ARCH SOC ESP OFTALMOL. 2011;86(3):85–88 ARCHIVOS DE LA SOCIEDAD ESPAÑOLA DE OFTALMOLOGÍA
ARCHIVOS DE LA SOCIEDAD ESPAÑOLA DE OFTALMOLOGÍA
Contenido Editorial La retina como marcador biológico de daño neuronal Artículos originales Comparación de tres instrumentos de tomografía de coherencia óptica, un time-domain y dos Fourierdomain, en la estimación del grosor de la capa de fibras nerviosas de la retina Idoneidad de tratamiento en sospechosos de glaucoma. Estudio de concordancia con el grupo de estudio RAND Atrofia de la capa de fibras nerviosas de la retina en pacientes con esclerosis múltiple. Estudio prospectivo con dos años de seguimiento Comunicaciones cortas Hipercorrección secundaria a transposición muscular aumentada Crítica de libros, medios audiovisuales y páginas web oftalmológicos Clinical Neuro-Ophthalmology: The Essentials Sección histórica Del mal de la rosa y la queratoconjuntivitis pelagrosa Sección iconográfica El estrabismo de Rembrandt Sociedades y Reuniones Científicas Ofertas de trabajo
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Diagnosis of systemic disease after bilateral retinal arterial macroaneurysm J. Mateo,* L. Lavilla, A.J. Mateo, J.A. Cristóbal, C. Recio Hospital Clínico Universitario Lozano Blesa, Servicio de Oftalmología, Zaragoza, Spain
A RT I C L E I N F O R M AT I O N
A B S T R A C T
Case report: An 85 year old male suffered vision loss in both eyes due to ruptured bilateral
Received on July 22, 2010
retinal arterial macroaneurysms.
Accepted on Dec. 22, 2010
Discussion: We report this unusual case and show the importance of studying these types of patients in order to detect associated systemic diseases.
© 2010 Sociedad Española de Oftalmología. Published by Elsevier España, S.L. All rights reserved.
Aneurysm Rertinal artery Retinal haemorrhage Photocoagulation Angiography
Diagnóstico de patología sistémica tras macroaneurisma arterial retiniano bilateral R E S U M E N
Caso clínico: Un varón de 85 años sufrió pérdida de visión en ambos ojos debido a la rotura
de macroaneurismas arteriales retinianos bilaterales.
Discusión: Se comenta este caso inusual y hablamos de la importancia de estudiar a estos
pacientes para detectar enfermedades sistémicas asociadas.
© 2010 Sociedad Española de Oftalmología. Publicado por Elsevier España, S.L.
Introduction Retinal arterial macroaneurysms are arteriole dilatations, typically in the first divisions of the retinal arterial tree, unilateral and unique. They affect more women than
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men and are rare in patients under 60 years of age. These macroaneurysms are usually associated to high arterial pressure (HAP), ischemic cardiopathy, cerebrovascular accidents (CVA), arteriosclerosis or hyperlipidemia.1-3 In addition, in the literature we have found descriptions of
*Corresponding author. E-mail: [email protected]
(J. Mateo). 0365-6691/$ - see front matter © 2010 Sociedad Española de Oftalmología. Published by Elsevier España, S.L. All rights reserved.
ARCH SOC ESP OFTALMOL. 2011;86(3):85–88
Figure 1 – Left eye premacular fibrin, retained by the posterior hyaloid. OCT section 0-180°.
associations to other diseases such as neurofibromatosis type 1 or sarcoidosis.4 Macroaneurysms do not give symptoms or decompensation and therefore their diagnosis is frequently accidental. Decompensations can be acute, with hemorrhage due to rupture of the aneurysm wall, as well as chronic due to filtration of plasmatic material involving the formation of hard exudates.1,2 The treatment will depend on the risk of visual loss. The macroaneurysms which do not give symptoms are usually left untreated, whereas the ones that do can be subjected to laser photocoagulation.2 When an extended hemorrhage conceals the macroaneurysms, indocyanine green angiography (ICG) is useful for preparing the differential diagnostic with other causes of macular hemorrhage.2
Clinical case An 85-year-old patient referred due to sudden visual acuity loss in the left eye (LE). The patient was not taking medication
and did not have general or ophthalmological pathology history. Upon exploration, the patient VA was of hand movement in LE. The ocular fundus revealed a probable retinal macroaneurysm in the upper temporal limit. It was studied with optic coherence tomography (OCT), which showed a pre-retinal mass of uniform density retained by the posterior hyaloid corresponding to a fibrin accumulation (fig. 1). After discussing with the patient the possibility of performing vitrectomy to evacuate the premacular fibrin, an expectant attitude was adopted. The patient’s evolution was positive with VA recovery in the LE, which improved to 4/10 after 3 months. When the fibrin cleared up, a macroaneurysm was observed in the upper temporal arch. AGF was performed with a new OCT which revealed a recovery of the foveal morphology with the detachment of the posterior hyaloid (fig. 2). When it was verified that the aneurysm was permeable, it was decided to perform photocoagulation around it. The right eye exploration did not reveal alterations.
