Foveal Exudative Macroaneurysm Treated with Intravitreal Ranibizumab

Juxtafoveal Retinal Arterial Macroaneurysm Diagnosed on Ancillary Imaging

Purpose: To describe a case of retinal arterial macroaneurysm, a rare, focal arterial dilatation that is commonly found temporally within the first 3 orders of retinal arterial bifurcations. Methods: An observational case report was evaluated. Results: A 49-year-old man with prediabetes and hypercholesteremia presented with decreasing vision and a paracentral scotoma in the right eye. His ocular history was insignificant. There was significant intraretinal and subretinal fluid with perifoveal exudates. After 2 intravitreal injections of aflibercept for a tentative diagnosis of branch retinal vein occlusion, there was no improvement. Intravenous fluorescein angiography showed a small retinal arterial macroaneurysm less than 60 µm from the foveal avascular zone that was treated with low-power focal laser photocoagulation. This resulted in complete resolution of the macular edema with significant improvement in visual acuity. Conclusions: This rare and successfully treated case of an exudative juxtafoveal retinal arterial macroaneurysm highlights the importance of multimodal imaging in establishing an accurate diagnosis.

Retinal detachment following focal laser to ruptured retinal artery macro aneurysm

A 53-year-old lady presented with inferior retinal detachment (RD) following focal laser for retinal artery macroaneurysm (RAM). She underwent focal laser with intravitreal gas injection elsewhere; however, no retinal break was localized on the examination. The patient was taken up for vitreoretinal surgery. Intraoperatively, it was noted that the retinal detachment was not extending to the retinal periphery and primary retinal break was not localized even during the scleral depression. Under high magnification, using a macular lens, a slit-like retinal break was noted at the area of previous focal laser. Focal laser for RAM probably caused this retinal break leading to RD.

The clinician needs to be aware that during focal laser of ruptured RAM, haemorrhage may preclude the view of retinal structures leading to inadvertent use of excessive laser energy. Retinal breaks may form at the site of laser due to coagulative necrosis. During surgical management of RD in such cases, the area of focal laser should be thoroughly examined under high magnification to avoid missed breaks.

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.

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.

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.