Arteriolar Macroaneurysm Research Articles

A Case Report on IRVAN Syndrome

Idiopathic retinal vasculitis, arteriolar macroaneurysms, and neuroretinitis (IRVAN) is a rare condition predominantly affecting young, healthy females without systemic disease. We present the case of a 35-year-old female who presented with a 3-month history of decreased visual acuity without associated symptoms. Ophthalmological examination revealed reduced visual acuity in both eyes, papillary oedema, stellate macular oedema, and haemorrhages bilaterally. Retinal imaging confirmed IRVAN syndrome. Treatment included pan-retinal photocoagulation (PRP) and intravitreal bevacizumab injections, resulting in macular oedema regression.

Optical coherence tomogrpaphy in differential diagnosis of retinal arteriolar macroaneurysms

Aim. To study the prevalence and topographical distribution of retinal exudation in eyes with retinal arteriolar macroaneurysms (RAM) and in those with macular branch retinal vein occlusions (mBRVO).
 Methods. The prevalence of optical coherence tomography (OCT) signs (different types of retinal hemorrhages and accumulation of fluid as well as hard and soft exudates) was evaluated in 28 eyes with RAM (22 males, 6 females, mean age 66.0 9.9 years) versus 17 eyes with mBRVO (9 males, 7 females, mean age 56.9 10.5 years). Topographical distribution of retinal exudation on OCT retinal maps was evaluated in 7 RAM eyes (6 males, 1 female, mean age 66.0 11.7 years) and 8 mBRVO eyes (5 males, 3 females, mean age 60.1 19.2 years). The measures were 1) position of the point of the maximum retinal thickness in relation to the macular center and RAM, 2) difference between maximum retinal thickness in the macular center and that at the site of RAM localization (surrogate control point in mBRVO eyes).
 Results. Soft exudates and intraretinal fluid accumulation were mostly associated with mBRVO (p = 0.007 and p 0.001, respectively), while hard exudates were found almost exclusively in RAM eyes (p 0.001). Central retinal thickness in RAM eyes was lower than that of mBRVO eyes, 453.1 148.6 m and 797.5 179.6 m, respectively (p = 0.001). The point of maximum retinal thickness was found at the site of RAM localization in 8 out of 9 RAM cases (88.9%), and within the central subfield in 8 out of 8 mBRVO cases (100%). The difference between maximum retinal thickness in the macular center and at the site of RAM localization (surrogate control point in mBRVO eyes) was 77.9 174.1 m and 148.3 100.4 m for RAM and mBRVO eyes, respectively (p 0.001).
 Conclusions. Evaluation of exudative signs and their topographic distribution based on OCT data may be used for differential diagnosis and laser treatment planning in RAM.

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

There is no established therapy for exudative-hemorrhagic complications in primary retinal arteriolar macroaneurysm (RAM). 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. 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). Symptomatic RAMs can be treated successfully with anti-vascular endothelial growth factor injections, leading to a decrease in macular edema.

Multimodal Imaging of Adult-onset Coats’ Disease

The majority of Coats’ disease cases are diagnosed in the first decade of life, though cases with symptom onset and first diagnosis in adulthood are well documented. While the cases diagnosed in childhood and adulthood share many of the characteristic features that define Coats’ disease, adult cases have been shown to present with less severe disease manifestations and an increased incidence of macroaneurysms with perianeurysmal hemorrhage. We present two cases of Coats’ disease diagnosed in adulthood that demonstrate prominent arteriolar macroaneurysms with perianeurysmal hemorrhages and contribute to an understanding of the adult Coats’ phenotype.

Direct navigated laser photocoagulation as primary treatment for retinal arterial macroaneurysms

ObjectivesTo compare the efficacy and safety of conventional and navigated laser photocoagulation as the primary treatment option for retinal arteriolar macroaneurysm (RAM).MethodsEleven (9 male and 2 females, mean age 65.1 ± 12.1 years) and 17 (13 male and 4 females, mean age 66.2 ± 8.9 years) patients were included in conventional laser photocoagulation (CLP) and navigated laser photocoagulation (NLP) groups, respectively. The primary outcome measures were LogMAR best-corrected visual acuity (BCVA) and central retinal thickness at the end of the follow-up. The secondary outcome measure was total laser energy applied during the procedure.ResultsAt the end of the mean follow-up of 11.4 ± 4.0 months, baseline LogMAR BCVA increased significantly from 0.65 ± 0.14 to 0.26 ± 0.12 (p < 0.001) in CLP group and from 0.57 ± 0.33 to 0.29 ± 0.34 (p < 0.001) in NLP group. Central retinal thickness decreased significantly from 514.5 ± 53.2 µm to 295.3 ± 11.3 µm (p < 0.001) and from 494.0 ± 111.2 µm to 285.8 ± 51.4 µm (p < 0.001) in CLP and NLP group, respectively. Total laser energy and number of laser burns applied per procedure in NLP group was statistically significantly lower than in CLP group (0.28 ± 0.13 J vs 0.59 ± 0.06 J, p < 0.001 and 28.5 ± 14.2 burns vs 48.9 ± 5.1 burns, respectively, p < 0.001). No adverse events related to laser treatment was noted in study groups during the follow-up.ConclusionThis study demonstrated superiority of navigated laser photocoagulation compared to conventional laser photocoagulation in primary treatment of RAM which results from similar efficacy and safety of both techniques with lower mean total laser energy and number of laser burns required for navigated laser photocoagulation.

