Chapter 123 – Retinal Arterial Macroaneurysms
JANICE E. CONTRERAS
ROBERT A. MITTRA
WILLIAM F. MIELER
JOHN S. POLLACK
• Localized fusiform or saccular dilation of a retinal arterial vessel within the first three orders of bifurcation.
• Retinal hemorrhage (intraretinal, subretinal, preretinal, and vitreous).
• Protein and lipid exudation.
• Macular edema.
• Leaking, telangiectatic vessels in the capillary bed that surrounds the macroaneurysm.
• Retinal artery occlusion.
• Retinal vein occlusion.
Although aneurysms of the retinal arteries have been noted since the early 1900s, Robertson in 1973 was the first to coin the term macroaneurysm to describe a distinct clinical entity that consisted of an acquired focal dilation of a retinal artery within the first three orders of bifurcation. Macroaneurysms vary from 100–250?µm in diameter, are saccular or fusiform in shape, and are differentiated readily from capillary microaneurysms, which are usually less than 100?µm in diameter. Retinal arterial macroaneurysms can be further differentiated from the vessel dilations seen in Coats’ disease, which are multiple saccular outpouches of predominantly the venous and capillary system, associated with marked telangiectasia and lipid exudation, primarily found in young males.
Although the clinical course of a retinal arterial macroaneurysm is often benign, in some cases significant visual morbidity results from macular hemorrhage, exudate, or edema, or from the development of a vitreous hemorrhage.
EPIDEMIOLOGY AND PATHOGENESIS
Retinal arterial macroaneurysms tend to occur in older people; most case series include subjects over the age of 60 years.       Multiple studies conclusively confirm a marked female preponderance, in the range of 60–100%.        Macroaneurysms typically occur in one eye, with bilaterality in less than 10%.  The most consistent systemic association of retinal arterial macro-aneurysms is with hypertension—a large controlled study reported it in 79% of patients. 
The exact pathogenesis of a macroaneurysm is unknown, but several authors have developed compelling theories. Many have compared retinal arterial aneurysms to cerebral arterial aneurysms, which are generally 100–300?µm in diameter, are also more common in women than men, and occur in patients over 50 years of age with a history of hypertension.   Chronic hypertension, along with the replacement of arterial smooth muscle by collagen associated with aging, may effect a focal dilation of the arterial wall in an area of weakness or prior damage. Lavin et al. postulated that macroaneurysms are detected more frequently at arteriovenous crossings, because at these locations the arterial and venous walls are in contact without an adventitial layer, which results in an area of limited structural support. Other investigators have noted the development of macroaneurysms at the sites of previously detected emboli.  They hypothesize that focal arterial damage secondary to embolization can lead to aneurysm formation. Gass now believes that the focal, yellow arterial plaques present are actually atheromas that occur at the site of defects in the arterial wall. He proposes that the previously reported emboli were, in fact, atheromas.
Abdel-Khalek and Richardson detected specific differences between aneurysms that led to hemorrhagic complications and those that resulted in lipid exudation. They found that saccular or “blowout” aneurysms were more prone to bleed, possibly as a result of a thin, stretched aneurysmal sac. This type of lesion develops closer to the optic nerve head, where perfusion pressures are higher. In addition, systolic blood pressures above 200?mmHg are more common in patients who have bleeding macroaneurysms. Fusiform dilations, on the other hand, are more prone to result in exudation and to be associated with venous occlusions.  It is possible that the cause of those aneurysms that eventually lead to hemorrhagic complications is more dependent on hypertension and vessel wall damage, while the cause of those that lead to exudation is more contingent upon local vascular factors.
