Intravitreal bevacizumab for macular complications from retinal arterial macroaneurysms

[Diagnostic and treatment options for retinal arterial macroaneurysms in relation to our cases]

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.

Objective Assessment of Retinal Artery Macroaneurysm With Optical Coherence Tomography Angiography

Retinal artery macroaneurysm (RAM) is an acquired retinal arteriole dilatation with vision-threatening complications. Diagnosis of this condition can be made clinically, supported by multi-modal imaging modalities, commonly optical coherence tomography (OCT) and dye-based angiography studies which show the lesion itself and the complications to the adjacent retina. We report a case of an 83-year-old patient with renal impairment who had the diagnosis and monitoring of RAM done using optical coherence tomography angiography (OCT-A) as an alternative to conventional fluorescein angiography. This case highlighted the use of OCT-A using Cirrus 5000 with AngioPlex (Zeiss, Jena, Germany) as a useful diagnostic and monitoring tool for RAM with its features that enables objective quantification of the disease activity via vessel and perfusion density pre- and post-laser treatment.

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.

[Avoiding mistakes in anti-VEGF intravitreal injection therapy]

Intravitreal injection (IVI) of drugs for treatment of various macular diseases is now one of the most frequently performed surgical procedures worldwide. As mostly chronic diseases are treated, the indications for treatment often mean a continuous treatment over years with a corresponding effort regarding spatial, personnel and financial resources. The diagnosis and indications for treatment are nowadays mainly made by spectral domain optical coherence tomography (SD-OCT). The ability to clinically assess and evaluate a fluorescence angiography is less practiced, although these are still a component of the indications for intravitreal injections. Therefore, it can happen that despite all diligence patients may receive anti-vascular endothelial growth factor (VEGF) treatment, sometimes permanently, based on a misinterpretation of the macular diagnosis or disease activity and these indications, once made, are rarely questioned or retracted. Therefore, the aim of this manuscript is to point out possible and typical misinterpretations in the indications or continuation of IVI treatment with anti-VEGF by means of case studies and to sensitize for differential diagnoses.

Clinical variations and therapeutic challenges in the management of symptomatic retinal artery macroaneurysm: a tertiary center experience

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.

Clinical characteristics of retinal arterial macroaneurysms and prognosis of different interventions

PURPOSE

To estimate the clinical characteristics of retinal arterial macroaneurysms (RAM) and evaluate the prognosis of different interventions.

METHODS

This study is a meta-analysis. The databases PubMed, EMBASE, and Ovid from inception to January 2021 were searched to identify the relevant studies. R software version 3.6.3 was used to perform the statistical analyses. Results in proportion with 95% confidence interval were calculated by means of Freeman-Tukey variant of arcsine square transformation.

RESULTS

Sixty-nine studies involving 1332 patients were finally included. The pooling results indicated that 91% (95% CI [88 ~ 94%]) of the RAM patients were over sixty, 73% (95% CI [68 ~ 77%]) were female, and 73% (95% CI [66 ~ 79%]) have hypertension. By observation, the RAM closure rate was 64% (95% CI [39 ~ 86%]), the visual acuity (VA) improved in 55% (95% CI [40 ~ 71%]) of the patients, and the VA of 64% (95% CI [54 ~ 74%]) hemorrhagic versus 27% (95% CI [15 ~ 41%]) exudative patients improved significantly. By laser, the closure rate was 96% (95% CI [87 ~ 100%]), the VA improved in 73% (95% CI [65 ~ 80%]) of the patients, and the VA of 66% (95% CI [47 ~ 84%]) hemorrhagic versus 35% (95% CI [23 ~ 47%]) exudative patients improved significantly. By anti-VEGF, the closure rate was 98% (95% CI [93 ~ 100%]), the VA improved in 90% (95% CI [74 ~ 100%]) of the patients, and the VA of 58% (95% CI [18 ~ 94%]) hemorrhagic versus 67% (95% CI [31 ~ 96%]) exudative patients improved significantly.

CONCLUSION

RAM are most commonly seen in the elderly with a marked female predominance and a strong association with hypertension. Patients receiving laser or anti-VEGF treatments get higher closure rate and better visual prognosis than those with observation alone. Hemorrhagic RAM have a better visual prognosis by observation or laser treatment, while exudative RAM have a better visual prognosis by anti-VEGF treatment.

