Purpose To find out clinical characteristics, therapeutic options, and visual outcome in symptomatic retinal artery macroaneurysm (RAMA) patients. Method Newly diagnosed cases of symptomatic RAMA from January 2015 to December 2019 were included. Fifteen eyes of 15 patients with mean age 62.46 years ± 14.89 (SD) fulfilled the inclusion criteria. Result Hypertension was present in 66.6% of the patients, and the commonest site was superotemporal (12 eyes, 80%). The most commonly employed treatment was Nd: Yag laser hyaloidotomy in 4 eyes (26.6%). Other treatments were intravitreal bevacizumab in 3 eyes (20%), focal laser with intravitreal bevacizumab in 3 eyes (20%), PPV with focal laser (13.3%) in 2, focal laser only in one (6.6%), PPV with focal and intravitreal bevacizumab in one (6.6%). The mean best-corrected visual acuity (BCVA) at baseline was 1.35 ± 0.84 LogMAR, which improved to 0.39 ± 0.53 LogMAR at the last follow-up. Presenting VA 0.77 (±0.40) improved to 0.20 (±0.17) p value (0.180) in intravitreal bevacizumab only group, 1.29 (±0.35) to 0.75 (±0.15) p value 0.66 in Nd: Yag laser group, 2.67 (±0.58) to 0.46 (±0.28) p value 0.019 in PPV group and did not improve in combined anti-VEGF and focal laser group due to dense hard exudates at the fovea in one and persistent cystoid macular edema in another case. Conclusion With regard to its presentation, which can vary tremendously, there are no approved guidelines for its treatment. The present study reinforces the need for a treatment guideline development. Customization of treatment should be considered depending on the clinical presentation of each case.

1. Clinical variation and therapeutic challenges in the management of
Symptomatic Retinal Artery Macroaneurysm: An Experience with 21 Cases
Dr. Deepak Khadka, MD
Consultant Vitreoretina Specialist
Senior Faculty and MD Ophthalmology Coordinator
National Board of Medical Specialties
BP Eye Foundation
Children Hospital for Eye Ear and Rehabilitation Services (CHEERS)
Bhaktapur, Nepal

2. Retinal Artery Macroaneurysm
Introduction:
Acquired saccular or fusiform ectasias of mostly second order retinal
arteries.
Large Macroaneurysm can actually traverse the full thickness of retina.
According to the most dominant finding (Lavin et al)
Quiescent
Hemorrhagic
Exudative
According to FFA (Moosavi et al)
Saccular
Fusiform

3. Epidemiology
1 in 9000 eyes (Xu et al)
Usually develops in 6th decade of life (Mean 57-71Yrs).
Fernandez et al and Rabb et al reported RAMA in 16 yrs. old Girl.
Female>Male(70-80% Female Rabb et al)
RMA usually single (20% multiple) and 10 bilateral
Hypertension in 31-80%
Association with Hyperlipidaemia, systemic vasculitis (PAN, Sarcoidosis, RA has been
reported.

4. Pathogenesis
Most commonly reported site is superotemporal arcade
1st Hypothesis
Arteriosclerosis
Vessel wall thrombosis
Decrease wall Elasticity
Elevated luminal Pressure
Aneurysmal Dilation

5. 2nd Hypothesis
Emboli (Associated with vessel harbouring RAMA)
Intraluminal Thrombosis
Mechanical Damage to endothelium or Adventitial vessel wall
Aneurysm Formation
AV crossings
Vessel wall
contact without
support of
adventitial layer

6. Symptoms/Prognosis
 Usually presents with sudden painless loss of vision.
 Many cases are asymptomatic.
 RMA remain unchanged for years but most will undergo thrombosis,
fibrosis and involution.
 Most have preservation of vision unless they have extensive
subfoveal haemorrhage and or macular oedema.

7. Causes of loss of vision
Embolic or thrombotic occlusion of vessel.
Sub ILM bleed.
Subretinal/Intraretinal/Vitreous haemorrhage.
Macular Oedema.
Associated venous occlusions

8. Clinical Findings
 Key findings is the presence of blood at the multilayers including
preretinal, Intraretinal, Subretinal space or the presence of Vitreous
haemorrhage.
 Less common finding Exudative maculopathy.

9. Investigations
FFA : Typically demonstrates an immediate filling of aneurysm with
sometimes late leakage.
ICG: hemorrhage inhibits view of FFA
OCT: helpful in exudative type of Macroaneurysm. Round or oval Hyper
reflective lesion in the inner retinal layers. Macular Oedema.
USG B Scan: To rule out other pathologies

10. Treatment
 Indication for treatment
 If decreasing vision due to Macular Oedema.
 Premacular haemorrhage causing decrease in Vision.
 Dense non clearing vitreous haemorrhage.

11. Treatment Modalities
 Observation(Asymptomatic Cases)
 Focal laser at the Aneurysm and around the lesion.(Threshold vs
subthreshold)
 Nd Yag Laser Hyaloidotomy
 PPV with focal laser/RtPA
 Anti VEGF if associated macular Oedema.

