibrotic mass along the superotemporal arcade with associated intraretinal and subretinal hemorrhaging and macular edema. The OCT of the right eye revealed drusen and a neurosensory detachment with reflective material that likely represents red blood cells. The OCT of the left eye showed drusen.  With a significant loss of vision, anti-VEGF treatment with a sample of Eylea was recommended, to which she agreed. When seen 5 weeks later, the OCT revealed that the macular edema had nearly resolved. Clinically, the hemorrhaging was reduced and the vision had improved to 20/100-1.

Retinal artery macroaneurysm is a bulging of the arterial wall due to focal weakness of the blood vessel wall. It is associated with hypertension. Patients can loss vision from preretinal, intraretinal, or subretinal hemorrhage; or from macular edema. The typical clinical course involves fibrosis of the macroaneurysm and resolution of the hemorrhage and edema, but the bleeding and/or swelling can damage photoreceptors. Given evidence that anti-VEGF treatment might expedite resolution of the edema (1,2), a sample of Eylea was given to our patient, which appeared to improve the clinical course.

1. Sweifel, SA, Tönz MS, Pfenniger L, Becker M, Michels S. Intravitreal anti-VEGF therapy for retinal macroaneurysm. Klin Monbl Augenkeilka 2013;230:392-5.

2. Cahuzac A, Scemama C, Mauget-Faÿsse M, Sahel J-A, Wolf B. Retinal arterial macroaneurysms: clinical, angiographic, and tomographic description and therapeutic management of a series of 14 cases. Eur J Ophthalmol 2016;26:36-43.

Case Photos

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This patient had a retinal artery macroaneurysm presenting as a fibrotic mass along the superotemporal arcade with associated intraretinal and subretinal hemorrhaging and macular edema. The OCT of the right eye revealed drusen and a neurosensory detachment with reflective material that likely represents red blood cells. The OCT of the left eye showed drusen.  With a significant loss of vision, anti-VEGF treatment with a sample of Eylea was recommended, to which she agreed. When seen 5 weeks later, the OCT revealed that the macular edema had nearly resolved. Clinically, the hemorrhaging was reduced and the vision had improved to 20/100-1.

Retinal artery macroaneurysm is a bulging of the arterial wall due to focal weakness of the blood vessel wall. It is associated with hypertension. Patients can loss vision from preretinal, intraretinal, or subretinal hemorrhage; or from macular edema. The typical clinical course involves fibrosis of the macroaneurysm and resolution of the hemorrhage and edema, but the bleeding and/or swelling can damage photoreceptors. Given evidence that anti-VEGF treatment might expedite resolution of the edema (1,2), a sample of Eylea was given to our patient, which appeared to improve the clinical course.

1. Sweifel, SA, Tönz MS, Pfenniger L, Becker M, Michels S. Intravitreal anti-VEGF therapy for retinal macroaneurysm. Klin Monbl Augenkeilka 2013;230:392-5.

2. Cahuzac A, Scemama C, Mauget-Faÿsse M, Sahel J-A, Wolf B. Retinal arterial macroaneurysms: clinical, angiographic, and tomographic description and therapeutic management of a series of 14 cases. Eur J Ophthalmol 2016;26:36-43.

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