Combined Intravitreal Bevacizumab and Laser Photocoagulation to Treat Retinal Arterial Macroaneurysms

Purpose: To investigate the effects of intravitreal bevacizumab injection combined with laser photocoagulation in patients with retinal microaneurysms.Methods: We retrospectively reviewed the medical records of 21 eyes of 21 patients who underwent intravitreal bevacizumab injection and/or laser photocoagulation to treat retinal macroaneurysms. Eleven eyes received the combination therapy (CT) and 10 eyes monotherapy (MT) (either bevacizumab injection or laser photocoagulation). Changes in visual acuity, central macular thickness, macroaneurysm size and location, blood pressure, and the lipid level were compared between the two groups.Results: The mean patient age was 74.0 ± 10.5 years and the mean study period 7.0 ± 5.3 months. The mean macroaneurysm diameter of the CT group was 480.00 ± 292.30 μm and that of the MT group 328.75 ± 87.09 μm. The diameter was significantly larger in the CT group (p = 0.002). The initial visual acuities were 0.91 ± 0.66 and 0.88 ± 0.83 in the CT and MT groups, respectively. At the 4-month follow-up, the visual acuities were 0.33 ± 0.26 and 0.17 ± 0.29 in the CT and MT groups, respectively, and had significantly improved only in the CT group (p = 0.042). The initial central macular thicknesses were 441.82 ± 226.81 and 541.63 ± 401.97 μm in the CT and MT groups, respectively. At the 4-month follow-up, the figures were 293.60 ± 46.10 and 269.00 ± 48.34 μm in the CT and MT groups, respectively, and had significantly decreased only in the CT group (p = 0.043). Compared to the initial findings, the proportion of patients whose final visual acuities improved by more than two lines were 73% and 40%, respectively, thus significantly higher in the CT group (p < 0.001).Conclusions: Combined intravitreal bevacizumab injection and laser photocoagulation treatment of retinal macroaneurysms improve visual acuity and decrease macular thickness.

Influence of bevacizumab therapy and intraretinal hemorrhage in long-term outcomes of hemorrhagic retinal arterial macroaneurysm

This study aimed to evaluate the long-term visual outcomes of hemorrhagic retinal arterial macroaneurysm (RAM), particularly focusing on the influence of bevacizumab therapy and intraretinal hemorrhage (IRH) on the outcomes. This retrospective study included 49 patients diagnosed with hemorrhagic RAM. Patients were divided into the bevacizumab group and observation group depending on the whether they were administered bevacizumab treatment and the IRH group and the non-IRH group based on the presence of IRH at the fovea. Best-corrected visual acuity (BCVA) at diagnosis was compared with that at the final visit. Further, the BCVA at the final visit was compared between the study groups. Multivariate analysis was also performed to identify factors associated with poor BCVA at the final visit. The mean follow-up period was 24.8 ± 15.3 months. The mean logarithm of minimal angle of resolution BCVA was significantly improved from 1.37 ± 0.70 at diagnosis to 0.72 ± 0.62 at the final visit (P < 0.001). There was no significant difference in the BCVA at the final visit between the bevacizumab group and observation group (P = 0.576). However, the BCVA at the final visit was significantly worse in the IRH group than in the non-IRH group (P = 0.002). In multivariate analysis, the presence of IRH was significantly associated with poor BCVA (P = 0.007). Significant long-term visual improvement was noted in hemorrhagic RAM. However, the presence of IRH at the fovea was associated with poor visual prognosis. Bevacizumab therapy did not significantly influence the outcomes.

INTRAVITREAL ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR INJECTIONS FOR EXUDATIVE RETINAL ARTERIAL MACROANEURYSMS

PURPOSE

There is no established therapy for exudative-hemorrhagic complications in primary retinal arteriolar macroaneurysm (RAM).

METHODS

Retrospective multicenter interventional study of anti-vascular endothelial growth factor in symptomatic RAMs. Central macular thickness in μm and best-corrected visual acuity in logMar were correlated with the RAM size and distance to the macula. Statistical analyses were performed using paired comparisons and Pearson correlation.

RESULTS

Thirty-two eyes (32 patients) were treated with a mean of 2.7 injections over a mean follow-up of 16.6 months. Initial best-corrected visual acuity correlated with the RAM size and distance to the macula (P = 0.02). Central macular thickness decreased by 131,180, and 211 μm at 1, 2, and 3 months after the first injection (P < 0.001). Best-corrected visual acuity improved by 0.47 and 0.38 Early Treatment Diabetic Retinopathy Study lines at 2 and 3 months (P = 0.005). Anti-vascular endothelial growth factor response correlated with the RAM size (P = 0.04) and the distance to the macula (P = 0.009).

CONCLUSION

Symptomatic RAMs can be treated successfully with anti-vascular endothelial growth factor injections, leading to a decrease in macular edema.