Idiopathic retinal vasculitis, arteriolar macroaneurysms and neuroretinitis (IRVAN): case series of three patients with multimodal imaging

PurposeTo describe the clinical presentation, disease progression, treatment and complications of IRVAN.MethodsRetrospective review of three patients with a diagnosis of IRVAN seen at the Birmingham and Midland Eye Centre between 2010 and 2017. Multimodal imaging investigations included wide‐field fluorescein angiography, optical coherence tomography, and indocyanine green angiography.ResultsA total of 6 eyes from 3 patients with bilateral disease were included. All six eyes were treated with panretinal photocoagulation (PRP). One eye received a dexamethasone implant for refractory macular oedema and exudation. One eye was treated with Avastin injections for persistent optic disc neovascularization. All 3 patients were treated with oral steroids at some point in the course of their disease and one was subsequently immunosuppressed with mycophenolate mofetil. Visual outcomes varied. One patient maintained excellent visual acuity of 6/6 in both eyes at 72‐months follow‐up. The second patient experienced progressive visual loss from 6/9 right eye, 6/6 left eye at presentation; to 6/18 right eye, 6/60 left eye at 12 months follow‐up due to macular exudation despite aggressive PRP and intravitreal Ozurdex. The third patient deteriorated from 6/5 right eye, 6/4 left eye at presentation to 6/60 right eye at 6 months, despite aggressive PRP. He had recurrent vitreous haemorrhages in the right eye secondary to NVD despite further interventions with Avastin injections; seven years after presentation, vision remained at 6/60 right eye and 6/18 left eye.ConclusionsThe cadence of progression of IRVAN can vary greatly, despite aggressive treatment with PRP, intravitreal steroids, and anti‐VEGF agents. We observed variation in disease progression both among patients as well as within the same individual, supporting an individualized approach to therapy.

Retinal arteriolar macroaneurysms and central retinal vein occlusion in a patient with complete pulmonary atresia.

Retinopathy in cyanotic heart disease arises due to hypoxia and polycythaemia. We report the development of central retinal vein occlusion, and two arteriolar macroaneurysms in a normotensive patient with polycythaemia secondary to complete pulmonary atresia. A 44-year-old woman with polycythaemia secondary to complete pulmonary atresia, presented with unilateral reduced vision of hand movements in the right eye. Ocular assessment and hematological investigations were performed. Management was conservative. Visual acuity was hand movements in the right eye, 6/5 in the left eye. Fundus assessment found right central retinal vein occlusion, and vessel tortuosity in the left eye. Hematological tests revealed an elevated red blood count, hemoglobin, heamatocrit, but normal plasma viscosity. Three months later, two arteriolar macroaneurysms developed in the left superotemporal arcade. Vision of 6/5 was retained in the left eye, hence no laser treatment was given. Subsequent follow-up revealed gradual involution of both macroaneurysms. Multiple retinal arteriolar macroaneurysms may occur in association with cyanotic heart disease such as pulmonary atresia. They appear to involute spontaneously, hence conservative management is appropriate.

Retinal Arteriolar Macroaneurysm and Congenital Retinal Macrovessel

Variations in the morphology of the aneurysm and its serosanguineous complications serve to make a retinal arteriolar macroaneurysm, a common masquerading entity, particularly if it is accompanied by another un-associated retinal vascular abnormality. The authors present a patient who had an unusually large retinal arteriolar macroaneurysm in conjunction with a congenital retinal macrovessel.

Arteriolar macroaneurysm on the optic disk associated with branch retinal vein occlusion.

