Retinal Imaging Conference Brooke LW Nesmith, M.D. University of Louisville Department of Ophthalmology and Visual Sciences 8/7/2014
Patient Presentation CC: Routine yearly diabetic eye exam HPI: 59yo female presents for her yearly diabetic eye exam. She has no visual complaints, although does state she has noticed a new floater OS in the past month.
Medical History POHx: None PMH: NIDDM x 2 years (HA1C 6.2%), HTN, Graves Disease, Pacemaker, Valve replacement Meds: Warfarin, Furosemide, Levothyroxine, Atorvastatin, Spironolactone, Lisinopril Allergies: NKDA
Exam 20/20 3mm BCVA P (-) RAPD T TP 20/20 3mm 19 19 EOM: Full OU CVF: Full OU
Exam OD OS Ext/L/L wnl wnl Conj wnl wnl K wnl wnl AC wnl wnl Iris/Lens +NS +NS
Color Fundus Photo OU OD: ON pink and sharp; MVP WNL OS: Area of pre-, intra-, and sub-retinal hemorrhage along inferotemporal arcade
Autofluorescence OD OD: WNL
Autofluorescence OS OS: Areas of hypoautofluorescence along the inferior arcade corresponding to areas of hemorrhage seen clinically
FA Photo OD Mid AV phase: WNL
FA Photo OS Early phase: Areas of hypofluorescence along inferotemporal arcade
FA Photo OS Mid AV phase: Areas of hypofluorescence along inferotemporal arcade
Assessment and Plan A: 59yo female with diabetes and hypertension presents with retinal arterial macroaneurysm associated with multilevel retinal hemorrhages inferiorly without leakage on FA. P: Observation
Retinal Arterial Macroaneurysm Acquired large arteriolar dilation Usually within first 3 orders of vasculature bifurcations, at branch points Women, ages 50 to 80, HTN 10% bilateral, 20% multiple Natural course usually favorable Vision loss secondary to macular edema or hemorrhage
Retinal Arterial Macroaneurysm Treatment Laser treatment direct studies vary as to benefit complications BRAO, CNV, subretinal fibrosis
Retinal Arterial Macroaneurysm Treatment Pneumatic displacement with tissue plasminogen activator for submacular hemorrhage Surgical removal of associated hemorrhage with vitrectomy Photodisruption of the internal limiting membrane or the posterior hyaloid using Nd:YAG or argon laser to release the hemorrhage
Retinal Arterial Macroaneurysm Treatment 23 patients with symptomatic retinal arterial macroaneurysm Retrospective case series As needed monthly injections of bevacizumab vs observation Quicker resolution of macular edema and hemorrhage in bevacizumab group, but no statistically significant difference in BCVA improvement or central macular thickness improvement at final visit.
Retinal Arterial Macroaneurysm Treatment 38 patients with foveal complications from macroaneurysms Prospective nonrandomized study All patients received 3 monthly injections of bevacizumab Closure of macroaneursym in 36 cases, complete resolution of macular edema and regression of hard exudates in 100%
Retinal Arterial MacroaneurysmTreatment
References Rabb M, Gagliano DA, Teske, MP. Retinal Arteriolar Macroaneurysms. Surv Ophthalmol 1988;33:73-96. Hudomel J, Imre. Photocoagulation treatment of solitary aneurysm near the macula lutea: Report of a case. Acta Ophthalmol 1973;Sl:633-638. Brown DM, Sobol WM, Folk JC, Weingeist TA. Retinal arteriolar macroaneurysms: long-term visual outcome. Br J Ophthalmol 1994;78(7(:534-538. Battaglia P M, Iacono P, Pierro L, Papayannis A, Kontadakis S, Bandello FM. Subthreshold laser treatment versus threshold laser treatment for symptomatic retinal arterial macroaneurysm. Invest OphthalmolVis Sci 2012 Apr 2;53(4):1783-6. Hillenkamp J, Surguch V, Framme C, et al. Management of submacular hemorrhage with intravitreal versus subretinal injection of recombinant tissue plasminogen activator. GraefesArch ClinExpOphthalmol 2010 Jan;248(1):5-11 Zhao P, Hayashi H, Oshima K, Nakagawa N, Ohsato M. Vitrectomy for macular hemorrhage associated with retinal arterial macroaneurysm. Ophthalmology 2000;107(3):613-617. Iijima H, Satoh S, Tsukahara S. Nd:YAG laser photodisruption for preretinal hemorrhage due to retinal macroaneurysm. Acta Ophthalmol 2005;83(2):240-241.
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