To treat or not to treat: a clinical series of retinal arterial macroaneurysms: A single-center retrospective study

Retinal arterial macroaneurysms (RAMs) develop as outpouchings of the arterial wall that is weakened by arteriosclerosis. The traditional treatment of RAMs comprises observation, focal laser photocoagulation, or surgery. Recently, intravitreal injection of anti-vascular endothelial growth factor (VEGF) drugs has been announced as an effective therapy for fovea-threatening RAMs and quickly improve visual acuity and central retinal thickness (CRT).In the retrospective series, medical charts and ocular images of 24 patients diagnosed as having RAM between May 2011 and November 2018 in our facility were reviewed to delineate clinical manifestations and visual prognosis in RAM patients receiving different treatment modalities. Twenty-four patients (25 eyes; 11 men and 13 women) were enrolled, and one eye with comorbidity of branch retinal vein occlusion was excluded. The mean age of the patients was 69.00 ± 13.45 years. Fourteen patients (58.33%) had a history of hypertension, and 17 patients (70.83%) were aged > 60 years. Furthermore, patients with fovea-threatening RAMs presented with either hypertension or were aged > 60 years.Eyes with fovea involvement (n = 18) were analyzed and separated into two groups according to their treatment modalities: those receiving anti-VEGF intravitreal injections (n = 13) and observation only (n = 5). The baseline visual acuity revealed no significant difference in the two groups. In patients receiving anti-VEGF intravitreal injections, a significantly better visual acuity was detected after anti-VEGF intravitreal injections than the baseline visual acuity (logMAR, 0.78 ± 0.51 vs 1.52 ± 0.48, P < .001), and CRT significantly improved (505.50 ± 159.26 μm vs 243.60 ± 60.17 μm, P = .001). Patients receiving anti-VEGF intravitreal injections also revealed better final visual acuity than those in the observation group (logMAR, 0.78 ± 0.51 vs 1.34 ± 0.48, P = .04).A systematic work-up for hypertension and arteriosclerotic disease could be considered the recommended procedure once RAM has been diagnosed. With better final visual acuity, significant visual improvements, and fast reduction of CRT observed in patients with fovea-threatening RAMs receiving anti-VEGF intravitreal injections, intravitreal anti-VEGF was considered an effective therapy for complicated RAM. During the follow-up period, the majority of RAM eyes had good maintenance of visual function even with foveal complications.

Retinal Arterial Macroaneurysms: Updating your Memory on RAM Management

Purpose of review

This is a comprehensive review of management options for retinal arterial macroaneurysms (RAMs). Although close observation is typically recommended for RAMs not involving or threatening the macula, other treatment modalities can be considered for exudative or hemorrhagic complications that are vision-threatening.

Recent findings

New imaging technologies like optical coherence tomography angiography (OCT-A) have been able to detect RAMs without the need of dye injection, further elucidating our understanding of blood flow within and around them. Observation alone is usually adequate treatment when lesion not threatening the fovea. Laser photocoagulation and intravitreal injection of vascular endothelial growth factor (VEGF) inhibitors have effectively been used for management of exudative RAMs, whereas options including injection of VEGF inhibitors, tissue plasminogen activator (tPA), vitrectomy, gas, and yttrium aluminum garnet (YAG) laser have been used for hemorrhagic RAMs.

Summary

To date, there is no consensus regarding management of symptomatic exudative or hemorrhagic complications of RAM. Additionally, a case report is presented within this paper to illustrate the successful treatment of a hemorrhagic RAM in a symptomatic 65-year-old man using intravitreal bevacizumab.

Treatment of macular hemorrhage in retinal arterial microaneurysm: anatomic site-oriented therapy

PURPOSE

To investigate the usefulness of anatomic site-oriented therapy for macular hemorrhage secondary to retinal arterial macroaneurysm (RAM).

STUDY DESIGN

Retrospective observational study, clinical case series METHODS: Twenty-seven consecutive patients (27 eyes) with macular hemorrhage secondary to RAM were classified according to the retinal layer(s) with hemorrhage identified by optical coherence tomography into 4 types and treated differentially. Vitrectomy was conducted for subinternal limiting membrane hemorrhage (SILMH), intravitreal gas injection for subretinal hemorrhage (SRH) or intraretinal hemorrhage (IRH), and vitrectomy and intravitreal air/gas exchange for multilevel hemorrhage (at least 2 among SILMH/SRH/IRH).