The clinical picture of macroaneurysms can be highly variable, dependent on whether the macroaneurysm is hemorrhagic or exudative in nature. Hemorrhagic macroaneurysm can result in acute loss of vision with evidence of subretinal, intraretinal, or preretinal hemorrhage on ocular examination ( Fig. 123-1 ). Often the hemorrhage obscures the site of the aneurysm, but the presence of a localized preretinal and subretinal hemorrhage over a major retinal artery should suggest the possibility of its presence. A nonclearing vitreous hemorrhage without evidence of retinal tear or posterior vitreous detachment may be the result of a macroaneurysm. Because bleeding tends to thrombose the aneurysm, detection once the hemorrhage has cleared may be difficult. The involved artery often retains a focal tortuosity or Z-shaped kink at the location of the involuted aneurysm, which lends indirect evidence in support of the diagnosis.
Patients also can experience a more gradual decline in vision secondary to serous fluid and lipid accumulation in the macula ( Fig. 123-2 ). Exudative macroaneurysms most often are located on the temporal vascular arcades, although rarely macroaneurysms can occur on the optic nerve head, cilioretinal artery, and nasal vessels.  They frequently demonstrate a circinate lipid pattern (see Fig. 123-2 ). Finally, asymptomatic macroaneurysms
Figure 123-1 Hemorrhagic macroaneurysm. Note the preretinal and subretinal hemorrhages directly above and below the artery.
Figure 123-2 Exudative macroaneurysm. Note the aneurysm along the superotemporal arcade, with marked lipid exudation that extends into the central macula.
may be discovered on routine examination. These have only a small (or absent) cuff of hemorrhage and lipid exudation associated with them. Up to 10% of macroaneurysms may be pulsatile initially; although some investigators maintain that this shortly precedes rupture, most believe it is of no prognostic significance.
A well-documented association of macroaneurysms occurs with retinal vein occlusions, often in the artery that serves the vascular territory of the occluded vein. Distal arterial narrowing and arterial occlusion of the involved vessel also are common and have been reported to occur in 26% and 8% of cases, respectively. In addition, one report exists of the development of retinal macroaneurysms in a 62-year-old patient who has a history of congenital arteriovenous communications. 
DIAGNOSIS AND ANCILLARY TESTING
Diagnosis of lesions is based on the characteristic fundus appearance, as described above. Macroaneurysms which have undergone closure may be recognized by Z-shaped deformities in the involved vessel (see above).
Fluorescein angiography may reveal or confirm the presence of a macroaneurysm, usually demonstrating immediate, complete filling of the aneurysm ( Fig. 123-3 ). In some cases, irregular and incomplete filling may be associated with partial thrombosis, and a faint shell (or no) fluorescence may be displayed with a completely involuted macroaneurysm.  Leakage from the wall of the aneurysm is common in active lesions. Evidence of arteriolar narrowing usually is present proximal and distal to the macroaneurysm. In many cases, microvascular abnormalities
Figure 123-3 Fluorescein angiogram of a typical macroaneurysm. Note the complete early filling of the macroaneurysm with fluorescein dye.
Figure 123-4 Macroaneurysm with surrounding dilated and telangiectatic capillary bed. A, Note the large bilobed macroaneurysm with surrounding circinate lipid. B, The fluorescein angiogram shows dilated, tortuous capillaries and microaneurysms surrounding the macroaneurysm. (Courtesy of Susan Fowell, MD.)
surround the aneurysm, including a wider capillary-free zone, capillary dilation, capillary nonperfusion, microaneurysms, and intra-arterial collateral vessels ( Fig. 123-4 ).
In cases with dense hemorrhage when fluorescein angiography does not provide definitive evidence of a retinal arterial macroaneurysm, indocyanine green angiography may be a useful adjunct. Because the absorption and emission spectra are in the near-infrared range, the dye can better penetrate through dense hemorrhages, revealing structures that may otherwise be obscured. Additionally, in treatment of a macroaneurysm, indocyanine green dye may leak less than fluorescein, thus providing well-defined images.
Figure 123-5 Venous macroaneurysm secondary to branch retinal vein occlusion. A, Note the venous aneurysm superior to the disc occurring in the setting of a branch retinal vein occlusion. B, Fluorescein angiogram showing hyperfluorescence in the venous anerysm. There was no late leakage from this lesion. (Courtesy of Susan Anderson-Nelson.)
