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Retinal Artery Macroaneurysm −An Uncommon
Manifestation of Radiation Retinopathy
Divyansh Mishra, Mahesh Shanmugam, Sonali Lomte, Rajesh Ramanjulu, Surendra Pal
Department of Vitreoretina, Sankara Eye Hospital, Banglore, Karnataka, India
Abstract
To describe two cases of radiation retinopathy (RR) presenting with clinical and imaging characteristics of retinal artery macroaneurysm
(RAM). The first case had radiotherapy to the right side of the brain 17 years prior to ocular manifestation, developed vitreous hemorrhage
secondary to RAM in the right eye (RE) was managed with intravitreal anti-vascular endothelial growth factor. Second case had radiotherapy
to right side of neck 6 years back, developed multiple tributary vein occlusions in RE, and was treated with sectoral laser. One year later,
developed premacular and subretinal hemorrhage with RAM and managed with pars planavitrectomy and anti-VEGF. On subsequent follow
up second patient had persistent cystoid macular edema which was managed with intravitreal triamcinolone acetonide and focal laser to RAM.
Keywords: Radiation retinopathy (RR), retinal artery macroaneurysm (RAM), Macular edema
Key Messages: Retinal artery macroaneurysm (RAM) although uncommon can present as radiation retinopathy.
INTRODUCTION
Radiotherapy for cancers of the head and neck can result in
radiation retinopathy (RR).
[1]
Therapeutic doses can cause
RR between 6 months and 3 years post radiotherapy,
with devastating visual outcomes.
[2]
Retinal artery
macroaneurysms (RAMs) are round or fusiform dilatation
of retinal arteries that occur within first three branches of
retinal arteries. It is commonly observed in elderly females
with hypertension.
[3]
In our cases, we highlight RAM as an
unusual manifestation of RR which to the best of our
knowledge has not been reported in any literature.
CASE REPORTS
Case 1
A 33 year old male ,with history of radiotherapy to right side
of brain 17 years before for hemangiopericytoma type 2
which is now in complete remission, presented with
sudden painless diminution of vision in right eye (RE) of
2 days duration. He had no history of diabetes mellitus,
hypertension, or any other systemic illness. External
examination of the face showed right temporalis muscle
atrophy [Figure 1a,b]. His best corrected visual acuity
(BCVA) was 6/36 in RE and 6/6 in left eye (LE). Anterior
segment (AS) of RE showed corneal filaments with punctate
epithelial erosions and posterior chamber intraocular lens
(had cataract surgery 17 years before), LE was normal.
Schirmer test was 7 mm in RE and 19 mm in LE. Dilated
fundus examination of RE demonstrated vitreous and
preretinal hemorrhage with subretinal yellow deposits
suggestive of hard exudates along the superotemporal
arcade, LE was normal. He was advised to maintain
restricted activity. On review 2 weeks later, vitreous
hemorrhage had significantly regressed and fundus view
was better than at the time of the presentation [Figure 1c].
Fundus fluorescein angiography (FFA) of RE [Figure 1d–f]
showed perifoveal microaneurysm suggestive of
microangiopathy and vitreous hemorrhage with no signs of
Address for correspondence: Dr Sonali Lomte, Department of Vitreoretina,
Sankara Eye Hospital, Kundalhalli Gate, Airpor t, Varthur Road, Banglore
560037, Karnataka, India.
E-mail: spl11sep@gmail.com
Received: 19 June 2021 Revised: 19 December 2021
Accepted: 28 February 2022 Published: 9 December 2022
This is an open access journal, and articles are distributed under the terms of the
Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows
others to remix, tweak, and build upon the work non-commercially, as long as
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For reprints contact: reprints@medknow.com
How to cite this article: Mishra D, Shanmugam M, Lomte S, Ramanjulu
R, Pal S. Retinal Artery Macroaneurysm −An Uncommon Manifestation
of Radiation Retinopathy. Niger J Ophthalmol 2022;30:123-7.
Access this article online
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Website:
www.nigerianjournalofophthalmology.com
DOI:
10.4103/njo.njo_38_21
Case Report
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neovascularization indicating haemorrhage secondary to
RAM. RE optical coherence tomography (OCT)
[Figure 2a] through fovea showed normal foveal contour,
with preretinal hyperreflective material temporally
suggestive of hemorrhage with some intraretinal
hyperreflective foci and minimal retinal thickening. OCT
angiography of RE [Figure 2b] did not show any preretinal
neovascularization. Patient was treated with RE intravitreal
anti-VEGF Bevacizumab (1.25 mg/0.05 mL). At 1 month of
follow-up, BCVA in RE was 6/6. RE fundus examination
showed significantly decreased vitreous and preretinal
hemorrhage. OCT of RE [Figure 2c] revealed RAM which
was masked by hemorrhage and dry fovea with minimal
intraretinal fluid temporal to fovea.
Case 2
A 67-year-old male with history of intravenous chemotherapy
and radiation to right side of the neck 6 years back for neck
cancer came for routine examination. He had no history of
hypertension, diabetes mellitus, or any other systemic illness.