RESULTS

Complete displacement or resolution of the macular hemorrhage was achieved in all 27 eyes: 7 with SILMH, 7 with SRH, 3 with IRH, and 10 with multilevel hemorrhage. Compared with the baseline score, the 3-month postoperative Early Treatment Diabetic Retinopathy Study score (mean ± SD) improved significantly in SILMH (+42.9 ± 6.9 letters; P < .0001, paired t test), multilevel hemorrhage (+23.9 ± 14.4 letters; P = .0005), and SRH (+17.7 ± 18.4 letters; P = .0440), but not in IRH (+6.7 ± 9.0 letters; P = .3228). Compared with the baseline thickness, the 3-month postoperative central retinal thickness decreased significantly in multilevel hemorrhage (-930.3 ± 290.8 µm; P < .0001), SILMH (-628.4 ± 177.0 µm; P < .0001), IRH (-508.3 ± 72.1 µm; P = .0066), and SRH (-476.9 ± 300.0 µm; P = .0056). The central ellipsoid zone was detectable in 7/7 eyes with SILMH but in none of the eyes in the other 3 groups (P < .0001). No retinal detachment or macular hole occurred in any eyes.

CONCLUSION

For macular hemorrhage secondary to RAM, anatomic site-oriented therapy using different treatments targeting the hemorrhagic retinal layers is useful. The optimal treatments for individual hemorrhagic retinal layers require further studies.

Intravitreal ranibizumab or conbercept for retinal arterial macroaneurysm: a case series

BACKGROUND

There is no consensus for the standard treatment of retinal arterial macroaneurysm (RAM). Intravitreal anti-vascular endothelium growth factor (anti-VEGF) is an alternative treatment option for RAM. The purpose of this study is to describe the clinical efficacy of intravitreal ranibizumab or intravitreal conbercept for retinal arterial macroaneurysm.

CASE PRESENTATION

Three cases that presented with symptomatic RAM were treated with intravitreal anti-VEGF agents. Two eyes received two intravitreal ranibizumab injections with a time interval of one month and completed a one-year follow-up, while one eye only received one intravitreal conbercept injection and was followed up for six months. Both the retinal thickness and the visual acuity were significantly improved at the final clinic visit. The macular hemorrhage and edema were resolved. There were no ocular or systemic side effects.

CONCLUSIONS

Intravitreal ranibizumab or conbercept might be used as a therapeutic option for symptomatic retinal arterial macroaneurysm patients. Anti-VEGF therapy should be further investigated in a larger series with longer follow-up for this disease profile.

Treatment of intravitreal bevacizumab combined with focal laser photocoagulation in the case of macular telangiectasia type 2 with retinal arterial macroaneurysm

Macular telangiectasia type 2 (Mac Tel 2) is a bilateral disease of unknown cause with characteristic changes of the retinal vasculature. To the best of our knowledge, we could not find any reported cases of Mac Tel 2 with retinal arterial macroaneurysm (RAM). Our aim is to report a case of Mac Tel 2 with RAM.

Retinal racemose hemangioma with retinal artery macroaneurysm: Optical coherence tomography angiography (OCTA) findings

Purpose

To describe a rare case of retinal racemose hemangioma (RRH) with retinal artery macroaneurysm (RAM) and its optical coherence tomography angiography (OCT-A) finding before and after treatment.

Observations

Congenital arteriovenous (AV) communications or RRH is a rare developmental anomaly associated with various ocular conditions. RRH alone is usually asymptomatic, and vision loss occurs when associated with other ocular complications like retinal vein occlusion, hemmorage, macular edema and macroaneurysm. In this communication we describe a case of a 44-year-old female having RRH who presented with active, leaking RAM with subretinal hemmorage. OCT-A through the lesion demonstrated an active aneurysm which on subsequent treatment with anti VEGF and focal laser photocoagulation showed involution of aneurysm.

Conclusions and importance

RRH is usually asymptomatic and may be associated with vision threatening ocular complications like RAM. OCT-A helps in giving additional dynamic blood flow information in RAM.

Treatment of intravitreal bevacizumab combined with focal laser photocoagulation in the case of macular telangiectasia type 2 with retinal arterial macroaneurysm

Macular telangiectasia type 2 (Mac Tel 2) is a bilateral disease of unknown cause with characteristic changes of the retinal vasculature. To the best of our knowledge, we could not find any reported cases of Mac Tel 2 with retinal arterial macroaneurysm (RAM). Our aim is to report a case of Mac Tel 2 with RAM.

Optical Coherence Tomography Angiography of Retinal Arterial Macroaneurysm before and after Treatment

A case of retinal arterial macroaneurysm (RAM) is presented with multimodal imaging, including commercially available optical coherence tomography angiography (OCT-A). Following treatment with intravitreal bevacizumab, reduction of flow signal through the RAM is documented. OCT-A provides useful information for the diagnosis and management of at least some patients with RAM, without the need for traditional fluorescein angiography.

Ruptured Retinal Arterial Macroaneurysm Secondary to Toxoplasmic Kyrieleis Arteriolitis: A Case Report

Purpose

The aim of this report was to describe multimodal ocular imaging findings in a patient who presented with a ruptured retinal arterial macroaneurysm (RAM) associated with toxoplasmic Kyrieleis arteriolitis.

