1. 망막 conference
서울성모병원 안과
R2 성윤미

2. 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(-/-)
HBP : poor control

3. 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

5. ICG
FAG, ICG no hot spot Os

6. OCT foveal hm os

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

8. 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

10. Foveal Hm

11. 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

13. FAG

14. Retinal artery macroanuerysms

15. 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

16. Epidemiology
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Age : 60세 이전은 거의 없다.

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

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

19. 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

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

21. 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

22. : 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

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

24. Natural History

25. 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

26. 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

27. YAG laser hyaloidotomy
Large non-absorbing preretinal hemorrhage overlying macula

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

29. 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

30. Intravitreal anti-VEGF injection

31. Thank you for your attention!