ARTERIOLAR MACROANEURYSM ON THE OPTIC DISK ASSOCIATED WITH BRANCH RETINAL VEIN OCCLUSION Toshiyuki Fujiwara, MD, Tomohiro Iida, MD, Kimimori Saito, MD, Ichiro Maruko, MD

Purpose: To report a case of an arteriolar macroaneurysm on the optic disk associated with branch retinal vein occlusion (BRVO). Method: Patient chart review. Patient: An 80-year-old man presented with a retinal arteriolar macroaneurysm on the optic disk on the root of a papillomacular vein, which caused BRVO. Results: Eight months later, the macroaneurysm shrank spontaneously and became fibrous tissue. The hemorrhage and edema due to BRVO resolved. Discussion: We speculate that the macroaneurysm was located on and compressed the epipapillary portion of the papillomacular vein, resulting in BRVO. With spontaneous involution of the macroaneurysm, the compression resolved, and the clinical findings improved. RETINAL CASES & BRIEF REPORTS 3:21–23, 2009

From the Department of Ophthalmology, Fukushima Medical University School of Medicine, Fukushima, Japan.

Case Report An 80-year-old man reported metamorphopsia in the left eye. Fundus examination revealed a red mass one sixth of a disk diameter on the left optic disk. The mass was located on the root of a papillomacular vein, and retinal flame-shaped hemorrhages radiated from the optic disk in the area drained by the papillomacular vein associated with macular edema (Fig. 1). Best-corrected visual acuity was 20/25 in the right eye and 20/20 in the left eye. The right eye had a senile cataract, and the left eye was pseudophakic. The right fundus was normal. The general medical history was relevant for hypertension. Fluorescein angiography showed a hyperfluorescent mass on the left optic disk immediately after dye injection. In the early venous phase, fluorescein dye filled the mass inhomogeneously (Fig. 2A). The papillomacular vein showed a filling delay and dye leakage (Fig. 2B). The mass did not leak on late-phase fluorescein angiograms. On the basis of these findings, we diagnosed a retinal arteriolar macroaneurysm on the optic disk associated with BRVO. The patient was observed without treatment. Eight months later, the macroaneurysm shrank and became white fibrous tissue. The retinal hemorrhage and edema resolved (Fig. 3). Fluorescein angiography revealed that capillary hyperpermeability still remained at the macular area, but the vein reflux improved (Fig. 4). In addition, retinal venous collaterals were seen on the optic disk. Visual acuity did not change during the follow-up period.

A

rteriolar macroaneurysms on the optic disk have not been well described. Most heal spontaneously by fibrosis, with preservation of good visual function.1 However, a few may cause complications such as intraretinal and subretinal hemorrhage,2,3 exudation, vitreous hemorrhage,4,5 and branch retinal artery occlusion.4,6,7 The incidence of complications of macroaneurysms located on the optic disk is unknown because of the rarity of the condition. We report a case of an arteriolar macroaneurysm on the optic disk associated with branch retinal vein occlusion (BRVO).

The authors have no proprietary interest in any aspect of this study. Reprint requests: Toshiyuki Fujiwara, MD, Department of Ophthalmology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima 960-1295, Japan; e-mail: fujiwara@ seagreen.ocn.ne.jp

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Fig. 1. Fundus photograph of the left eye of an 80-year-old man at the first visit shows a red mass on the optic disk on the root of a papillomacular vein. There are flame-shaped hemorrhages in the area of the papillomacular vein and macular edema.

