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Poster 27 - The Natural Course of a Retinal Artery Macroaneurysm: A Case Report and Review
POSTER 27 The Natural Course of a Retinal Artery Macroaneurysm: A Case Report and Review Dustin L. Reece, O.D. and Jeffrey T: Joy, O.D. Salisbury VA Medical Center, 1601 Brenner Avenue, Salisbury, North Carolina 28144
Background: Retinal artery macroaneurysm (RAM)
is a dilation of a retinal artery within the posterior pole. A focal ectasia results from a weakened intima within the arterial wall. It can remain asymptomatic or decrease vision secondary to macular edema. It is most commonly associated with hypertension and atherosclerosis. Asymptomatic RAMS are observed for possible spontaneous involution, while focal laser photocoagulation is indicated for secondary macular edema if vision is threatened. A vitrectomy or focal YAG laser may be indicated for speeding re-absorption of pre-macular hemorrhage that blocks view of the macula. This case will discuss the advantages and disadvantages of the various treatment options, including observation for spontaneous involution versus other modes of treatment. Case Report: A 77-year-old man came to us with a chief symptom of sudden painless vision loss O.D. Medical history was significant for hypertension and anemia. Vision on presentation was light perception O.D. and 20120 O.S. Confrontations were limited O.D., with a central scotoma. IOPs were slightly elevated O.S. > O.D., and retinal evaluation revealed a large anterior retinal hemorrhage blocking the macula O.D. A laboratory workup indicated anemia and an elevated erythrocyte sedimentation rate. The patient was monitored several times over the next two months for macular involvement. Follow-up visits showed continuous spontaneous involution of the RAM and re-absorption of the retinal hemorrhage, with subsequent improvement in visual acuity to 201400. Four fundus photographs were obtained covering the course of this RAM, from onset to resolution. Conclusion: Retinal artery macroaneurysms can manifest as a visually threatening condition. Most are associated with underlying cardiovascular conditions,and 25% show a high 5-year post RAM mortality rate. A thorough systemic workup is indicated in all conditions, and should be treated appropriately. Our patient presents as a classic RAM with associated anemia and well-controlled hypertension, and was monitored closely for several months for spontaneous
involution. Observation for spontaneous involution is the best course of treatment initially, until macular involvement can be determined. Vitrectomy or a focal YAG laser is another option, if view of the macula is obstructed.
POSTER 28 Radial Optic Neurotomy in Central Retinal Vein Occlusion Emily Frank, O.D., Randall Wong, M.D., Zoe Lazarou, O.D., and Ed Wasloski, O.D. Omni Eye Specialists, 7008 Security Boulevard, Suite 100, Baltimore, Maryland 21236
Background: Central retinal vein occlusion (CRVO)is a leading cause of vision loss. Currently, there are few proven treatment options for patients afflicted with this disorder. Although the exact location of vein occlusion is still debated, relaxing the cribriform plate via intravitreal radial optic neurotomy has provided promising preliminary results. Case Report: A 62-year-old man with a history of hypertension and diabetes mellitus came to us for a 2- to 3-week decrease in vision O.S. The best-correctedvisual acuity O.S. was 20160, with an intraretinal hemorrhage noted on fundus examination. The diagnosis of impending CRVO was made. Within three months, the vision decreased to 201200 0.S with optic nerve head edema, intraretinal hemorrhage, and cystic macular edema on fundus examination. Due to the worsening condition and the poor chance of improvement, a radial optic neurotomy (RON) was performed O.S. This procedure, in which a surgical knife is used to penetrate approximately 2 mm into the nasal nerve head, was performed along with a pars plana vitrectomy and kenelog administration. Four months after this procedure, the visual acuity O.S. returned to 20140, with marked improvement of funduscopic appearance and formation of disk optociliary shunt vessels. Conclusion: RON is a promising treatment for CRVO, a condition that currently has few treatment options. The risks of this procedure have included creating an opening for neovascularization, damaging the circle of Zinn-Haller, and creating an opening for subretinal fluid to accumulate, leading to retinal detachment-none of which were demonstrated in this case. The improvement witnessed after RON may not only be due to a larger area for central retinal vein outflow by relaxing the cribiforrn plate, but also to acceleration of optociliary shunt vessel formation. 367
