Case presentation and discussion retina department Ispahani islamia eye hospital Dhaka Bangladesh

1. Presenter
Dr. Md. Rezwanul Hasan
Fellow, Vitreo-Retina Department
IIEI&H, Dhaka
Case presentation

2. Particulars of the Patient
• Name : Mr. Kuddus Dewan
• Age : 60 years
• Sex : Male
• Address : Tongi, Gazipur

3. Chief complaints
• Gradual dimness of vision in Left eyes
for about 5 days.

4. Past ocular History
• Use of Presbyopic glass for about 20 years.

5. Other Medical history
• Diabetic for 5 years.
• Hypertensive for 5 years.

6. General examination
Appearance Normal
Body build Average
Pulse 80 beats/min
Blood pressure 140/85 mm of Hg. with
medication
Temperature 98⁰F
Anemia Absent
Jaundice Absent
Edema Absent

7. Ocular examination
R/E L/E
VA DV- 6/18 ,
with PH-6/12
DV- 1/60 ,
with PH- NI
Conjunctiva Normal Normal
Cornea Clear Clear
A/C Normal Normal
Pupil RRR RRR
Lens NS-1 NS-1
Vitreous Clear Clear
IOP 14 mm of Hg 16 mm of Hg.

8. CFP

9. Differential Diagnosis
• Retinal Artery Macroaneurysm
• Branch Retinal Vein Occlusion
• Exudative ARMD
• Polypoidal choroidal vascuolopathies (IPCV)

10. Investigations
Blood Sugar
Fasting - 6.5 mmol/l
2HABF – 8.2 mmol/l
• OCT (L/E)
• FFA (L/E)

11. OCT :

12. FFA
OS

13. Diagnosis :
Ruptured Retinal Artery Macroaneurysm

14. Treatment :
• Intravitreal Inj. Avastin (L/E)

15. F/U after 2
months
At Presentation
• Visual Acuity : L/E = 6/60 with
PH - 6/24
After 2 Months
• Visual Acuity : L/E = 1/60 with
PH - NI

16. • First described in 1973, retinal arterial
macroaneurysm is characterized by the
presence of vascular dilation or outpouching of
a retinal artery or arteriole.
• They are commonly associated with macular
exudation and hemorrhage, which may result in
decreased visual acuity.
• Female preponderance (ratio of 3:1 ), typically
after 60 years of age and with a medical history
of systemic hypertension and/or arteriosclerotic
vascular disease.
Discussion

17. • Often, RAM is noted on clinical examination but the
patient is asymptomatic.
• The involved artery may be narrowed proximally
and distally to the microaneurysm.
• Severe vision loss can occur from leakage of the
aneurysm with resultant hemorrhage into the
vitreous cavity, subhyaloid space and/or
intraretinally or subretinaly.
CLINICAL PRESENTATION

18. • Many times, “Hourglass hemorrhage” defined
as the simultaneous presence of preretinal and
subretinal hemorrhage, can be seen.
• Serous fluid can also collect intraretinally.
producing diffuse or focal cystoid macular
oedema with or without the accumulation of
lipid exudates.
CLINICAL PRESENTATION

19.  Exudative ARMD
 Branch Retinal Vein Occlusion
 Capillary Hemangioma
 Polypoidal choroidal vascuolopathies
 Diabetic Macular Oedema
 Subretinal neovascular membranes
 Radiation Retinopathy
 Leber Miliary Aneurysms
DIFFERENTIAL DIAGNOSIS

20. • Macroaneurysms more commonly affect the right
eye than the left.
• The supero temporal artery is most commonly
involved.
• However, macroaneurysms also have been
reported in cilioretinal arteries, on the optic nerve
head and associated with congenital retinal
macrovessels.
• Bleeding is a common complication of aneurysm
formation and can occur beneath the retina, the
retinal pigment epithelium (RPE), or the internal
limiting membrane (ILM) or into the vitreous.
VASCULAR SIGNS & SITES OF OCCURRENCE
Distribution of MAs in 34 patients.
Retinal artery macroaneurysms: clinical and fluorescein angiographic features in 34 patients. (2006, November 21). Retinal
artery macroaneurysms: clinical and fluorescein angiographic features in 34 patients. https://doi.org/10.1038/sj.eye.6702068