Discussion Retinal arteriolar macroaneurysms have been reported to develop on the first two orders of the arteriolar tree in 71.43% of cases.8 The development of a macroaneurysm is rare on the optic disk. Palestine et al9 reported macroaneurysms on the optic disk in only 3 of 35 cases of macroaneurysms. Schatz et al (Retinal arterial macroaneurysms: a large collaborative study. Presented at the American Academy of Ophthalmology Annual Meeting; Chicago, IL; November 1980) reported 3 cases with a macroaneurysm on the optic disk in a series of 143 cases of retinal arterial macroaneurysms. To our knowledge, there has been no report of a retinal macroaneurysm on the optic disk with BRVO. The differential diagnosis of a vascular mass on the optic disk includes retinal arteriolar macroaneurysm, angiomatosis retinae, artery and vein blood vessel loop formation, persistent hyaloid artery, and cavernous hemangioma. In the current case, a mass on the optic disk showed hyperfluorescence in the early arterial phase by fluorescein angiography, and there was no vascular formation in the mass. Therefore, the origin was thought to be the artery. The patient was diagnosed with a retinal arteriolar macroaneurysm on the optic disk associated with BRVO. Management of optic disk macroaneurysms can be problematic because of the risk of visual field loss with application of laser photocoagulation; however, optic disk macroaneurysms may involute spontane-

Fig. 2. A, Fluorescein angiogram 18 seconds after dye injection in the left eye on the first visit shows a hyperfluorescent mass on the optic disk. Fluorescein dye fills the mass inhomogeneously. B, A late-phase fluorescein angiogram shows leakage from the vein and capillaries.

ously with no sequelae. As a result, in the current case, we opted against therapeutic intervention. Eight months later, the macroaneurysm shrank spontaneously and became white fibrous tissue. Involved vessels at the nerve head showed a slightly anomalous branching pattern with course above and below horizontal raphe. These vessels isolated from other central retinal veins; therefore, we considered them as cilioretinal vessels. We speculate that the macroaneurysm was located on and compressed the epipapillary portion of the papillomacular vein, resulting in BRVO. This vessel bended closely under the macroaneurysm; therefore, BRVO may have occurred easily. With spontaneous involution of the macroaneurysm, the compression resolved, and the clinical findings improved.

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Fig. 4. Eight months after the first visit, fluorescein angiogram 19 seconds after dye injection shows improvement of the occluded vein reflux. Fig. 3. Eight months after the first visit, the macroaneurysm has involuted and shrunk to white fibrous tissue. The retinal hemorrhage and edema have resolved. Involved vessels at the nerve head are tortuous with course above and below horizontal raphe and bended closely white fibrous tissue. Retinal venous collaterals are seen on the optic disk (arrow).

4. 5. 6.

References 7. 1. 2.

3.

Kowal L, Steiner H. Arterial macroaneurysm of the optic disc. Aust N Z J Ophthalmol 1991;19:75–77. Brown GC, Weinstock F. Arterial macroaneurysm on the optic disk presenting a mass lesion. Ann Ophthalmol 1985;17:519– 520. Ichibe M, Oya Y, Yoshizawa T, Abe H. Macroaneurysm on

8. 9.

the optic disk associated with congenital retinal arterial malformation. Retina 2004;24:985–986. Quhill F, Smith JM, Scotcher SM. Arterial macroaneurysm on the optic disc. Eye 2004;18:321–322. Nakamura K, Iida T. A case of retinal arteriolar macroaneurysm on the optic disc. Jpn J Clin Ophthalmol 1998;52:126–128. Iwasawa A, Majima A, Shirai S, Taki M. Bilateral prepapillary macroaneurysm. Report of a case. Jpn J Clin Ophthalmol 1989;43:619–623. Shioya N. A case of macroaneurysm at the optic disc with central retinal arterial branches occlusion. Folia Ophthalmologica Japonica 1981;32:262–268. Tezel T, Gu¨nalp I, Tezel G. Morphological analysis of retinal arterial macroaneurysms. Doc Ophthalmol 1994;88:113–125. Palestine AG, Robertson DM, Goldstein BG. Macroaneurysms of the retinal arteries. Am J Ophthalmol 1982;93:164–171.

Arteriolar macroaneurysm on the optic disk associated with branch retinal vein occlusion.

To report a case of an arteriolar macroaneurysm on the optic disk associated with branch retinal vein occlusion (BRVO)...
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