To report a case of an arteriolar macroaneurysm on the optic disk associated with branch retinal vein occlusion (BRVO). Patient chart review. An 80-year-old man presented with a retinal arteriolar macroaneurysm on the optic disk on the root of a papillomacular vein, which caused BRVO. Eight months later, the macroaneurysm shrank spontaneously and became fibrous tissue. The hemorrhage and edema due to BRVO resolved. We speculate that the macroaneurysm was located on and compressed the epipapillary portion of the papillomacular vein, resulting in BRVO. With spontaneous involution of the macroaneurysm, the compression resolved, and the clinical findings improved.

Retinal arteriolar macroaneurysms overlying the optic nerve.

Retinal arteriolar macroaneurysms typically involve the second and third order arterioles. Macroaneurysms involving the first order arterioles, specifically overlying the optic nerve, have been infrequently reported. This is a retrospective case series. Two patients were found to have an arteriolar macroaneurysm overlying the optic nerve. The first, a 77-year-old man, had focal laser photocoagulation to the macroaneurysm. The second, a 75-year-old woman, had spontaneous resolution of the lesion without treatment. Final visual acuity was 20/25 in the treated patient compared to 20/80 in the untreated patient. Retinal arteriolar macroaneurysms overlying the optic nerve will involute spontaneously or as a result of focal laser photocoagulation. The associated macular edema may result in permanent visual loss. Focal laser treatment over the optic nerve did not cause optic nerve damage.

Hypertension and the eye

This article reviews the findings of systemic hypertension in the eye and how these changes represent disease in the eye itself, as well as the predictive value of fundoscopic findings in relation to overall health. Systemic hypertension is associated with observable changes in the retinal microvasculature, including retinopathy, choroidopathy and optic neuropathy, as well as with an increased risk of ocular vascular abnormalities such as arterial and venous occlusive disease, retinal arteriolar macroaneurysm formation and embolic events. Hypertension also confers increased risk for development and progression of diabetic retinopathy, glaucoma and age-related macular degeneration. Grading systems have been proposed that attempt to correlate observed ocular hypertensive changes with systemic vascular disease severity, morbidity and mortality. The widespread availability of digital imaging systems and computer analysis along with revised grading systems has enabled a more precise and reliable examination. This has renewed the interest in the use of routine fundoscopic screening for patients with hypertension in an effort to identify microvascular changes that may provide prognostic information for cardiovascular risk stratification and disease progression. Identification of early microvascular changes on fundoscopic examination using reliable and reproducible imaging techniques may become an important and routine screening modality for the prevention and management of both the ocular and systemic complications of hypertension.

Ocular manifestations of systemic arterial hypertension

Hypertension is a major cause of cardiovascular disease and is also a risk factor for various ocular diseases. Hypertension exerts its effects on the retinal, choroidal and optic nerve circulations. In this article, the various ocular manifestations of hypertension are reviewed. Retinal microangiopathy is strongly associated with blood pressure and risk of cardiovascular diseases, including stroke, cognitive decline and heart disease. Higher blood pressure is an important risk factor for the development and progression of diabetic retinopathy and has also been implicated in the pathogenesis of retinal vein occlusion, retinal artery occlusion, retinal arteriolar emboli and macroaneurysm. Hypertension has also been inconsistently linked with glaucoma and age-related macular degeneration. The management of patients with these ocular conditions should include appropriate assessment and management of hypertension.

Branch Retinal Artery Occlusion Associated with Rupture of Retinal Arteriolar Macroaneurysm on the Optic Disc

Branch Retinal Artery Occlusion Associated with Rupture of Retinal Arteriolar Macroaneurysm on the Optic Disc

Retinal arteriolar macroaneurysms: long-term visual outcome.

Visual outcome was analysed in 16 consecutive eyes with symptomatic retinal arteriolar macroaneurysms treated by direct laser photocoagulation and 26 consecutive symptomatic eyes followed with no treatment. No difference existed between groups in presenting visual acuity, macular involvement, presence of macular subretinal fluid, or presence or location of associated haemorrhage. The mean follow up was 41 months. In the 26 untreated eyes, visual acuity was improved by 2 or more lines in 13 (50%), was unchanged in nine (35%), and decreased in four cases (15%). In the 16 treated cases, three improved (19%), seven were unchanged (43%), and six had decreased visual acuity (38%). The average minimum angle of resolution improved 0.53 log units in untreated cases and decreased 0.14 log units in treated cases (p = 0.02). Multivariable logistic regression modelling analysis revealed that laser treatment remained a significant risk factor for final visual acuity of less than 20/80 even when controlling for the effects of subretinal haemorrhage and foveal subretinal fluid (odds ratio 8.4, p = 0.01). Laser photocoagulation directly to the macroaneurysm did not improve the visual outcome in this series.