Figure 2 – Evolution of the LE. Appearance of the LE macula and the arterial macroaneurysm after the reabsorption of the fibrin, with retinographies, AGF and OCT. Posterior hyaloid detachment in the macula area can be seen. OCT section 0-180°.
ARCH SOC ESP OFTALMOL. 2011;86(3):85–88
Figure 3 – LE posterior pole appearance after laser photocoagulation around the macroaneurysm. At this time, the RE posterior pole was normal.
The photocoagulation caused the thrombosis of the aneurysm. The VA of the LE remained at 4/10 (fig. 3). One year later, the patient returned to the practice, this time with acute loss of vision in the RE. He exhibited a VA of hand movement and 4/10 in the LE. The the ocular fundus revealed a pre-retinal hemorrhage in the right eye.. An expectant attitude was again maintained, after which the VA recovered and improved up to 4/10 in 3 months. AGF was performed, evidencing a macroaneurysm in the lower temporal arch of the RE, and and OCT revealed a posterior hyaloid detachment in the macula (fig. 4). Photocoagulation was performed around the aneurysm, which thrombosed. At present the patient exhibits a VA of 4/10 in BE, with dense corticonuclear cataracts which will be operated in the near future. In addition, a vascular risk assessment was made which revealed HAP and auricular fibrilation, at present being controlled with medical treatment.
Discussion This paper presents an unusual case of bilateral retinal arterial macroaneurysm in a male patient. These
macroaneurysms are acquired lesions of the first retinal arteriole branches, generally unilateral and unique and occurring more frequently in women.1 Said aneurysms usually evolve positively, with frequent spontaneous thrombosis in a few months, although they can cause loss of vision with pre-, intra-or sub retinal hemorrhage. The pre-and intra-retinal hemorrhages usually reabsorb without sequels, but subretinal hemorrhages can cause neurosensory retina degeneration. Accordingly, various authors have proposed treatments such as evacuating vitrectomy, rupture of the posterior hyaloid with YAG laser, rtPA injections or displacement of the hemorrhage with air or gas.5 If the hemorrhage conceals the macroaneurysm, the differential diagnostic includes a choroidal neovascular membrane, traumatic or Valsalva retinopathy or choroidal melanoma. In these cases, ICG is useful as it detects macroaneurysms concealed in AGF due to the screen effect of the blood.3 Our patients exhibited a lesion which was highly suggestive of macroaneurysm at the edge of the premacular fibrin in LE. For this reason ICG was not formed. In the RE, and even though the blood concealed the aneurysm, ICG was not performed due to the history of the LE. Usually, macroaneurysms are treated only if they have become decompensated and/or exhibit a high risk of vision
Figure 4 – RE retinographies, AGF and OCT. bleeding due to retinal arterial macroaneurysm in the inferior temporal arch. Posterior hyaloid detachment over the macula. OCT section OCT 0-180°.
ARCH SOC ESP OFTALMOL. 2011;86(3):85–88
loss. The usually applied treatment is laser photocoagulation.2 In our case, both macroaneurysms exhibited bleeding which caused acute vision loss. Accordingly, once they became visible, AGF was performed to verify their patency for subsequent laser photocoagulation. The evolution was good with thrombosis of the macroaneurysms and improvement of visual acuity in both eyes. Due to the association of arterial macroaneurysms with HAP, ischemic cardiopathy, CVA or arteriosclerosis with high mortality rates within the 5 years of diagnostic, it is advisable to study the vascular risk factors of these.1 Our patient was not being treated for any disease but, when assessed by Internal Medicine, was diagnosed with HAP and auricular fibrillation, and accordingly was placed under medical treatment.
Conflict of interest None of the authors have declared any conflict of interest.
R e f e r e n c e s
1. Panton RW, Goldberg MF, Farber MD. Retinal arterial macroaneurysms: risk factors and natural history. Br J Ophthalmol. 1990;74:595-600. 2. García Campos J, Morillo Sánchez MJ. Macroaneurisma arterial retiniano. In: Piñero A, editor. La retina caso a caso. Barcelona: Glosa; 2007. p. 71-8. 3. Theodossiadis PG, Emfietzoglou I, Sfikakis PP, Panagiotidis D, Grigoropoulos VG, Theodossiadis GP. Simultaneous bilateral visual loss caused by rupture of retinal arterial macroaneurysms in a hypertensive patient. Acta Ophthalmol Scand. 2005;83:120-2. 4. Koyama Y, Shibuya Y, Ohira A. Bilateral retinal macroaneurysms with neurofibromatosis type 1. Acta Ophtalmol Scand. 2003;81:200-1. 5. Hillenkamp J, Surguch V, Framme C, Gabel VP, Sachs HG. Management of submacular hemorrhage with intravitreal versus subretinal injection of recombinant tissue plasminogen activator. Graefes Arch Clin Ophthalmol. 2010;248:5-11.