Multimodal imaging and clinical evolution in a case of atypical retinal arterial macroaneurysm.
Author: Berta Sánchez Fernández (Spain)
Co-authors: Isabel María Baquero Aranda, Jose Diaz Bernal
To describe a single case of an atypical retinal arterial macroaneurysm using multimodal imaging including fundus fluorescein angiography (FFA), swept-source OCT (OCT), swept-source OCT angiography (OCT-A), fundus autofluorescence (FAF) and indocyanine green angiography (ICGA) and to report its clinical evolution.
Ophthalmology department. Hospital Universitario Virgen de la Victoria, Málaga.
Case report. A 28-year-old Caucasian male with no previous medical history presented to our hospital complaining of a small superior scotoma in his right eye with acute onset. No other symptoms were referred. On examination, best corrected visual acuity was 20/20 in both eyes. Fundus examination revealed a large and round subretinal haemorrhage with a smaller intraretinal haemorrhage associated, both along the inferotemporal arterial vascular arcade, not involving the macula. The left fundus was normal. Slit-lamp anterior chamber examination and intraocular pressures were normal. Horizontal sectional images obtained with OCT showed a well circumscribed areas of intraretinal and subretinal haemorrhages. It also showed a round cavity with a hyperreflective wall and a dark lumen adjacent to a small intraretinal break on the external boundary of the retina, which corresponded with the ruptured retinal macroaneurysm. External layers appeared to connect with the subretinal space. One week later, FFA of the right eye revealed a small light-bulb hyperfluorescent structure with leakage within the area blocked by the haemorrhages and emanating from an artery confirming the diagnosis. OCT-A also showed high blood flow in different retinal layers where the macroaneurysm was located.
A comprehensive ophthalmological and general evaluation making differential diagnosis with several pathologies, revealed he just had history of cigarette smoking and elevated erythrocyte sedimentation rate. Observation with closely monitoring was decided, as there was no macular involvement. Fibrin formation and minimal retinal pigment epithelium changes occurred when haemorrhages began to disappear around one month after symptoms onset progressively. Small aggregates formed clusters in external retinal layers as a result of haemorrhages reabsorption, seen as hypoautofluorescent foci in FAF. These aggregates showed hypofluorescence rounded by hyperfluorescence areas with dark spots in FFA. Complete multimodal imaging was performed during two years of follow up, including OCT-A, FFA and ICGA. All of them demonstrated spontaneous involution of macroaneurysm after approximately four months. The inferotemporal area of the affected retina presented a significant thinning with atrophic changes in external layers during evolution, but final best-corrected visual acuity was 20/20 with a little peripheral residual scotoma.
Multimodal imaging was found useful to approach the diagnosis of ruptured retinal arterial macroaneurysm in a young patient with no diseases or risk factors associated. Our findings could effectively demonstrate the structural characteristics of this pathology and its anatomical evolution during follow up examinations.
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