Many clinical entities simulate retinal arterial macroaneurysms. Schulman et al. reported large-capillary aneurysms secondary to retinal venous obstruction. These aneurysms are similar in dimension to macroaneurysms, but they originate from the venous side of the capillary bed and may result in visual loss from macular edema, serous elevation of the macula, and circinate lipid exudation.
Venous macroaneurysms also are seen after retinal vein obstruction   ( Fig. 123-5 ). Cousins et al. recently reviewed their patients involved in the Branch Vein Occlusion Study and noted four types of aneurysms in the area of the vein occlusion:
• Arterial macroaneurysms
• Capillary macroaneurysms (Schulman et al.  )
• Venous macroaneurysms
• Collateral-associated macroaneurysms
All four types were associated with hemorrhagic and lipid exudation and were found in areas of capillary nonperfusion.
Kimmel et al. reported a case of a temporal branch retinal vein obstruction that masqueraded as a macroaneurysm with the Bonet sign, which consists of hemorrhage at an arteriovenous crossing that indicates an incipient branch vein occlusion. Given the similar patient characteristics and that these two entities are seen together often, differential diagnosis can be difficult. One patient was reported to have had a Valsalva episode that resulted in rupture of a retinal arterial macroaneurysm. In another report, a lesion that simulated an optic nerve head tumor associated with a branch retinal arterial obstruction was eventually diagnosed as a macroaneurysm after 6 months of follow-up.
Figure 123-6 Coats’ disease. A, The classic fundus picture of Coats’ disease with massive lipid exudation causing an exudative retinal detachment. B, Fluorescein angiogram from the same patient with large telangiectatic vessels and numerous leaking aneurysms.
Retinal telangiectasia of Coats’ disease can be differentiated from a macroaneurysm based on age of onset, gender predilection, multiplicity of aneurysmal dilations that involve mainly the venous and capillary systems, and association with a large net of telangiectatic vessels, as revealed on fluorescein angiography ( Fig. 123-6 ). The adult–Coats’ or juxtafoveal telangiectasis syndrome also can be distinguished on the basis of multiple, small-caliber telangiectatic vessels observed in the characteristic temporal macular location; however, one report of a typical macroaneurysm that developed into a Coats’ disease–like picture demonstrates that the distinction can sometimes be blurred.
Capillary hemangiomas of the retina usually are associated with retinal edema, exudate, and hemorrhage-like macroaneurysms, but they are typically peripheral and generally have large dilated, tortuous afferent and efferent vessels. Angiomas also can occur on the optic nerve head, where differentiation from macroaneurysms may be particularly difficult. Capillary hemangiomas usually are inherited and often are seen as part of Von Hippel–Lindau disease, which is autosomal dominant with multiple systemic findings that include cerebellar hemangioblastoma, renal cell carcinoma, and pheochromocytoma. A nonfamilial form of acquired angioma, however, which lacks the characteristic large dilated vessels, has been described and more easily can be confused with macroaneurysm ( Fig. 123-7 ). The acquired lesions are either primary, idiopathic, or secondary to a variety of underlying ocular conditions, most commonly retinitis pigmentosa and uveitis. These lesions, or vasoproliferative tumors, can display considerable growth seen on long-term follow-up, which further differentiates them from macroaneurysms.
The accumulation of a subretinal hemorrhage in the macula from a macroaneurysm in an elderly patient with evidence of drusen and pigmentary changes may be confused with a choroidal
Figure 123-7 Idiopathic retinal vasoproliferative tumor. A typical inferiorly located lesion with conspicuous lack of dilated feeder and drainage vessels. (From McCabe CM, Mieler WF. Arch Ophthalmol. 1996;114:617.)
Figure 123-8 Submacular hemorrhage simulating choroidal neovascularization. A, Prominent submacular hemorrhage in an elderly patient simulating choroidal neovascular membrane. B, Same patient 3 months later following spontaneous resolution of hemorrhage.
neovascular membrane from age-related macular degeneration ( Fig. 123-8 ). If suspicion of a macroaneurysm exists, then careful examination of the nearby artery and fluorescein angiography are indicated.