VOLUME 75INUMBER 6lJUNE 2004
OPTOMETRY
Background: Retinal artery macroaneurysm (RAM)
is a dilation of a retinal artery within the posterior pole. A focal ectasia results from a weakened intima within the arterial wall. It can remain asymptomatic or decrease vision secondary to macular edema. It is most commonly associated with hypertension and atherosclerosis. Asymptomatic RAMS are observed for possible spontaneous involution, while focal laser photocoagulation is indicated for secondary macular edema if vision is threatened. A vitrectomy or focal YAG laser may be indicated for speeding re-absorption of pre-macular hemorrhage that blocks view of the macula. This case will discuss the advantages and disadvantages of the various treatment options, including observation for spontaneous involution versus other modes of treatment. Case Report: A 77-year-old man came to us with a chief symptom of sudden painless vision loss O.D. Medical history was significant for hypertension and anemia. Vision on presentation was light perception O.D. and 20120 O.S. Confrontations were limited O.D., with a central scotoma. IOPs were slightly elevated O.S. > O.D., and retinal evaluation revealed a large anterior retinal hemorrhage blocking the macula O.D. A laboratory workup indicated anemia and an elevated erythrocyte sedimentation rate. The patient was monitored several times over the next two months for macular involvement. Follow-up visits showed continuous spontaneous involution of the RAM and re-absorption of the retinal hemorrhage, with subsequent improvement in visual acuity to 201400. Four fundus photographs were obtained covering the course of this RAM, from onset to resolution. Conclusion: Retinal artery macroaneurysms can manifest as a visually threatening condition. Most are associated with underlying cardiovascular conditions,and 25% show a high 5-year post RAM mortality rate. A thorough systemic workup is indicated in all conditions, and should be treated appropriately. Our patient presents as a classic RAM with associated anemia and well-controlled hypertension, and was monitored closely for several months for spontaneous
involution. Observation for spontaneous involution is the best course of treatment initially, until macular involvement can be determined. Vitrectomy or a focal YAG laser is another option, if view of the macula is obstructed.
POSTER 28 Radial Optic Neurotomy in Central Retinal Vein Occlusion Emily Frank, O.D., Randall Wong, M.D., Zoe Lazarou, O.D., and Ed Wasloski, O.D. Omni Eye Specialists, 7008 Security Boulevard, Suite 100, Baltimore, Maryland 21236
Background: Central retinal vein occlusion (CRVO)is a leading cause of vision loss. Currently, there are few proven treatment options for patients afflicted with this disorder. Although the exact location of vein occlusion is still debated, relaxing the cribriform plate via intravitreal radial optic neurotomy has provided promising preliminary results. Case Report: A 62-year-old man with a history of hypertension and diabetes mellitus came to us for a 2- to 3-week decrease in vision O.S. The best-correctedvisual acuity O.S. was 20160, with an intraretinal hemorrhage noted on fundus examination. The diagnosis of impending CRVO was made. Within three months, the vision decreased to 201200 0.S with optic nerve head edema, intraretinal hemorrhage, and cystic macular edema on fundus examination. Due to the worsening condition and the poor chance of improvement, a radial optic neurotomy (RON) was performed O.S. This procedure, in which a surgical knife is used to penetrate approximately 2 mm into the nasal nerve head, was performed along with a pars plana vitrectomy and kenelog administration. Four months after this procedure, the visual acuity O.S. returned to 20140, with marked improvement of funduscopic appearance and formation of disk optociliary shunt vessels. Conclusion: RON is a promising treatment for CRVO, a condition that currently has few treatment options. The risks of this procedure have included creating an opening for neovascularization, damaging the circle of Zinn-Haller, and creating an opening for subretinal fluid to accumulate, leading to retinal detachment-none of which were demonstrated in this case. The improvement witnessed after RON may not only be due to a larger area for central retinal vein outflow by relaxing the cribiforrn plate, but also to acceleration of optociliary shunt vessel formation. 367
VOLUME 75INUMBER 6lJUNE 2004
OPTOMETRY