Methods

We report the case of a 64-year-old man with a history of systemic hypertension and dense amblyopia of the left eye who presented with decreased vision and new floaters in the left eye. Color fundus photography, spectral-domain optical coherence tomography, fluorescein angiography, and indocyanine green angiography were used as diagnostic imaging tools.

Results

No signs of hypertensive retinopathy were noted in the right eye. Multiple chorioretinal scars characteristic of previous toxoplasmosis were revealed in the left eye, with one covering most of the macula. Periarterial plaques or Kyrieleis arteriolitis were observed in retinal arteries surrounding the toxoplasmic retinal scars. Multiple RAMs were observed in these vessels, one of which was acutely ruptured. A perivenular plaque associated with a chronic branch retinal vein occlusion (BRVO) was noted along the same arcade at the arteriovenous crossing.

Conclusion

RAM formation and BRVO can present as possible long-term complications of toxoplasmic Kyrieleis arteriolitis. This is the first reported case demonstrating an association between toxoplasmic Kyrieleis arteriolitis and RAM formation.

Intravitreal ranibizumab for retinal arterial macroaneurysm: long-term results of a prospective study

PURPOSE

To evaluate the potential efficacy and safety of primary intravitreal ranibizumab in patients with symptomatic retinal arterial macroaneurysm (RAM).

METHODS

This prospective study comprised 5 eyes with RAM treated with intravitreal ranibizumab. At baseline, all patients underwent best-corrected visual acuity (BCVA) measurement, ophthalmic examination including slit-lamp biomicroscopy, and central foveal thickness (CFT) measurement using optical coherence tomography. Fluorescein angiography was also performed to confirm diagnosis. Patients were examined at 1 month after injection and monthly thereafter. Main outcome measures included changes in BCVA and CFT. Safety was assessed by ophthalmic examination and report of systemic adverse effects.

RESULTS

There was a statistically significant difference in BCVA (p<0.001) and CFT (p<0.001) before and after the ranibizumab injection at the end of the follow-up of 13.4 ± 3.2 months. One injection appeared to be sufficient for the resolution of macular edema and absorption of hemorrhages. No observable ocular or systemic side effects were found. One patient developed foveal atrophy.

CONCLUSIONS

Intravitreal ranibizumab seems to be effective and safe for the treatment of symptomatic RAM.

Intravitreal Anti-Vascular Endothelial Growth Factor for Macular Edema due to Complex Retinal Arterial Macroaneurysms

Introduction

Complex retinal arterial macroaneurysms (RAM) are often accompanied by hemorrhage and/or affect the macula. We evaluated the effect of intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy using ranibizumab or aflibercept with or without laser photocoagulation in the treatment of macular edema due to RAM.

Methods

A case report of two patients with secondary macular edema caused by RAM is presented. The first case was a 76-year-old female treated with two 0.5-mg injections of ranibizumab and additional focal laser photocoagulation. This patient presented a solely intraretinal exudation. The second patient was a 96-year-old female, who received one 2.0-mg injection of aflibercept. She showed sub- and intraretinal edema. We documented the clinical courses of these patients based on fundus photography, fluorescein angiography, and spectral-domain optical coherence tomography. Patients were followed-up for 12 months.

Results

Patients were treated successfully using anti-VEGF therapy (ranibizumab or aflibercept) with or without laser photocoagulation. In both cases, we observed a complete regression of the macular edema and an increase in visual acuity.

Conclusion

RAM can manifest with heterogeneous findings. Intravitreal anti-VEGF therapy with or without laser photocoagulation may be an effective treatment option in cases of macular edema due to RAM. Aflibercept and ranibizumab seem to be a potent anti-VEGF therapy for RAM. Individualized patient care is needed.

Are Multiple Retinal Arterial Macroaneurysms Considered a Sign of Cerebral Aneurysms?

The aim of this study is to report the coexistence of retinal arterial macroaneurysms (RAMs) and cerebral aneurysms (CAs) in a 58-year-old woman with hypertension. She was noted as having a 1-week history of vision loss in her left eye, along with a 2-month history of a nonspecific headache. Visual acuity was 20/32 in her left eye and 20/20 in her right eye. A fundus examination revealed multiple areas of retinal hemorrhages that were surrounded by circinate exudation in her left eye, as well as the generalized attenuation of the retinal arteries in both of her eyes. Angiographically, hyperfluorescent round leakage points confirmed the presence of five saccular RAMs. Surprisingly, computed tomography angiography completed based on the recommendation of neurology department identified three saccular CAs. Aging, hypertension, and female preponderance are the common risk factors for both RAMs and CAs. Accordingly, RAMs and CAs may exist simultaneously in hypertensive patients. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:79-82.].

