AN 80-YEAR-OLD white woman with a history of ischemic heart disease, hypertension, and hypercholesterolemia complained of decreased vision of the left eye and a gray spot centrally. On examination, visual acuity was 20/25 OD, 20/50 OS, and intraocular pressure was 18 mm Hg OU. Examination of the left eye while it was dilated revealed an intraretinal hemorrhage that appeared raised and that was associated with a central white region, consistent with an arterial macroaneurysm. Her ophthalmologist immediately referred her to our photographic service for a fluorescein angiogram of the left eye. After the procedure was explained to the patient, she was positioned at the fundus camera. The area of intraretinal hemorrhage, as described by her ophthalmologist, was noted along the superior arcade in close proximity to the disc. In addition, preretinal hemorrhages were present over the macroaneurysm and in the nasal inferior quadrant. This was documented with a preinjection red-free image (Figure 1). Five milliliters of 10% sodium fluorescein was then injected into an anticubital vein at a rate of 1 mL/s. Approximately 3 seconds postinjection, just before the prearterial phase, this arterial macroaneurysm ruptured spontaneously. Figure 1. View LargeDownload Preinjection red-free image showing preretinal hemorrhages over the macroaneurysm. The early frames show no typical choroidal filling. The first hyperfluorescence appears at 15 seconds and is associated with presumed macroaneurysm along the superotemporal arcade. The early transit phase shows an explosive hyperfluorescence emanating from this presumed macroaneurysm with a blood flow screen of hypofluorescence extending down along the area between the nerve and the macula (Figure 2). More striking flow is seen as the transit time progresses with real-time hemorrhage of the macroaneurysm being documented in all frames (Figure 3). Significant leakage and bleeding is seen in the later frames (Figure 4). Figure 2. View LargeDownload Early arterial phase of the fluorescein angiogram shows explosive hyperfluorescence along with blood flow hypofluorescence. Figure 3. View LargeDownload At 25 seconds postinjection, fluorescein continues to emanate from the ruptured macroaneurysm and begins to follow the path of the hemorrhage. Figure 4. View LargeDownload Significant leakage of fluorescein and blood is recorded during the recirculation phase. Comment A retinal arterial macroaneurysm is relatively rare and is generally seen in elderly women with systemic hypertension. It can be described as a thinned area along a retinal arteriole that is constantly pounded by systolic blood pressure in a patient with hypertension. This area of the blood vessel begins to bulge like a weak spot in a garden hose. An arterial macroaneurysm during fluorescein angiography is usually seen as uniform filling of a bulging arteriolar lesion in the early stage of the angiogram. Its appearance remains constant during all phases of the angiogram and it is commonly referred to as the lightbulb phenomenon. Many times a retinal macroaneurysm is not visible because of the overlying hemorrhage. Macular edema can also be seen in the late stage. In this patient, the rupture took place during angiography. Theoretically, compression of the globe may have limited the size of the hemorrhage; this maneuver is performed occasionally to limit hemorrhages encountered during laser procedures. This patient's last documented visual acuity had improved to 20/50 OS postrupture. Witnessing an arterial macroaneurysm spontaneously rupture and capturing it on film is an extremely rare occurrence. Corresponding author: Joseph G. Territo, Retina Associates of Western New York, 890 Westfall Rd, Rochester, NY 14618.
Archives of Ophthalmology – American Medical Association
Published: Jan 1, 2000
Keywords: fluorescein angiography,rupture, spontaneous
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