There are several reported cases of retinal arterial macroaneurysms with massive subretinal hemorrhage appearing as a dark mass simulating choroidal melanoma. Fluorescein angiography and ultrasonography can aid in the diagnosis.
A distinct entity of multiple aneurysms that involve all the major retinal vessels in both eyes, with neuroretinopathy, vitreous and anterior chamber inflammation, and angiographic evidence of arteritis, has been called the IRVAN (idiopathic retinal vasculitis, aneurysms, and neuroretinitis) syndrome   ( Fig. 123-9 ). The cause of this rare disorder is unknown. The disparate clinical findings and the young age range of the patients readily differentiate it from macroaneurysms.
Figure 123-9 IRVAN syndrome. A, Multiple arterial dilations in a patient with IRVAN syndrome. B, Fluorescein angiogram readily documents the numerous aneurysms in the juxtapapillary region.
The only consistent systemic association with retinal arterial aneurysms is systemic arterial hypertension. In a case-control series this was observed in 79% of patients with macroaneurysm and 55% of controls. The difference was found to be statistically significant. The evaluation of a patient who has a macroaneurysm but who has no previous history of hypertension should include the measurement of blood pressure.
Gold et al. described a pathology specimen from a patient with a single macroaneurysm and a large ring of circinate lipid in the macula. They found a macroaneurysm located at an arteriovenous crossing, surrounded by dilated capillaries and a heterogeneous accumulation of collagen, hemosiderin, and lipid, with a paramacular deposition of lipid and proteinaceous exudate in the outer plexiform layer. It was proposed that the dilated capillary network that surrounded the macroaneurysm was the source of serous and lipid exudation into the macula. Other reports of ruptured aneurysms have shown evidence of a break in the artery covered by a dense fibrin–platelet clot that contains blood, exudate, lipid-laden macrophages, hemosiderin, and fibroglial reaction products in amounts that vary among patients ( Fig. 123-10 ).
TREATMENT, COURSE, AND OUTCOME
Although treatments using the xenon arc  and argon   and dye yellow     lasers, both directly at and around the macroaneurysm, have been described, a laser approach remains controversial. Most authors agree that hemorrhagic macroaneurysms, especially those which cause vitreous or preretinal hemorrhage, tend to thrombose and ultimately result in a better visual outcome than do exudative macroaneurysms, which may
Figure 123-10 Retinal arteriolar macroaneurysm. PAS-stained trypsin-digest preparation. (Courtesy Streeten BW. In: Yanoff M, Fine BS. Ocular pathology, ed 4. London: Mosby; 1995.)
eventually cause macular edema.    Therefore, patients who have decreased acuity secondary to retinal or vitreous hemorrhage probably should be followed for several months to enable spontaneous clearance. Many investigators believe that patients who have exudative macroaneurysm and significant macular involvement should undergo photocoagulation treatment, either directly to the lesion    or to the surrounding capillary bed, in an effort to close the macroaneurysm and the leaking perianeurysmal vessels. The rationale is that the poorest visual outcomes are observed when macular edema and lipid are allowed to remain for many months.
However, no prospective trial of laser therapy for macroaneurysm has been performed, and the several small uncontrolled clinical series demonstrate mixed results. Abdel-Khalek and Richardson treated 10 eyes and noted visual improvement in two, with no change in seven, and a visual decrease in one. Palestine et al. were unable to show a visual benefit using laser for eyes with macular pathology in six treated eyes versus five controls. Joondeph et al.  reported improvement in visual acuity in 8 of 12 cases using the dye yellow laser, while another recent case-control study showed that direct laser treatment resulted in a significantly greater risk for a visual acuity of less than 20/80 when compared with controls. Laser surgery also is associated with an increased threat of arteriolar occlusion, which theoretically may be amplified when using the dye yellow laser.  Until further definitive studies are performed to elucidate the proper role of and method for using lasers in the treatment of macroaneurysms, laser therapy should be reserved for select exudative macroaneurysms that involve the macula and threaten the fovea with the progressive accumulation of lipid. When employing laser, argon green or dye yellow lasers can be used with long-duration burns (0.2–0.5 seconds) and large spot sizes (500?µm in diameter).