Long-Term Management of Complications of Retinal Artery Macroaneurysms with Intravitreal Aflibercept Injection

PURPOSE

To report the 1-year follow-up results of intravitreal aflibercept injection (IAI) for the management of complications of retinal artery macroaneurysms (RAM).

METHODS

A retrospective, noncomparative, interventional case series of 4 eyes of 4 patients (all female, aged 68-91 years, 3 treatment naive) treated with IAI 2 mg for complications of RAM [macular edema (ME) 2, submacular hemorrhage (SMH) 1, and vitreous hemorrhage (VH) 1] was conducted. Baseline parameters consisted of complete ocular examination, medical history, best-corrected Snellen VA, fundus photography, IVFA and SD OCT, unless precluded by VH (1). All patients completed ≥1 year follow-up.

RESULTS

Baseline VA was hand motions in the eye with SMH (31 mm² area and 1,478 μm thickness); 20/40 and 20/100 with ME (CST 390 and 337 μm, respectively), and 20/200 in the eye with VH. At 1 month, both patients with ME showed resolution of ME with CST <300 μm with improvement in VA which was maintained through 1 year. VH resolved in one eye at 1 month with no recurrence after 1 year. The eye with SMH developed macular scar and had counting fingers vision at 1 year. Thrombosis of RAM was noted in all eyes and hairpin-like remodeling of artery in one. No eye required repeat injection or laser.

CONCLUSION

ME and VH from RAM were effectively treated with IAI. However, the eye with thick SMH had poor visual outcome despite thrombosis of RAM. Single IAI provided effective therapy for complications of RAM with excellent anatomical and visual results in each eye, except one with thick SMH, and merits further study.

Angiographic features and disease outcomes of symptomatic retinal arterial macroaneurysms

PURPOSE

Symptomatic retinal arterial macroaneurysms (RAM) are primarily investigated by fundus fluorescein angiography after presenting with visual disturbance. The natural history includes spontaneous regression and occasionally occlusion of the arteriole distal to the aneurysm. RAM may be managed conservatively. Interventional treatment options include focal argon laser photocoagulation, Nd:YAG laser hyaloidotomy, and pars plana vitrectomy. The purpose of this study was to elicit the rates of distal vessel occlusion and aneurysm thrombosis in RAM at presentation, and their relevance to the treatment of RAM. Furthermore, visual outcomes were examined.

METHODS

Retrospective review of cases of RAM presenting to a tertiary ophthalmology care centre was accomplished in a university teaching hospital. The angiographic features, treatment indications, and visual outcomes in patients with RAM were recorded. Angiographic features noted were distal vessel patency and aneurysm thrombosis at presentation.

RESULTS

Ten patients with RAM were identified. Ninety percent had an angiographically patent distal arteriole, with 40 % showing spontaneous thrombosis of the aneurysm sac at presentation. Patients presenting with a spontaneously thrombosed RAM were managed conservatively, those with flow within the aneurysm wall were treated with focal laser, and those with subhyaloid haemorrhage underwent Nd:YAG laser hyaloidotomy. LogMAR visual acuity improved from 0.3 (±0) at presentation to 0.15 (±0.1) in the conservative group, and from 0.78 (±0.23) to 0.24 (±0.18) in those who underwent one intervention. One patient lost vision after multiple RAM.

CONCLUSION

Thrombosis within the aneurysm wall is an important feature in deciding to treat RAM, and selective use of interventions improves vision in affected patients.

Intravitreal bevacizumab in congenital retinal macrovessel with retinal arteriolar macroaneurysm

Congenital retinal macrovessel (CRM) refers to an aberrant vessel, usually a vein, which traverses the macula and supplies both sides of the horizontal raphe. It is a rare condition, mostly asymptomatic and discovered on routine examination. We describe a case of both arterial and venous CRM with a macroaneurysm along the arterial CRM that presented with decreased vision due to prominent lipid exudation at the macula. Treatment with intravitreal bevacizumab resulted in a favourable anatomical as well as functional outcome. To the best of our knowledge, this is the first report of this unusual presentation of CRM, and its successful management with intravitreal bevacizumab.

Foveal Exudative Macroaneurysm Treated with Intravitreal Ranibizumab

PURPOSE

We report a case of a foveal macroaneurysm with long-standing macular edema in a rare location, successfully treated with intravitreal ranibizumab.

METHODS

We report the case of a 52-year-old man with left eye long-term visual loss due to macular edema caused by a retinal macroaneurysm, localized about 400 μm from the center of the fovea, and its response to 6 monthly ranibizumab intravitreal injections. His best-corrected visual acuity and morphological data evaluated by optical coherence tomography and fluorescein angiography are presented.