21. • The pathogenesis of RAM is thought to be secondary to a
combination of several mechanisms causing blood vessel
wall weakness and subsequent aneurysmal dilatation.
• The main mechanisms thought to underlie RAM
formation include focal ischemia to blood vessel walls,
chronic hypertensive and arteriosclerotic vascular wall
damage, and inherent structural defects in blood vessels.
• Histopathologically, RAMs are found to have arterial
dilatation with variable degrees of artery wall
hyalinization and surrounding retinal exudate or
hemorrhage
Pathogenesis
Fig: Histopathology of a
ruptured RAM with
preretinal, intraretinal and
subretinal hemorrhage

22. While the diagnosis of RAM is mostly clinical, imaging—
especially fluorescein angiography—can be a useful
adjunctive tool.
On FFA, one can see immediate uniform filling of the
macroaneurysm .
Partial filling may be seen if the aneurysm is
spontaneously involuting or is partially thrombosed.
Many times, there can be no view of the RAM because
it’s hidden by hemorrhage overlying the
macroaneurysm.
Imaging of RAM

23. Imaging of RAM
RAM can present with microaneurysms,
nonperfusion, IRMA, and telangiectasis.
Leakage can be seen if there is CME, and
distortion of retinal architecture can be seen in
the setting of ERM formation
OCT can be used for the identification of
subretinal fluid and hemorrhage, macular
edema and ERM formation and can be used to
monitor the effects of therapy

24. Imaging of RAM
• B scan If extensive vitreous
haemorrhage obscures the view of
the fundus, ultrasound B scan can
be used to exclude conditions
such as retinal tears, detachments.
• ICGA If significant haemorrhage
renders FFA inconclusive, ICGA
may be a useful alternative,
allowing deeper penetration
through the areas of
haemorrhage.
FFA VS. ICGA. In the presence of excessive blood with significant
blocked hyperfluorescence, ICGA may be superior to FFA. RAM
is completely obscured by blood on FFA (2A) but can be seen
clearly on ICGA (2B).

25. Diagnostic challenges Despite several imaging options at our
disposal, diagnosing RAM may prove challenging when
extensive haemorrhage is present.
In such cases, examining the fellow eye closely may help
guide the physician.
Important diagnostic clues for RAM include absence of
drusen and the presence of significant hypertensive
retinopathy in the fellow eye in the setting of an asymmetric
vascular lesion with lipid or blood concentrated around the
bifurcation of an arteriole in the affected eye.

26. Management
Most macroaneurysms can be observed.
The visual prognosis depends on whether secondary hemorrhage or exudation
involves the central macular region.
In such instances, vision can be reduced to counting fingers or worse.
Spontaneous improvement can occur, particularly when the blood is located
superficially within the retina.

27. Interventions
• May be required in cases of exudative or
hemorrhagic RAMs. or recurrent/persistent cystoid
macular oedema.
• Anti-vascular endothelial growth factor therapy
has emerged as a useful treatment modality for
RAMs.
• Laser of the artery and surrounding area may
decrease flow and intraluminal pressure, thereby
reducing the macroaneurysm.
• YAG-laser hyaloidotomy incase of dense subhyaloid
haemorrhage has been performed to release the
sequestered blood into the vitreous cavity.

28. PROGNOSIS
The visual prognosis is excellent for many patients
with macroaneurysm.
The natural history of these lesions suggests that
most close spontaneously, with restoration of near-
normal vision.

29. TAKE HOME MESSAGE
• RAMs are rare clinical findings occurring
most often in older, hypertensive women.
• While anti-VEGF therapy can be a useful
treatment option to improve vision and
decrease macular oedema, more complex
RAMs may require laser photocoagulation
and / or surgical intervention.