CaseWise 21

Intravitreal bevacizumab for retinal artery macroaneurysm

Introduction
Retinal artery macroaneurysm (RAM) is an acquired retinal vascular abnormality, typically a solitary, round or fusiform aneurysm arising in one of the 4 major retinal arteries at the posterior pole of the eye. It is commonly seen in elderly hypertensive females. It may be detected incidentally in a routine ophthalmic examination of an asymptomatic patient or may present with sudden or gradual loss of vision due to macular edema, lipid exudation and pre retinal, retinal and subretinal hemorrhage in the macular area1
Case report
A female, of age 67 years, reported to us with the chief complaints of diminution of vision in right eye since 3 months. She had undergone cataract extraction with intraocular lens implant 12 years back in both eyes. She was a known hypertensive and was on antihypertensive medication. Her blood pressure was 170/90mmHg at the time of presentation.  She had a Best Corrected Visual Acuity (BCVA) of 6/36 in right eye and 6/6p in left eye. Anterior segment examination showed pseudophakia in both eyes. Intraocular pressure was 15mmHg in right eye and 17mmHg in left eye. Fundus examination of right eye showed a boat shaped premacular hemorrhage with a reddish mass 2/3rd disc diameter size along the supero-temporal retinal arteriole, one disc diameter away from the fovea (Fig .1). It was also associated with intraretinal haemorrhage at macula, with the presence of hard exudates temporally. Left eye fundus examination was within normal limits. On Fundus Fluorescein Angiogram(FFA) there was a blocked fluorescence along the area of hemorrhages and cattle truck phenomenon beyond the area of the suspected lesion which was pointing towards the diagnosis of retinal artery macroaneurysm (Fig .1).  She was given an intravitreal bevacizumab injection following which there was significant absorption of haemorrhage. She received two more doses of intravitreal bevacizumab at an interval of 1 month in right eye. The patient recovered to 6/9, 4 months following the injections (Fig.3) with almost complete absorption of haemorrhage.

Fig.1: (To the left)   Fundus photograph of right eye showing retinal artery macroaneurysm and boat shaped pre retinal haemorrhage, intra and subretinal bleed and exudates; (To the right)  Fluorescein angiogram of right eye showing blocked fluorescence(yellow arrow) due to haemorrhage
Fig .2: Fundus photograph of right eye showing resolving pre retinal haemorrhage (green arrow) and exudates (black arrow), 1 month following first dose of intravitreal bevacizumab 
Fig.3: (To the left)   Fundus photograph of right eye showing gradual resolution of pre retinal haemorrhage(green arrow) and exudates(black arrow) and fibrosis of RAM(blue arrow); (To the right)  Fluorescein angiogram of right eye showed  reduction in blocked fluorescence(yellow arrow) at second and fourth month follow up.
Fig.4: Fundus photograph of right eye at her last follow up, showing complete resolution of haemorrhage and exudates and fibrosed RAM (blue arrow)

Discussion
RAM are commonly seen in elderly hypertensive females as in this case. Spontaneous resolution of aneurysm with varying degrees of functional recovery is  known to occur.2   Long-term persistence of exudates or hemorrhages leads to a progressive photoreceptor damage with functional impairment.3 Early treatment may be desirable in attempting to avoid irreversible anatomic and visual damage.3 Laser photocoagulation is commonly recommended for management of RAM.4 Doing laser in the presence of hemorrhage in our case was difficult and could have led to damage to retinal layers at the macula. Intra vitreal bevacizumab was given with the rationale that its anti VEGF action would be effective in a case of macroaneurysm1. Our experience is similar to other case reports showing benefit of intravitreal anti VEGF in cases of ruptured RAM with macular edema. Intravitreal bevacizumab injection likely hastens resolution of macular edema and hemorrhage secondary to retinal arterial macroaneurysm.1 Intravitreal bevacizumab injection could be an effective treatment option for symptomatic retinal arterial macroaneurysm.1

References
1. Cho et al. Intravitreal Bevacizumab for Symptomatic Retinal Arterial Macroaneurysm  Am J Ophthalmol 2013;155: 898–904.doi: 10.1016/j.ajo.2012.12.003

2. Tonotsuka T, Mai M, Saito K, Iijima H. Visual prognosis for symptomatic retinal arterial macroaneurysm. Jpn J Ophthalmol 2003; 47(5):498–502.doi:10.1016/s0021-5155(03)00104-7

3. Tsujikawa A, Sakamoto A, Ota M, et al. Retinal structural changes associated with retinal arterial macroaneurysm examined with optical coherence tomography. Retina 2009; 29(6):782–792.doi: 10.1097/IAE.0b013e3181a2f26a

4. Goldhagen et al.Retinal Arterial Macroaneurysms and their management, Curr Ophthalmol Rep. 2019 June doi: 10.1007/s40135-019-00202-3

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