22.1 Features
Retinal arterial macroaneurysms (RAMs) are acquired, saccular or fusiform dilatations of large retinal arterioles, usually within the first three orders of bifurcation. The diameter of dilatation is typically within 100 to 250 µm. This is most commonly seen in women older than 60 years with hypertension (~75%) and dyslipidemia.
22.1.1 Common Symptoms
Commonly asymptomatic. Sudden painless vision loss may occur due to vitreous, retinal, or subretinal hemorrhage. More slowly developing vision loss may occur secondary to edema and exudation.
22.1.2 Exam Findings
Focal saccular dilatation of retinal arterioles. Intravitreal, preretinal, intraretinal, and subretinal hemorrhages are possible from RAM rupture. Macular edema and surrounding circinate exudates are common (▶ Fig. 22.1).
Fig. 22.1 Retinal arterial macroaneurysm with circinate lipid exudate as seen on (a) fundus photo and (b) fluorescein angiography.
22.2 Diagnostic Tests and Findings
22.2.1 Fluorescein Angiography or Ultra-Widefield Fluorescein Angiography
Early images display focal macroaneurysm filling with possible leakage in late images.
22.2.2 Indocyanine Green Angiography or Ultra-Widefield Indocyanine Green Angiography
Images display focal macroaneurysm filling. Useful for diagnosis in presence of preretinal, intraretinal, and subretinal hemorrhages.
22.2.3 Optical Coherence Tomography and OCT Angiography
Optical coherence tomography (OCT) is useful for evaluating structural alterations associated with exudation, including intraretinal fluid and subretinal fluid. In addition, OCT can be helpful to delineate hemorrhage location. Occasionally, the vascular dilation may be visualized on the OCT. OCT angiography (OCTA) can readily visualize the saccular dilation of the retinal vessel flow abnormality if the structural change is within the field of the OCTA. Widefield OCTA may be useful for identifying more peripheral RAM.
22.3 Critical Work-up
Evaluation for hypertension and dyslipidemia.
22.4 Management
22.4.1 Treatment
Observation with close follow-up and management of hypertension and/or dyslipidemia. Most RAMs do not require treatment as most regress spontaneously, particularly after hemorrhage (▶ Fig. 22.2). Cases of significant subretinal hemorrhage or vitreous hemorrhage call for pars plana vitrectomy with subretinal tissue plasminogen activator (in cases of subretinal hemorrhage). Focal laser photocoagulation directly to the RAM is considered for visually significant exudation. Downstream vascular occlusion may complicate laser photocoagulation so caution should be exercised if the RAM is located upstream to the fovea.
Fig. 22.2 Ruptured retinal arterial macroaneurysm (RAM) with subretinal hemorrhage on (a) fundus photo with (b) subsequent resorption of hemorrhage at 3 month follow-up visit. (c) Ultra-widefield fluorescein angiography demonstrates clear RAM at site of hemorrhage.
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