망막 conference 서울성모병원 안과 R2 성윤미

권0곤 M/59 2012.7.12 c/c dec VA(OS) o/s) 내원 당일 오전 DM/HBP (-/+) for 10 yrs, po med Ocular op/trauma(-/-) 25521643 HBP : poor control

Ocular Examinations VA OD 1.0 OS FC20(NC) IOP 8/8 mmHg Conj. OD not injected OS not injected Cornea OD clear OS clear AC OD >4CT at center, >1/2CT at pph. & cell(+) OS >4CT at center, >1/2CT at pph. & cell(trace) Pupil OD round & nl sized OS round & dilated d/t cycloplegics Lens OD mild NU OS mild NU FD OD nl optic disc c dot Hm. at parafoveal area OS nl optic disc c sub ILM Hm c subretinal Hm

ICG FAG, ICG no hot spot Os

OCT foveal hm os

Retinal artery macroaneurysm(OS) Plan) Yag laser(OS) O-FMx4 VDF

2012.7.23(2wks later) VA OD 1.0 OS 0.32 IOP 8/8 mmHg Fds OS nl optic disc c sub ILM Hm (dec ) c subretinal Hm, vit Hm(+) Plan) VDF

Foveal Hm

2012.8.22 (1mo later) VA OD 1.0 OS 1.0 IOP 11/10 mmHg Fds OS nl optic disc c subretinal Hm (dec) c vit Hm(dec) Plan) VDF FAG no leak os

FAG

Retinal artery macroanuerysms

Introduction acquired focal dilatations of the retinal arterioles typically located at arterial bifurcations or arteriovenous crossings within the first three divisions of arteriolar branching Involvement of the superotemporal and inferotemporal arcades : most common Multiple aneurysms often found in different arteries of the same eye but bilateral involvement is seen only in 10% of occurrences

Epidemiology ccc Age : 60세 이전은 거의 없다.

Epidemiology Usually unrelated to any other retinal disease Vascular problem Hypertension Arteriosclerotic cardiovascular disease 60대~70대 (M/C) Female Unilateral (bilateral 10%)

F/62, 고혈압 Subretinal hemorrhage Round dilatation at arterial bifurcation

Pathogenesis Focal damage of arterial wall 정확한 기전은 밝혀지지 않음 만성고혈압에 의한 혈관손상 혈관의 유전적 구조 결손 동정맥 교차부위의 약화로 인한 국소적 확장 embolism에 의한 국소적인 혈관벽의 손상 동맥주위염에 의한 혈관의 구조적 변화

Clinical feature Asymptomatic if macular not involved 건강검진에서 우연히 발견 On funduscopic examination, macroaneurysms are round or fusiform dilations of the arterial wall

Clinical feature 임상양상에 따른 자연경과(Abdel-Khalek, Richardson) 급성부전(Acute decompensation) subretinal, intraretinal, vitreous hemorrhage에 따른 급격한 시력 소실 (hourglass Hm) 만성부전(Chronic decompensation) Vascular leakage에 의한 retinal edema, lipid exudate 축적으로 인한 점진적 시력 소실 the most common presenting symptom is acute or insidious loss of vision due to hemorrhage, retinal edema, or exudation involving the central macular region. One third to two thirds of patients have an associated hemorrhage, which may be located in the subretinal space, within the retina, beneath the internal limiting membrane, or in the vitreous cavity. A hemorrhage involving more than one of these locations is characteristic of retinal arterial macroaneurysm, and the term hourglass hemorrhage has been suggested to describe the simultaneous collection of preretinal and subretinal heme

: spontaneous resolution 20 month : spontaneous resolution Threatening macula The aneurysm may be visible within the hemorrhage as a white or yellow spot A subretinal hemorrhage may simulate a choroidal melanoma or choroidal neovascularization. Occasionally, patients present with dense vitreous hemorrhage from a retinal artery macroaneurysm. Chronic exudation from the macroaneurysm often leads to intraretinal edema and lipid deposition. These deposits may adopt a circinate pattern, prompting the observer to search for a macroaneurysm in the center of the lesion Subretinal fluid accumulation may lead to a neurosensory retinal detachment. VA 20/25

Clinical feature Pulsatile macroanuerysm Hemorrhage beneath the RPE Greater risk of vitreous hemorrhage Hemorrhage beneath the RPE Dark lesion Malignant melanoma, ARMD

Natural History

Fluorescein angiography Early phase aneurysm fills in early phase Late phase little staining of vessel wall~marked leakage Fail to demonstrate the macroaneurysm(Blockage by hemorrhage) Indocyanine green angiopathy Early phases of the fluorescein angiogram usually demonstrate immediate, uniform filling of the macroaneurysm Partial filling may occur due to obliteration of the lumen resulting from thrombosis or spontaneous involution. The involved artery is typically patent but may be narrowed and irregular proximal and distal to the lesion. Surrounding microvascular abnormalities, including capillary microaneurysms, telangiectasias, and nonperfusion, are often seen. The late phases of the angiogram may demonstrate only faint staining of the involved vessel or may demonstrate marked leakage resulting in cystoid or diffuse retinal edema. Intraretinal and preretinal hemorrhage may block background retinal and choroidal fluorescence or may obscure the macroaneurysm itself ICG With relatively dense intraretinal or preretinal hemorrhages, ophthalmoscopy and fluorescein angiography may not be able to demonstrate the macroaneurysm due to the blocking effect of the overlying blood. Indocyanine green (ICG) angiography can be useful in these cases because the increased penetrance of ICG fluorescent light through blood may allow visualization of the macroaneurysm as a discrete hyperfluorescent lesion

Treatment Systemic investigations for HTN and cardiovascular disease. Observation Aymptomatic & no leakage & macula not involved Lesions can thrombose and spontaneous involution Laser photocoagulation No clear indication for treatment with laser. Direct laser photocoagulation If edema or lipid exudate threaten or involve fovea Cx. : retinal arteriole occlusion

YAG laser hyaloidotomy Large non-absorbing preretinal hemorrhage overlying macula

Submacular hemorrhage Intravitreal gas injection (+- tPA) Expandable gas with face-down positioning Vitrectomy Clearing macular hemorrhage

Intravitreal anti-VEGF injection VEGF-associated increased permeability in RAM Acquired arterial macroaneurysms of the retina. Br J Ophthalmol 1976 → Actively close the permeablilized artery and normalize the vessel Vascular endothelial growth factor (VEGF) in pathologic condition abnormal blood vessels increasing vascular permeability Anti-VEGF drugs inhibiting angiogenesis decreasing vascular permeability

Intravitreal anti-VEGF injection

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