A 73-YEAR-OLD woman had an 8-day history of a sudden, painless onset of hazy vision, and a scotoma in the inferior visual field of her right eye. Her medical history is remarkable for a cardiac bypass operation and a pneumonectomy for a lung carcinoma (classified as a lung carcinoma, with diaphragmatic invasion [T3], no lymph nodes involved [N0], and no metastasis [M0], or T3 N0 M0) 7 years ago. A pneumonectomy was performed at that time and the tumor was radically resected. On examination, her Snellen visual acuity was 20/60 OD and 20/20 OS. The ocular media were clear and the intraocular pressures were normal. Fundus examination of the right eye revealed a large, round, brownish tumor with a superficial hemorrhage (Figure 1). The left fundus was normal. Figure 1. View LargeDownload Funduscopy of the right eye reveals a well-circumscribed, large, round, brownish tumor. The location of the ruptured retinal arterial macroaneurysm (arrow), which is not clearly visible, is covered with superficial hemorrhage. Fundus appearance, A- and B-scan ultrasonography, and fluorescein angiography (Figure 2) were suggestive of a subretinal hemorrhage caused by a ruptured retinal arterial macroaneurysm. All blood investigations were normal, blood pressure level was not elevated, and chest x-ray films did not show signs of recurrence of the tumor. Figure 2. View LargeDownload Fluorescein angiography of the same eye, late frame (4.5 minutes). A large area of hypofluorescence is seen. The second bifurcation of the superior temporal artery is masked by a round area (arrow) with some hyperfluorescence at the edge. The retinal arterial macroaneurysm cannot be seen. Six weeks later, the visual acuity of her right eye had improved to 20/25 OD. At this time, funduscopy (Figure 3) characteristically showed the retinal arterial macroaneurysm. Figure 3. View LargeDownload Right fundus 6 weeks later clearly shows the retinal arterial macroaneurysm (arrow). All of the superficial hemorrhage and most of the subretinal blood has been reabsorbed, leaving behind a degenerated retina. Comment Acquired retinal arterial macroaneurysms were first described as a clinical entity in 1973 by Robertson.1 There is a female preponderance and an association with systemic hypertension, diabetes mellitus, and cardiovascular disease.1,2 There are a few reports in the literature in which retinal arterial macroaneurysms with subretinal hemorrhage are mistaken for melanomas of the uvea3,4; unnecessary enucleations have been performed in the past.3,4 However, meticulous funduscopy, fluorescein angiography, ultrasonography, and an observation period can help to make the correct diagnosis. Corresponding author: Peter L. Fritsche, MD, University Hospital Vrije Universiteit, Department of Ophthalmology, De Boelelaan 1117, PO Box 7057, Amsterdam 1007 MB, the Netherlands. References 1. Robertson D Macroaneurysms of the retinal arteries. Trans Am Acad Ophthalmol Otolaryngol. 1973;77OP55- OP67Google Scholar 2. Rabb MFGagliano DATeske MP Retinal arterial macroaneurysms. Surv Ophthalmol. 1988;3373- 96Google ScholarCrossref 3. Cibis GWFratkin J Hemorrhage into retinoschisis diagnosed as malignant melanoma. Am J Ophthalmol. 1979;8796- 97Google Scholar 4. Perry HDZimerman LEBenson WE Hemorrhage from isolated aneurysm of a retinal artery: report of two cases simulating malignant melanoma. Arch Ophthalmol. 1977;95281- 283Google ScholarCrossref
Archives of Ophthalmology – American Medical Association
Published: Dec 1, 2000
Keywords: hemorrhage,cancer,retinal arterial macroaneurysm
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