Retinal Macroaneurysm (RAM)

Retinal Macroaneurysm (RAM)
SYMPTOMS Quiescent retinal macroaneurysm: Typically asymptomatic
Exudative retinal macroaneurysm: Gradual central and/or peripheral vision loss
Hemorrhagic retinal macroaneurysm: Sudden central and/or peripheral vision loss
SIGNS Retinal macroaneurysms are 100-250 microns in diameter and typically seen in the superior temporal aspect of the posterior pole at an arteriovenous crossing
There are 3 types of retinal macroaneurysms
Quiescent retinal macroaneurysm: Typically does not involve the macula and is not associated with retinal hemorrhages and/or exudates (if there are hemorrhages and/or exudates, they are < 1DD in size)
Hemorrhagic retinal macroaneurysm: Most common retinal macroaneurysm (accounts for 50% of all RAMs), Tends to be seen closer to the optic nerve, Aneurysm is typically saccular (ballooning out on one side of the retinal artery), Majority of ruptured retinal macroaneurysm's content is blood with possibly some exudates, Typically appears as a large retinal hemorrhage (> 1DD) that typically involves the macula, Hemorrhage can involve multiple layers of the retina and vitreous (including the vitreous cavity, subhyaloid space, preretinal space, intraretina, and subretinal space), Hemorrhage may appear as an hourglass configuration (if it involves the subhyaloid/preretinal space and the subretinal space)
Exudative retinal macroaneurysm: Tends to occur further away from the optic nerve compared to other types of retinal macroaneurysms, Aneurysm is typically fusiform (circumferential widening of the retinal artery), Majority of ruptured retinal macroaneurysm's content is exudates with some blood, Typically appears as a large area of exudates (> 1DD) that typically involves the macula, Exudates typically appear as a circinate pattern around the macroaneurysm, Exudates can involve multiple layers of the retina and are associated with concomitant intraretinal and subretinal fluid
WORK-UP Pupils, EOMs, Full eye exam with dilated retinal exam, OCT analysis of the macula, OCT-Angiography, Fluorescein Angiography, Indocyanine Green Angiography, Fundus photos, Infrared photos, B-scan ultrasound (if unable to view the retina especially if retinal macroaneurysm is hemorrhagic), Watzke-Allen test, Macular photostress test, Amsler grid
TREATMENT Refer to PCP ASAP in order to get any systemic conditions under control and for a full work-up
Give take home Amsler grid in order to monitor for change
Patient should sleep with their head elevated in presence of a preretinal, subhyaloid, and/or intravitreal hemorrhage
Consider discontinuing or lowering the dosage of any blood thinners (needs to be discussed with PCP)
Quiescent retinal macroaneurysm without involvement of the macula: Needs to be monitored closely
Quiescent retinal macroaneurysm with involvement of the macula: Refer to retinal specialist ASAP for possible treatment which includes laser directly at the retinal macroaneurysm
Hemorrhagic retinal macroaneurysm: Refer to retinal specialist ASAP for treatment which includes laser directly at the retinal macroaneurysm or surrounding area, intravitreal anti-VEGF injections, ND:YAG laser hyaloidotomy, and pneumatic displacement
Exudative retinal macroaneurysm: Refer to retinal specialist ASAP for treatment which includes laser directly at the retinal macroaneurysm or surrounding area, intravitreal anti-VEGF injections, ND:YAG laser hyaloidotomy, and pneumatic displacement
FOLLOW-UP If monitoring quiescent retinal macroaneurysm, the patient should be seen back every 1-3 months until there is complete involution of the retinal macroaneurysm
Once retinal macroaneurysm is treated by the retinal specialist and the retina/macula is stable, the patient should be seen back in 3-6 months
ADDITIONAL LAB | TESTS The patient needs to follow-up with their PCP for additional testing if not already done which includes the following: Blood pressure, Fasting blood sugar, HbA1c, Lipid panel, CBC with differential, Thrombophilia screening (PT, TT, BT, PTT, INR, Protein C, Protein S, Anticardiolipin antibodies), Carotid duplex, Cardiac evaluation
ETIOLOGY Occurs due to weakness of an arterial wall (often times due to arteriosclerotic changes) and subsequent aneurysmal dilations
DIFFERENTIAL DX Wet age-related macular degeneration. Diabetic retinopathy, Hypertensive retinopathy
NOTES The most common systemic disease associated with a retinal macroaneurysm is hypertension (75% of the time)
Retinal artery occlusions and retinal vein occlusions can sometimes be associated with retinal macroaneurysms
Retinal macroaneurysms may eventually thrombose and involute
Laser applied directly to a macroaneurysm may sometimes cause a retinal artery occlusion
Retinal Macroaneurysm (RAM): Fundus photo demonstrating an exudative retinal macroaneurysm https://imagebank.asrs.org/file/3042/retinal-arterial-macroaneurysm
Posted in Ocular Conditions, Retina-Vascular