Author: Sofien Affes (Tunisia)
Co-authors: Saloua Ben Amor, Imen Kaibi, Mohamed Jeribi, Salma Gargouri, Amira Trigui
Purpose
To describe a case of spontaneous premacularsubhyaloidhemorrhage revealing a ruptured retinal arterial macroaneurysm(RAM) discovered during surgery and treated with Pars Plana Vitrectomy (PPV) and endolaser photocoagulation.
Setting/Venue
Department of ophthalmology, HabibBourguiba university hospital, Faculty of medicine, University of Sfax, Tunisia
Methods
A 67-year-old monophtalm male, with medical history of systemic hypertension, dyslipidemia and coronary artery disease, presented with acute loss of vision in the right eye.Complete ophthalmologic examination, fluorescein angiography and optical coherence tomography (OCT) were performed.
Results
Ocular examination revealed a corrected visual acuity of counting fingers at 50 cm and a grade 3 nuclear cataract. The funduscopy showed an intra retinal and premacularsubhyaloid hemorrhage. Subsequent fluorescein angiography revealed complete blockage of fluorescein in the macular region and we identified a thick pre-macular hyper-reflectivity through OCT. We evokeda ruptured RAM, valsalva retinopathy and age-related macular degeneration. The decision was to undergo surgery since the patient was monophtalm. We performed a combined phacoemulsification-PPV. The diagnosis of MAR was made during the surgery. It was treated with endolaser photocoagulation. Afterward, the postoperative visual acuity improved to 2/10.
Conlusions
RAM are acquired focal dilations of the retinal arterioles that occur within the first three orders of arteriolar bifurcation. They are commonly found in the temporal retina. The supratemporal artery is usually the most affected. The majority of MAR cases are asymptomatic. However, vision loss can occur from macular edema or hemorrhage due to ruptured macroaneurysm. Diagnosis is made on fundus examination and fluorescein angiography but, if the hemorrhage blocks visualization, they may be inconclusive as is the condition of our patient. In such cases, ICG angiography can be useful. OCT can also be helpful when edema or hemorrhage affects the macula. Currently, there is no approved guidelines for the treatment of RAM. Asymptomatic RAM without edema or hemorrhage can be observed but, in case of complicated RAM with hemorrhage involving the macula, an early treatment should be considered. For premacular hemorrhage, some therapeutic measures can be considered such as neodymium yttrium aluminum garnet (Nd:YAG), lasermembranotomy, PPV or intravitreal injections of anti-vascular endothelial growth factor (VEGF). For our patient, PPV was done to achieve rapid visual recovery.
Financial Disclosure
no financial relations
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