Ranibizumab for retinal arterial macroaneurysms

Abstract

Dear Editor, We read with great interest the case report entitled “Intravitreal ranibizumab in retinal macroaneurysm” by Wenkstern et al. [1] regarding the effects of intravitreal ranibizumab (Lucentis®; Genentech, Inc, South San Francisco, CA, USA) as monotherapy for retinal arterial macroaneurysms (RAM). RAM are acquired retinal vascular abnormalities, typically found as a solitary, round or fusiform aneurysm arising in one of the four major retinal arteries within the posterior pole of the eye. RAM predominantly affect middle-aged female patients with cardiovascular diseases, mainly systemic hypertension and arteriosclerosis [2, 3]. A focal embolic damage to arterial walls is thought to cause RAM, leading to localized ischemia with vascular endothelial growth factor (VEGF)-induced increased permeability and dilatation of the retinal artery. These cause visual impairment due to hemorrhage, exudation and macular thickening. Ranibizumab has been shown to reduce vascular permeability in choroidal neovascularization due to neovascular age-related macular degeneration [4], as well as in macular edema due to retinal vein occlusion [5]. The intravitreal administration of VEGF inhibitors may reduce the VEGF-induced vascular hyperpermeability present in the retinal changes due to RAM. Bevacizumab (Avastin®; Genentech, Inc, South San Francisco, CA, USA) has been reported to reduce macular edema in patients suffering from RAM [6]. As we share Dr Wenkstern's opinion about the limited visual improvement achieved with current therapeutic options, we have prospectively included five female patients (mean age 68.7 years) with visual loss and RAM in a pilot study to evaluate the efficacy of intravitreal ranibizumab injection for this disease. The inclusion criteria were: best-corrected visual acuity (BCVA) ≥0.5 logMAR, macular hemorrhage with foveal involvement; and macular edema with more than 350 μm as measured with spectral-domain optical coherence tomography (SD-OCT). Baseline examination included BCVA, SD-OCT and fluorescein angiography. We immediately applied a first intravitreal ranibizumab injection, and thereafter scheduled patients into a quarterly followup (according to the current follow-up periods for ranibizumab therapy in choroidal neovascularization) in order to assess BCVA improvement and SD-OCT changes. Re-treatments were performed whenever we documented a The authors have no financial interest to disclose.