12. Purpose/Methods
 To find out the clinical traits, treatment options, and visual outcome
among individuals with symptomatic RAMA
 Study focused on newly diagnosed RAMA(Jan 2015 to July 2021)
 21 cases were divided into 6 groups
Observation
Nd Yag Laser hyaloidotomy
Focal Laser
Intravitreal Bevacizumab
Intravitreal Bevacizumab plus focal laser
Pars Plana Vitrectomy group

13. Results
 The mean age was 65.95±14.65 years with female predominance 62% female.
 Right eye was affected in 13 (61.9%) and the most common site of MA was
superotemporal 17 (81.0%).
 The mean VA at presentation was 1.38±0.73logMar and the final VA after
treatment was 0.47±0.55 logMAR.
 Fifteen (71.4%) were known hypertensive
 Predominance of hemorrhagic variety 52.3%

14. Results
Treatment Average logmar VA at
Presentation (SD)
Average logmar VA at
Final (SD)
Mean VA
differenc
e (SD)
p-valuea
Intravit Bevacizumab (n=3) 0.77 (0.40) 0.20 (0.17) 0.51
(0.30)
0.180
Nd Yag Laser Hyaloidotomy
(n=4)
1.29 (0.35) 0.75 (0.15) 1.21
(0.38)
0.066
Focal Laser + Intravit
Bevacizumab (n=7)
1.22 (0.57) 0.97 (0.70) 0.25
(0.32)
0.109
PPV (n=5) 2.29 (0.39) 0.65 (0.23) 1.90
(0.56)
0.043*
Table 1. Clinical findings following different treatments among
patients of RAMA
a = Wilcoxon Signed Rank Test , *: Statistically significant at p<0.05 .
A case with Focal Laser only and a patient with observation not included in the analysis

15. SN Age Sex
No.
of MA
Eye Site Presentation Type Treatment/Observed
VA at
Presentation
Final
VA
F/U
Systemic
Diseases
1 28 F 1 LE SN VH H Focal Laser 0.78 0 6 Months
2 58 F 1 RE ST ME E
Intravit Bevacizumab (3
Dose)
1 0.3 4 months Hypertension
3 40 M 1 RE ST SHH H Nd Yag Laser Hyaloidotomy 1.78 0 6 Months Hypertension
4 58 F 1 RE ST SHH H Nd Yag Laser Hyaloidotomy 1 0 9 months Hypertension
5 60 M 1 LE ST ME E
Focal Laser + Intravit
Bevacizumab (3 Dose)
2 2 13 months Hypertension
6 53 F 1 RE ST ME E
Intravit Bevacizumab (3
Dose)
1 0 6 months
7 75 F 1 LE ST SHH/VH H
Nd Yag Laser Hyaloidotomy
+ PPV
2 0.3 18 months Hypertension
8 83 F 1 LE ST ME E
Focal Laser + Intravit
Bevacizumab (3 Dose)
1 1 13 months Hypertension
9 72 F 1 RE ST VH H PPV/Focal Laser 3 0.3 5 months Hypertension
10 51 F 1 LE ST SHH H Nd Yag Laser Hyaloidotomy 1.3 0.3 5 months Hypertension
11 79 F 1 LE IT VH H
Intravit Bevacizumab (1
Dose)/ PPV
3 0.78 7 months Hypertension
12 58 M 1 RE ST SHH H Nd Yag Laser Hyaloidotomy 1.08 0 4 months
13 75 M 1 RE ST ME E Intravit Bevacizumab 0.3 0.3 6 months
14 75 F 1 LE SN VH H Observation 0.78 0.3 3 months
Hypertension,
Cardiac Valve
Replacement
15 72 M 1 RE ST ME E
Focal Laser + Intravit
Bevacizumab (1 Dose)/ PPV
0.3 0.3 4 months
16 68 F 1 RE ST VH H PPV 1.7 0.4 4 months Hypertension
17 81 M 1 RE ST ME E
Focal Laser+Intravitreal
Bevacizumab 3 dose
1 0.4 3 months Hypertension
18 86 M 1 RE ST ME E
Focal Laser+Intravitreal
Bevacizumab 6 dose
1.47 1 6 months Hypertension
19 67 F 1 LE IT ME E
Focal Laser+Intravitreal
Bevacizumab 6 dose
1.77 1.77 6 months Hypertension
20 78 M 1 LE ST VH H PPV 1.77 0.17 2 months
21 68 F 1 LE ST ME E
Focal Laser+Intravitreal
Bevacizumab 3 dose
1 0.3 3 months Hypertension

16. 1st Case
28Yrs/F
Non Diabetic and Non Hypertensive
C/c: Sudden painless diminution of vision LE X1 day.
VA RE: 6/6; LE: 6/36

18. 6 weeks after 1st presentation
C/C – Recent Decrease in Vision 1 day
VA OD 6/6
OS 6/18
Anterior Segment – Unremarkable
Fundus-

19. 2nd case - 40/M with Hypertension
RAMA Immediately after Laser After 1 week

20. 3rd Case
58Yrs/F
C/c: Sudden painless diminution of vision RE
VA RE 6/36
BP 180/110mmHg

21. Diagnosis
Ruptured Retinal Artery Macroaneurysm
Treatment
3 Doses of Intravitreal Avastin given at monthly intervals.
VA RE 6/12 at 4 months

22. 4th Case
58/M
C/C: Sudden Painless loss of vision RE 1 day
(Hypertensive 1 year under treatment)
VA RE 1/60
3 month after Nd Yag Laser
with VA 6/6

23. 5th Case: Retinal Artery Macroaneurysm
Ruptured Macroaneurysm. Immediately After Laser After 1 week

24. After PPV After Laser and couple of AntiVEGF
6th case : Presentation with Dense VH 7th case : Presentation with gross exudative component

25. Thank you