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» Case Study - October 2002

History

49 y.o. African American male presents complaining of decreased vision in the right eye for the past few weeks. No complaints about the left eye.

Medical history

Poorly controlled hypertension

Examination

Vision: OD: 20/60 OS: 20/20
Pupils: Normal OU
Motility: Full OU
Intraocular pressures: Normal OU
Slit lamp examination: Normal anterior segments OU
Fundus Examination:

OD: Figure 1, 2 and 3
OS: Figure 4


Figure 1: Color photograph of the right fundus showing a round yellowish lesion stemming off an arterial. Note the surrounding subretinal hemorrhage and the yellow ring of exudates. (click picture for enlarged view)		Figure 2: A supero-temporal shot of the right fundus. Note the area of pigmented fibrosis at 1 o'clock position and the microvascular changes. The pigmented area likely represents an old fibrosed macroaneurysm. (click picture for enlarged view)


Figure 3: composite of the retina, OD (click picture for enlarged view)		Figure 4: Color fundus photo of the normal left eye. (click picture for enlarged view)

Ancillary tests

Fluorescein Angiogram:

OD: Figure 5 A and B
OS: Figure 6


Figure 5: Fluorescein angiogram shows early hyperfluorescence of the lesion seen in the center of the exudative ring. Note that the lesion comes off an arterial branch (click pictures for enlarged views)


Figure 6: Normal fluorescein angiogram OS (click picture for enlarged view)

Diagnosis

Arterial Macroaneurysm

Retinal arterial macroaneurysms are defined as saccular dilatation of retinal arteries occurring usually within 3 order of bifurcation. They are most commonly encountered along the superotemporal and inferotemporal arcades. Systemic hypertension is recognized as a predisposing factor. Clinical presentations vary widely from asymptomatic incidental finding to severe loss of vision due to a dense vitreous hemorrhage. Macular edema with exudates can affect visual acuity if they involve the macula as in our patient. Macroaneurysms can cause pre-retinal retinal or sub-retinal hemorrhage. Approximately 10% of macroaneurysms can be pulsatile on initial presentation but this is not a definite sign of impending rupture. On fluorescein angiogram, the aneurysm typically shows very early uniform filling with leakage seem commonly later in the test. Microvascular abnormalities surrounding the area of the macroaneurysm is common. The natural history for macroaneurysms is spontaneous resolution. Selected patients may be treated with laser photocoagulation but visual prognosis is dependant of the location and presentation. Most authorities agree that a quiet asymptomatic aneurysm that is not threatening the macula should not be treated.

Follow up

Our patient was treated with laser photocoagulation. Figure 7 shows the fundus one day after treatment and figure 8 is for the same aye 4 months after treatment. Visual acuity returned to 20/20 OD.



Figure 7: one day after laser treatment (click picture for enlarged view)		Figure 8: Four months after treatment (click picture for enlarged view)

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