RESULTS

His best-corrected visual acuity improved from 1/10 to 3/10 after the 3rd injection, and from 1/10 to 4/10 after the 6th one. The central retinal thickness was evaluated by optical coherence tomography and improved from 310 to 233 μm, with the resolution of both the associated serous detachments and the cystoid macular edema; an almost complete reabsorption of the hard exudates at the end of the treatment was also observed. The macroaneurysm lumen almost obliterated after the 3rd injection and completely collapsed at the end of treatment.

CONCLUSIONS

Intravitreal ranibizumab may be effective in the treatment of long-standing macular edema associated with foveal macroaneurysms. To the best of our knowledge, this is the first report of a retinal macroaneurysm located so close to the foveal avascular zone.

Long-term, therapy-related visual outcome of 49 cases with retinal arterial macroaneurysm: a case series and literature review

PURPOSE

Retinal arterial macroaneurysms (RAMAs) are acquired dilations of branches of the central retinal artery. Treatment depends on vision-limiting complications. We compare the long-term visual acuity (VA) in three groups according to treatment.

METHODS

49 charts of patients with RAMA were reviewed. 16 remained untreated, 15 received photocoagulation and 18 vitrectomy. Patients underwent full ophthalmological examinations and up-to-date imaging. We evaluated chosen therapy, complications and final VA at the last visit.

RESULTS

65% of the cohort was female, aged 75±11 years (mean±SD). Follow-up was 34±23 months. These parameters did not differ significantly between the three groups. In the observed group, initial VA was 0.48 (mean log MAR) vs 0.35 at the final visit, in the photocoagulation group 0.55 vs 0.59, and in the vitrectomy group 1.8 vs 0.77. VA was significantly worse at enrolment in the vitrectomy group, while all other VA differences were not significant.

CONCLUSIONS

The overall visual prognosis of RAMA was good, even after macular complications. VA remained unchanged in the observed and the laser groups and was comparable in all groups after 3 years. Based on an individual treatment decision, all therapies were effective and efficient. If subfoveal haemorrhage caused a macular hole, the VA outcome was limited.

Serial bevacizumab injections and laser photocoagulation for macular edema associated with a retinal artery macroaneurysm

An 84-year-old female with a history of hypertension and dyslipidemia was referred for a retinal artery macroaneurysm with exudation that had extended into the macula. She underwent a total of six injections of bevacizumab, with some improvement in visual acuity and retinal thickness. Due to persistent macular edema, focal laser photocoagulation was performed around the macroaneurysm. The vision remained at 20/30 during 20 months of follow up. Although anti-vascular endothelial growth factor therapy may improve vision and decrease retinal thickness in retinal artery macroaneurysm, recalcitrant cases may be treated with laser photocoagulation to seal the leaking vessel.

Subretinal injection of recombinant tissue plasminogen activator for submacular hemorrhage associated with ruptured retinal arterial macroaneurysm

PURPOSE

To evaluate the surgical outcomes of small-gauge vitrectomy with subretinal injection of recombinant tissue plasminogen activator (rt-PA) for a submacular hemorrhage caused by a ruptured retinal arterial macroaneurysm (RAM).

METHODS

Non-comparative, consecutive case-series performed at two ophthalmological institutions. We examined 22 eyes of 22 patients with a submacular hemorrhage associated with a RAM but without a preretinal or sub-internal limiting membrane hemorrhage at the fovea. During 25-gauge vitrectomy, approximately 4000-8000 IU of rt-PA was injected subretinally, followed by the injection of air or 10 % sulfur hexafluoride as a tamponade. The patients maintained an upright position for 1 hour, then turned to a facedown position for 1 to 3 days. The best-corrected visual acuity (BCVA) and postoperative complications were evaluated.

RESULTS

The average interval from the onset of symptoms to surgery was 8.4 ± 7.6 days, and the average size of the subretinal hemorrhage was 3.4 ± 1.0 disc diameters. The submacular hemorrhage was displaced from the foveal area in all eyes after 1 week. The mean baseline BCVA was 1.41 ± 0.41 logMAR units, and it improved to 0.91 ± 0.43 at 1 month and to 0.64 ± 0.45 at the final visit (P = 0.0001, P < 0.0001 respectively). A macular hole was detected intraoperatively in two eyes and postoperatively in two eyes, and both were closed by internal limiting membrane peeling or a second vitrectomy.

CONCLUSIONS

Small-gauge vitrectomy with subretinal rt-PA injection and gas tamponade were effective in displacing a submacular hemorrhage associated with a RAM.

