Ophthalmic Surgery, Lasers and Imaging Retina

The articles prior to January 2012 are part of the back file collection and are not available with a current paid subscription. To access the article, you may purchase it or purchase the complete back file collection here

Imaging 

Optical Coherence Tomography Imaging of Macular Hemorrhage Caused by Retinal Arterial Macroaneurysm

Arghavan Almony, MD; Mandeep Singh Dhalla, MD; Gaurav K. Shah, MD

Abstract

The authors report optical coherence tomography (OCT) findings of a hypertensive woman with retinal arterial macroaneurysm who noted sudden decreased vision in the left eye. Fluorescein angiography and OCT confirmed a diagnosis of retinal arterial macroaneurysm with macular hemorrhage, delineating the sub-internal limiting membrane and subretinal location of the hemorrhage. She subsequently underwent surgical displacement of the hemorrhage. OCT may be a useful imaging tool for evaluation and guidance of treatment in a hemorrhage involving the macula in retinal arterial macroaneurysm, diabetic retinopathy, and Terson’s syndrome.

Abstract

The authors report optical coherence tomography (OCT) findings of a hypertensive woman with retinal arterial macroaneurysm who noted sudden decreased vision in the left eye. Fluorescein angiography and OCT confirmed a diagnosis of retinal arterial macroaneurysm with macular hemorrhage, delineating the sub-internal limiting membrane and subretinal location of the hemorrhage. She subsequently underwent surgical displacement of the hemorrhage. OCT may be a useful imaging tool for evaluation and guidance of treatment in a hemorrhage involving the macula in retinal arterial macroaneurysm, diabetic retinopathy, and Terson’s syndrome.

Optical Coherence Tomography Imaging of Macular Hemorrhage Caused by Retinal Arterial Macroaneurysm

From the Barnes Retina Institute and the Department of Ophthalmology and Visual Sciences (AA, GKS), Washington University School of Medicine, St. Louis, Missouri; and the Retina Group of Florida (MSD), Ft. Lauderdale, Florida.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Gaurav K. Shah, MD, Barnes Retina Institute, 1600 S. Brentwood Blvd., Suite 800, St. Louis, MO 63144.

Received: February 19, 2009
Accepted: February 19, 2010
Posted Online: June 03, 2010

Introduction

In 1973, Robertson introduced the term “macroaneurysm” to describe saccular or fusiform retinal arterial lesions on the first three orders of the arterial tree usually found at arterial bifurcations.1,2 Retinal arterial macroaneurysms are typically seen in women in their sixth to eighth decade of life.3 Although most cases are unilateral, 10% of patients may have bilateral retinal arterial macroaneurysm.4 Systemic hypertension (found in approximately 75% of patients), arteriosclerosis, and hyperlipidemia are considered to be the main risk factors.4,5 Retinal arterial macroaneurysm may present with vitreous, sub-internal limiting membrane, intraretinal, and subretinal hemorrhage. We describe a patient with retinal arterial macroaneurysm in whom optical coherence tomography (OCT) was helpful in guiding surgical management of a macular hemorrhage. To our knowledge, there have been no prior reports of OCT findings in retinal arterial macroaneurysm.

Case Report

An 87-year-old woman with chronic systemic hypertension noted sudden painless decreased vision in the left eye and was referred for ophthalmic evaluation. At presentation, the patient had a systemic blood pressure of 176/90. Best-corrected visual acuity was 20/30 in the right eye and 6/200 in the left eye with no afferent pupillary defect. The patient was bilaterally pseudophakic and the anterior segment examination was unremarkable. Dilated fundus examination of the left eye revealed dense submacular hemorrhage. Fluorescein angiogram demonstrated early hyperfluorescence in a second-order branch of the inferotemporal artery and blocked fluorescence associated with sub-internal limiting membrane and subretinal hemorrhage (Fig. 1). OCT, performed to further characterize the layers in which the hemorrhage had occurred, showed involvement of the sub-internal limiting membrane layer (Fig. 2). Consequently, the patient underwent pars plana vitrectomy, internal limiting membrane peel for evacuation of sub-internal limiting membrane blood, sub-retinal tissue plasminogen activator injection, and air–fluid exchange to displace the subretinal hemorrhage inferiorly. Seven months after surgery, best-corrected visual acuity improved to 20/80 in the affected eye.