Several additional modalities have been advocated for treatment of premacular and submacular hemorrhage associated with retinal arterial macroaneurysms. The neodymium: yttrium–aluminum–garnet laser (Nd:YAG) has been employed in the treatment of dense premacular hemorrhage in order to speed visual recovery and potentially limit tractional macular detachment.    Nd:YAG photodisruption creates a focal opening in the anterior surface of the preretinal hemorrhage to allow for drainage of entrapped hemorrhage into the vitreous cavity. In a study of six eyes with preretinal hemorrhage secondary to macroaneurysm formation, all eyes showed improvement of vision within 1 week of Nd:YAG photodisruption. In a retrospective review of 21 eyes with premacular hemorrhage secondary to various causes, visual improvement occurred within 1 month in 16 of 21 eyes. However, seven patients required an additional vitrectomy for nonclearing vitreous hemorrhage and complications including a macular hole and retinal detachment. The macular hole occurred in an eye with a premacular subhyaloid hemorrhage of only one disc diameter. The authors postulated that the small size of the hemorrhage did not provide a sufficient dampening effect for the laser burst, and they recommend laser drainage only if the hemorrhage is beyond three disc diameters in size. This treatment modality can be used for rapid visual recovery, but it probably results in visual outcome no better than that with the natural course of the disease. Long-term studies are needed to better define the risks and benefits of laser photodisruption, especially in for hemorrhage associated with a retinal macroarterial aneurysm.
Pars plana vitrectomy with the use of tissue plasminogen activator (t-PA) has been advocated for the removal of dense, thick subretinal hemorrhage.   Patients with submacular hemorrhage secondary to a retinal arterial macroaneurysm have had generally favorable visual outcomes with this technique. However, it appears that patients with submacular hemorrhage secondary to retinal arterial macroaneurysms may obtain better visual outcomes than those with hemorrhage from other causes, such as age-related macular degeneration. McCabe et al. recently reviewed the cases of 41 patients with macular hemorrhage secondary to retinal artery macroaneurysms managed with observation alone and found that good visual outcomes often could be achieved with observation alone (see Fig. 123-9 ). Furthermore, visual outcomes were similar to those of reported cases of patients with submacular hemorrhage secondary to retinal arterial macroaneurysm treated surgically.
Most recently, investigators have treated submacular hemorrhage using pneumatic displacement both with and without the adjunct of intravitreous t-PA.    Pneumatic displacement is a technique initially suggested by Heriot for subfoveal hemorrhage. It consists of pretreatment with intravitreal t-PA followed by injection of perfluoropropane or sulfur hexafluoride gas, with prone positioning for at least 24 hours in order to compress the macula directly and displace the submacular hemorrhage inferiorly. His initial experience demonstrated displacement of the hemorrhage in 19 of 20 eyes with few complications. Hassan and colleagues reviewed the cases of 15 eyes treated with t-PA and pneumatic displacement and found that subfoveal blood can be displaced effectively, often with substantial initial improvement in visual acuity. Because retinal toxic effects from t-PA have been observed in animal studies, investigators recommend avoiding intravitreous injections of t-PA in concentrations greater than 25?µg/0.1?ml. Likewise, caution was advised in the use of intravitreous t-PA injection in patients with arterial macroaneurysm because of a possible increased risk of vitreous hemorrhage. Amid concerns of the toxicity of t-PA, Ohji et al.  reported a series of five patients treated with perfluoropropane gas followed by prone positioning, without pretreatment with t-PA. Vision improved and blood was displaced from the fovea partially or completely in all five patients. Nevertheless, they speculate that solid blood clots present longer than 1 week may not be displaced with gas compression alone.
In summary, the preferred treatment for patients with macular hemorrhage secondary to retinal arterial macroaneurysm remains controversial. The precise role of these advanced vitreoretinal techniques in the treatment of macroaneurysm will be clarified only with further study.
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