Microsoft Word - Irshad Haider Case R


 153

Case Report 

  

Retinal Artery Macroaneurysm with Hard 
Exudate 
 
Syed Irshad Haider, Sharif Hashmani, Sadaf shah 

 
Pak J Ophthalmol 2008, Vol. 24 No. 3 

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  . .  
See end of article for 
authors affiliations 
 
…  ………………………   
 
Correspondence to: 
Syed Irshad Haider 
 Hashmanis Hospital 
JM-75, Off M.A.Jinnah Road  
Jacob line Karachi 
 
Received for publication 
February’ 2008 
…  ………………………   

We report a case of retinal artery macroaneursym with hard exudates diagnosed 
at Hashmani Hospital, Karachi. Patient was a 60 year old woman with a history 
of hypertension. She reported to us for visual problems. On dilated fundus 
examination of right eye, fusiform arteriolar dilatation, central macular exudation, 
retinal hemorrhage along the superior temporal arcade was found. Retinal 
macroaneurysm was suspected by history, fundus finding and confirmed by 
fundus fluorescein angiography findings. 

 
etinal macroaneurysm is a localized dilatation 
of a retinal arteriole which usually occurs in 
the first three orders of the arterial tree. It has 

a predilection for elderly hypertensive women and 
involves one eye in 90% of case. Histological findings 
include macrovascular abnormalities (e.g. widening of 
the periarteriol capillary free zone, capillary dilation, 
nonperfusion, intra-arterial collaterals have been 
identified. Histological studies of the macroaneurysm 
show a break in the arterial wall, surrounded by a 
laminated layer of fibrin-platelet clot and blood. Lipid-
laden macrophages, hemosiderin, and fibrogial 
reaction are also observed. The pathophysiology 

formation of retinal macroaneurysm is associated with 
systemic hypertension in approximately 75% of 
patients and atherosclerotic disease, but serum lipid 
abnormalities also have been reported. About 10% of 
patient has focal arterial wall atheroma occurring at 
defect in the wall, which may be sites at risk of 
aneurysm formation. The aneurysm is sites of leakage 
of exudates and hemorrhage in the macula. Over time 
or after acute hemorrhage, spontaneous thrombosis 
and closure of the aneurysm may occur, in some cases, 
the artery may return to normal. 

 

R 



 154

CASE REPORT 
A 60 years old women presented with decreased 
vision in right eye. There was history of hypertension. 
On ocular examination the visual acuity (VA) in her 
right eye was 6/60 while in left eye was 6/12. The 
right eye was which could not be improved with 
glasses but left eye VA improved with glasses to 6/9. 
On silt lamp biomicroscopy examination the anterior 
segment of both eyes were normal. Intraocular 
pressure (IOP) was 16mmHg right eye and was 18 mm 

Hg left eye. On dilated fundus examination with +90D 
lens revealed right eye a saccular or fusiform arteriolar 
dilatation and associated retinal hemorrhage with 
hard exudation at the macula. The left eye fundus was 
normal. In fluorescein angiography findings during 
the venous phase demonstrating delayed filling of the 
retinal macroaneurysm with fluorescien dye. The 
aneurysm is obscured partially by the presence of  
 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
hemorrhage, but filling by the dye enhance visuali-
zation. During late phase showing complete filling of 
retinal macroaneurysm with late leakage. 
 
DISCUSION 
A retinal macroaneursym are acquired, dilatation of 
the large arterioles of the retina. This condition occurs 
most commonly in the sixth to seventh decade of life. 
The most common risk factor is hypertension 
generalized arterial sclerosis, serum lipid abnormal-

lities, vulsalva maneuver. The clinical features of 
macroaneurysm are impairment of central vision due 
to macular edema and hard exutadates formation. 
Sudden visual loss resulting from vitreous hemorr-
hage is uncommon. On fundus examination a saccular 
or fusiform arteriolar dilatation, associated with 
retinal hemorrhage is present in 50% of cases. Chronic 
leakage resulting in retinal edema with accumulation 
of hard exudates at the fovea is common and may 
result in permanent loss of central vision. The 



 155

management of retinal macroanesysms are control 
hypertension, serum lipids and laser photocoagu-
lation, laser hyaloidotomy. 
 
DIFFERENTIAL DIAGNOSIS: 
Hard exudates at the posterior pole 
• Background diabetic retinopathy. 
• Exudative age-related macular degeneration. 
• Exudative telangiectasia. 
• Old retinal branch vein occlusion. 
• Small retinal capillary haemangioma. 
• Radiation retinopathy. 
 
Deep Retinal or Subretinal Hemorrhages at the 
Posterior Pole. 
• Choroidal neovascularization. 
• Vulsulva retinopathy. 
• Idiopathic polypoidal choroidal vasculopathy. 
• Blunt ocular trauma. 
• Choroidal melanoma. 
• Terson syndrome associated with subarachnoid 

hemorrhage. 

 

CONCLUSION 
The visual prognosis is excellent for many patient. The 
natural history of macroaneurysm suggests that most 
close spontaneously with restoration of near normal 
vision. Chronic macular exudation and hemorrhage 
can lead to vision loss, which is an indication to 
consider laser photocoagulation. A study suggest that 
patient with pre-retinal hemorrhage or vitreous 
hemorrhage due to retinal macroaneurysms have a 
good visual prognosis, however, patients with subma-
cular hemorrhage have a poor visual prognosis. 
 
Author’s affiliation 
Dr. Syed Irshad Haider 
Hashmanis Hospital, JM-75, Off M.A. 
Jinnah Road, Jacob line Karachi 
Dr. Sharif Hashmani 
Hashmanis Hospital, JM-75, Off M.A. 
Jinnah Road, Jacob line Karachi 
Dr. Sadaf Shah 
Hashmanis Hospital, JM-75, Off M.A. 
Jinnah Road, Jacob line Karachi