Intravitreal bevacizumab and Ahmed glaucoma valve implantation in patients with neovascular glaucoma

AIM

To explore the efficacy of preoperative intravitreal bevacizumab (IVB) injection combined with Ahmed glaucoma valve (AGV) implantation in the treatment of neovascular glaucoma (NVG).

METHODS

This retrospective study included 35 eyes from 35 patients who underwent preoperative IVB and AGV implantation for treatment of NVG. Findings such as intraocular pressure (IOP) number of anti-glaucoma medications, visual acuity (VA), surgical success rates, and complications were recorded.

RESULTS

After AGV implantation, IOP was 18.2±4.0 mm Hg, 15.5±3.3 mm Hg and 9.8±2.6 mm Hg at 6, 12 and 36mo, significantly decreased compared with pre-IOP (P<0.01). The number of anti-glaucoma medications was 0.9±0.5, 0.8±0.9 and 0.8±0.6 at 6, 12 and 36mo, significantly decreased compared to pre-treatment (P<0.01). At last visit, there were 19 eyes with stable VA, 4 with VA improvement, 12 with diminished VA and 3 with complete loss light perception. There were 7 cases that failed during 3-year fellow up period. Cumulative probabilities of valve survival by Kaplan-Meier analysis were 82.9%, 74.1% and 71.0% at 12, 24 and 36mo, respectively. Cox stepwise regression analysis found that the survival time was significant associated with the pre-visual acuity <2/400 (P<0.05). Post-operative complications occurred in 8 eyes, of which hyphema presented in 2 eyes, choroidal effusion in 2 eyes.

CONCLUSION

The procedure of preoperative IVB and AGV implantation should be one of treatments for NVG because of its safety and effectiveness.

Laser therapy versus observation for symptomatic retinal artery macroaneurysms

PURPOSE

The optimal management approach to retinal arterial macroaneurysms (RAM) is unknown. This paper compares long-term outcomes in RAM treated with laser therapy versus observation.

METHODS

This is an IRB-approved retrospective study of patients with symptomatic RAM. Charts of patients with a diagnosis of RAM causing symptomatic visual loss were reviewed. Patients with less than 6 months follow up, other confounding diagnoses, or additional therapy beyond thermal laser were excluded. Statistical analysis was done using χ(2) or Student's t test as appropriate.

RESULTS

Forty-eight patients with RAM were identified and 27 were included in the study (13 treated, 14 observed). Mean visual acuity in the observation group improved from 20/120 to 20/96 (p = 0.53) compared to 20/280 to 20/54 (p = 0.0003) in the treated group. Subgroup analysis showed that visual acuity in primarily hemorrhagic lesions treated with laser therapy improved by 1.21 logMAR compared to a loss of 0.11 logMAR (p = 0.002) in those that were observed. In primarily exudative lesions, both treated and observed lesions showed an improvement of 0.32 logMAR. No patients in the treatment group had a final visual acuity below 20/200 compared to four in the observation group.

CONCLUSION

Treatment with direct laser photocoagulation was associated in this study with greater improvement in visual acuity and may decrease the risk of severe visual loss especially in primarily hemorrhagic RAM lesions. Compared to observation alone.

Ruptured retinal arterial macroaneurysm: diagnosis and management

Retinal arterial macroaneurysm is an acquired, focal dilation of a retinal artery, typically occurring within the first three bifurcations of the central retinal artery. The clinical presentation of a retinal arterial macroaneurysm is highly variable, making initial diagnosis difficult and differentials many. Identification of retinal arterial macroaneurysms is crucial to appropriately co-manage with the primary care physician for hypertension control. Prognosis is generally good and observation is often an adequate treatment. However, in cases of macular threat or involvement, some treatment options are available and referral to a retinal specialist is indicated.

Night blindness and Crohn's disease

Signs of malnutrition are common clinical features in Crohn's disease; and bowel resection, commonly needed in these cases, can aggravate malnutrition. These patients are at risk of developing vitamin A deficiency, which can lead to night blindness. We present a 60-year-old male, with history of Crohn's disease and multiple resections for strictures and fistulas leading to short bowel syndrome, with progressive bilateral loss of night vision (nyctalopia). Serum vitamin A level was markedly depleted (11 µg/dL, reference 20-120 µg/dL), and full-field electroretinogram testing demonstrated extinguished scotopic (rod function) responses and decreased amplitudes of photopic responses on 30 Hz flicker (cone function). He was started on vitamin A supplementation (initially intramuscular). His vitamin A level was back to normal (78 µg/dL), and night vision problems subjectively improved. Patients with Crohn's disease should be inquired about night vision problems. The presence of nyctalopia should prompt vitamin A level measurement and ophthalmology referral for further evaluation.