To treat or not to treat: a clinical series of retinal arterial macroaneurysms

Abstract

Retinal arterial macroaneurysms (RAMs) develop as outpouchings of the arterial wall that is weakened by arteriosclerosis. The traditional treatment of RAMs comprises observation, focal laser photocoagulation, or surgery. Recently, intravitreal injection of anti-vascular endothelial growth factor (VEGF) drugs has been announced as an effective therapy for fovea-threatening RAMs and quickly improve visual acuity and central retinal thickness (CRT). In the retrospective series, medical charts and ocular images of 24 patients diagnosed as having RAM between May 2011 and November 2018 in our facility were reviewed to delineate clinical manifestations and visual prognosis in RAM patients receiving different treatment modalities. Twenty-four patients (25 eyes; 11 men and 13 women) were enrolled, and one eye with comorbidity of branch retinal vein occlusion was excluded. The mean age of the patients was 69.00 ± 13.45 years. Fourteen patients (58.33%) had a history of hypertension, and 17 patients (70.83%) were aged > 60 years. Furthermore, patients with fovea-threatening RAMs presented with either hypertension or were aged > 60 years. Eyes with fovea involvement (n = 18) were analyzed and separated into two groups according to their treatment modalities: those receiving anti-VEGF intravitreal injections (n = 13) and observation only (n = 5). The baseline visual acuity revealed no significant difference in the two groups. In patients receiving anti-VEGF intravitreal injections, a significantly better visual acuity was detected after anti-VEGF intravitreal injections than the baseline visual acuity (logMAR, 0.78 ± 0.51 vs 1.52 ± 0.48, P < .001), and CRT significantly improved (505.50 ± 159.26 μm vs 243.60 ± 60.17 μm, P = .001). Patients receiving anti-VEGF intravitreal injections also revealed better final visual acuity than those in the observation group (logMAR, 0.78 ± 0.51 vs 1.34 ± 0.48, P = .04). A systematic work-up for hypertension and arteriosclerotic disease could be considered the recommended procedure once RAM has been diagnosed. With better final visual acuity, significant visual improvements, and fast reduction of CRT observed in patients with fovea-threatening RAMs receiving anti-VEGF intravitreal injections, intravitreal anti-VEGF was considered an effective therapy for complicated RAM. During the follow-up period, the majority of RAM eyes had good maintenance of visual function even with foveal complications.

Influence of bevacizumab therapy and intraretinal hemorrhage in long-term outcomes of hemorrhagic retinal arterial macroaneurysm

“…In RAM, hemorrhage can develop at various locations—preretinal, intraretinal, or subretinal locations 5 . The visual outcomes are generally comparable between RAM with and without hemorrhage 10 . In most patients, visual acuity improves as the hemorrhage resolves 5 .…”

“…Hemorrhage is a frequent presentation of RAM which can lead to a sudden loss of vision 5 – 10 . In RAM, hemorrhage can develop at various locations—preretinal, intraretinal, or subretinal locations 5 .…”

“…To date, numerous studies have reported the clinical course and visual outcomes of hemorrhagic RAM 5 – 10 , 13 , 14 . However, the sample size in these studies was relatively small.…”

Multiple ophthalmic sequelae of arterial hypertension

“…4 5 Success of RAM thrombosis following laser photocoagulation may be limited (~27%) and may result in aneurysm rupture or downstream ischaemia 5 while anti-VEGF therapy provides superior visual outcomes to observation. 6 Management of SRH depends on location, duration and patient factors (eg, suitability for surgery). Observation of RAM-associated SRH is reasonable, particularly with inferior fovea-sparing lesions (VA ≥6/12 in 37%).…”

“…Ophthalmic treatment modalities include focal laser techniques and/or intravitreal anti-VEGF 4 5. Success of RAM thrombosis following laser photocoagulation may be limited (~27%) and may result in aneurysm rupture or downstream ischaemia5 while anti-VEGF therapy provides superior visual outcomes to observation 6. Management of SRH depends on location, duration and patient factors (eg, suitability for surgery).…”