Fluorescein Angiogram of the Left Fundus Revealed Signs of Chronic Hypertension with Vascular Tortuosity and a Saccular Arterial Aneurysm Associated with Subretinal and Sub-Internal Limiting Membrane Hemorrhage.

Figure 1. Fluorescein Angiogram of the Left Fundus Revealed Signs of Chronic Hypertension with Vascular Tortuosity and a Saccular Arterial Aneurysm Associated with Subretinal and Sub-Internal Limiting Membrane Hemorrhage.

Optical Coherence Tomography of the Left Macula Clarified the Location of Hemorrhage Associated with the Retinal Arterial Macroaneurysm as Being Sub-Internal Limiting Membrane (arrow) and Subretinal in Location.

Figure 2. Optical Coherence Tomography of the Left Macula Clarified the Location of Hemorrhage Associated with the Retinal Arterial Macroaneurysm as Being Sub-Internal Limiting Membrane (arrow) and Subretinal in Location.

Discussion

In patients with retinal arterial macroaneurysm, spontaneous rupture of the macroaneurysm may lead to submacular hemorrhage involving the center of the fovea and subsequent poor visual outcome. Surgery with tissue plasminogen activator-assisted thrombolysis and displacement of the subretinal hemorrhage has been shown to improve best-corrected visual acuity.5 OCT may be particularly useful in determining cases that may benefit from surgical management. Pars plana vitrectomy may be indicated in patients where OCT highlights the location of the hemorrhage as being sub-internal limiting membrane. Although observation is always an option, hemorrhage in this location may not resolve spontaneously and may lead to permanent visual loss without appropriate management.

Our patient demonstrated subretinal hemorrhage, but also an area of hemorrhage that could have been interpreted as subhyaloid or sub-internal limiting membrane. However, OCT established the sub-internal limiting membrane location and led to a decision for surgical removal of the internal limiting membrane in addition to the pneumatic displacement. The location of the hemorrhage was confirmed intraoperatively as the hemorrhage was evacuated during internal limiting membrane peeling. Long-term follow-up and a larger study population in future studies will determine whether surgical intervention is indicated in cases of sub-internal limiting membrane hemorrhage for improved visual outcomes. OCT may be a useful diagnostic tool in evaluation and surgical planning in macular hemorrhage secondary to retinal arterial macroaneurysm, diabetic retinopathy, or Terson’s syndrome.

References

  1. Robertson DM. Macroaneurysms of the retinal arteries. Trans Am Acad Ophthalmol Otolaryngol. 1973;77:OP55–67.
  2. Abdel-Khalek MN, Richardson J. Retinal macroaneurysm: natural history and guidelines for treatment. Br J Ophthalmol. 1986;70:2–11. doi:10.1136/bjo.70.1.2 [CrossRef]
  3. Lewis RA, Norton EW, Gass JD. Acquired arterial macroaneurysms of the retina. Br J Ophthalmol. 1976;60:21–30. doi:10.1136/bjo.60.1.21 [CrossRef]
  4. Sekuri C, Kayikcioglu M, Kayikcioglu O. Retinal artery macroaneurysm as initial presentation of hypertension. Int J Cardiol. 2004;93:87–88. doi:10.1016/S0167-5273(03)00128-1 [CrossRef]
  5. Humayun M, Lewis H, Flynn HW Jr, Sternberg P Jr, Blumenkranz MS. Management of submacular hemorrhage associated with retinal arterial macroaneurysms. Am J Ophthalmol. 1998;126:358–361. doi:10.1016/S0002-9394(98)00090-7 [CrossRef]
Authors

From the Barnes Retina Institute and the Department of Ophthalmology and Visual Sciences (AA, GKS), Washington University School of Medicine, St. Louis, Missouri; and the Retina Group of Florida (MSD), Ft. Lauderdale, Florida.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Gaurav K. Shah, MD, Barnes Retina Institute, 1600 S. Brentwood Blvd., Suite 800, St. Louis, MO 63144.

10.3928/15428877-20100525-08

Sign up to receive

Journal E-contents