The natural history of Leber’s miliary aneurysms is described. A patient with Leber’s miliary aneurysm presented with count fingers visual acuity due to significant lipid exudates, intraretinal hemorrhages, and macular edema. Over the next 3 months, the macular edema resolved spontaneously and the visual acuity improved to 20/20. The dramatic improvement in both macular edema and visual acuity highlights the importance of conservative management before pursuing more invasive treatments.
[Ophthalmic Surg Lasers Imaging Retina. 2013;44:E15–E16.]
From Northern California Retina Vitreous Associates, Mountain View, California; and the Department of Ophthalmology, University of California, San Francisco, California.
The author has no financial or proprietary interest in the materials presented herein.
Address correspondence to Rahul N. Khurana, MD, Northern California Retina Vitreous Associates, 2485 Hospital Drive, Suite 200, Mountain View, CA 94040; 650-988-7480; fax: 650-988-7482; email:
Received: March 24, 2013
Accepted: July 17, 2013
Posted Online: October 18, 2013
Leber’s miliary aneurysms are part of the spectrum of primary retinal telangiectasia including Coats’ disease.1 Some of these aneurysmal telangiectasias have recently been reclassified as idiopathic macular telangiectasia, type 1.2 Leber’s miliary aneurysms involve multiple dilatations of major retinal vessels with intraretinal and subretinal exudation. We describe the natural history in Leber’s miliary aneurysms with a dramatic resolution of macular edema.
A 54-year old Vietnamese man with no medical history presented with a 2-week history of decreased vision in his left eye. His visual acuity was 20/20 in the right eye and count fingers at 3 feet in the left eye. Fundus examination of the right eye was unremarkable. Fundus examination of the left eye revealed multiple aneurysms along the superotemporal arcade surrounded by intraretinal hemorrhages and lipid exudates (Figure 1, page E16). Temporally, there was subretinal fibrosis surrounded by pigmented chorioretinal atrophy. In the macula, there was edema. Fluorescein angiography demonstrated vascular dilatations and staining of the fibrous tissue (Figure 2, page E16). Optical coherence tomography revealed significant macular edema.
Fundus photography shows multiple retinal telangiectasias (arrows) along the superotemporal arcade surrounded by intraretinal hemorrhages and lipid exudates. There is macular edema involving the fovea. Temporally, there is subretinal fibrosis (asterisk) surrounded by pigmented chorioretinal atrophy.
Fluorescein angiography demonstrates vascular dilatations along the superotemporal arcade and staining of the fibrous tissue temporally. There is an area of window defect surrounding the fibrous tissue.
Two weeks later, the patient returned for a planned laser photocoagulation. His visual acuity had spontaneously improved to 20/60, and there was less macular edema. Treatment was deferred and observation elected. The visual acuity continued to improve to 20/20, with resolution of the macular edema 3 months later (Figure 3, page E16). Follow-up through 28 months after initial evaluation revealed no recurrence of fluid and stable vision.
Fundus photography three months after initial presentation shows resolution of the macular edema with the presence of lipid exudates. There is a decrease in the intraretinal hemorrhages surrounding the multiple aneurysms.
The significant lipid exudation, multiple aneurysmal dilations, telangiectatic vessels, and macular edema illustrate the active aspects of Leber’s miliary aneurysm. The subretinal fibrosis and surrounding chorioretinal atrophy are likely due to spontaneously regressed lesions or chronicity of prior subretinal fluid.
If there are exudates or edema involving the macula, ablation of the aneurysms by laser photocoagulation may be considered. Intravitreal therapies involving anti-VEGF agents and steroids are effective for macular edema in vascular occlusive disease.3,4 However, the natural history of Leber’s miliary aneurysms can involve spontaneous resolution of submacular exudation as illustrated in this patient.1 The dramatic improvement in both macular edema and visual acuity highlights the importance of conservative management before pursuing more invasive treatments.
- Gass JDM. Stereoscopic Atlas of Macular Diseases: Diagnosis and Treatment. 4th ed. Maryland Heights, MO: Mosby; 1997:494–498.
- Yannuzzi LA, Bardal AM, Freund KB, Chen KJ, Eandi CM, Blodi B. Idiopathic macular telangiectasia. Arch Ophthalmol. 2006;124(4):450–460. doi:10.1001/archopht.124.4.450 [CrossRef]
- Brown DM, Campochiaro PA, Singh RP, et al. Ranibizumab for macular edema following central retinal vein occlusion: six-month primary end point results of a phase III study. Ophthalmology. 2010;117(6):1124–1133. doi:10.1016/j.ophtha.2010.02.022 [CrossRef]
- Ip MS, Scott IU, VanVeldhuisen PC, et al. A randomized trial comparing the efficacy and safety of intravitreal triamcinolone with observation to treat vision loss associated with macular edema secondary to central retinal vein occlusion: the Standard Care vs Corticosteroid for Retinal Vein Occlusion (SCORE) study report 5. Arch Ophthalmol. 2009;127(9):1101–1114. doi:10.1001/archophthalmol.2009.234 [CrossRef]