External examination of the face showed right torticollis with
neck stiffness. His BCVA was 6/9 in RE and 6/6 in LE. AS of
both eyes was normal. Dilated fundus examination of RE
[Figure 3a] demonstrated microaneurysms at the posterior
pole with multiple peripheral venous sclerosis. LE was
normal [Figure 3b]. FFA [Figure 3c–e] of the RE revealed
hyperfluorescence due to telangiectasia over posterior pole
and multiple peripheral areas of hypofluorescence due to
capillary nonperfusion (CNP), LE was normal. He was
diagnosed to have nonproliferative RR and sectoral laser
was performed to CNP areas. He was lost to follow-up
and came 1 year later with complaints of diminution of
vision in RE since 2 months. His BCVA was 6/60 in RE
and 6/6 in LE. AS of RE showed nuclear sclerosis cataract and
LE was normal. Dilated fundus examination of RE
demonstrated hemorrhagic RAM along the superior
temporal arcade with subhyaloid and subretinal
hemorrhage, peripheral retina showed laser scars. LE was
normal. The OCT [Figure 4a] showed preretinal material
shadowing foveal details, intraretinal hyperreflectivity along
the superior temporal vessel suggestive of RAM with
subretinal fluid (SRF) and intraretinal hyperreflective
material. He underwent RE phacoemulsification with
intraocular lens (IOL) implantation, pars plana vitrectomy
with internal limiting membrane peeling and intravitreal anti-
VEGF. At 1 month of follow-up, RE revealed resolving
hemorrhages and RAM lesion with peripheral laser scars
and dull foveal reflex. OCT [Figure 4b] showed cystoid
macular edema (CME) and RAM with minimal SRF.
Intravitreal triamcinolone acetonide (IVTA) 2 mg with
adjunct focal laser was performed to the RAM. One month
after IVTA, BCVA was 6/24 in RE and 6/6 in LE. AS of RE
showed posterior chamber intraocular lens (PCIOL), LE was
normal. Dilated fundus examination of RE demonstrated
involuted RAM with dry fovea and IVTA particles with
Figure 1: (a,b) Radiation sequelae and (c) fundus photograph of right eye (RE) showing vitreous and preretinal hemorrhage, subretinal yellow deposits
along superior temporal arcade, (d–f) fundus fluorescein angiography of RE showing focal hyperfluorescence due to microvascular abnormalities,
blocked fluorescence due to preretinal and vitreous hemorrhage and late hyperfluorescence along the superotemporal artery likely RAM.
Mishra, et al.: Retinal artery macroaneurysm
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peripheral laser marks, LE was normal. OCT RE [Figure 4c]
showed resolved CME.
DISCUSSION
Radiation retinopathy, a frequently encountered complication
of radiotherapy for ocular and periorbital cancers, is believed
to be linked to dose, duration of treatment, and concomitant
systemic factors.
[4-6]
Management of complications of RR
such as macular edema and proliferative disease includes
intravitreal anti-VEGF, IVTA, laser photocoagulation,
hyperbaric oxygen, pentoxifylline, photodynamic therapy
(PDT), and vitrectomy.
[7,8]
The RR typically presents with any combination of the
following findings: macular edema, optic disc edema,
Figure 2: (a) Optical coherence tomography (OCT) scan of right eye showing dry fovea with preretinal and intraretinal hyperreflective material, (b) no
preretinal neovascularization observed on vitreoretinal slab of OCTA, (c) OCT following anti-VEGF showing round cavity with hyperreflective wall and
dark lumen suggesting RAM (blue arrow) with intraretinal fluid temporal to fovea.
Figure 3: (a,b) Fundus photo of right eye (RE) showing perifoveal microaneurysms, left eye (LE) normal, (c,d) fundus fluorescein angiography (FFA)
of RE showing hyperfluorescence due telangiectasia over posterior pole and hypofluorescence due to capillary nonperfusion areas, (e) LE FFA no
significant abnormality noted.
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telangiectasias, microaneurysms, cotton–wool spots, hard
exudates, CNP, and retinal pigment epithelial atrophy, with
advancement to proliferative disease which include vitreous
hemorrhage, neovascular glaucoma, optic neuropathy, and
tractional retinal detachment.
[6]
However, to the best of our knowledge, RAM presenting as
manifestation of RR has never been reported before. RAM is
reported commonly in elderly females with hypertension and
cardiovascular diseases. In our case, patient had radiation
history to the face and he developed radiation sequelae to the
face and eye on the same side. The factors that favor radiation
retinopathy at the primary presentation are the faster
progression to cataract when compared with other eye in
both cases, multiple perifoveal microaneurysms in the first
case and perifoveal microaneurysm with peripheral CNP
areas in the second case. Thus, later development of RAM
can also be associated with the RR and age acting as additive
factor for the same in the second case.
Intracranial aneurysm following radiotherapy for head and
neck cancer has been reported.
[9]
Similarly, coexistence
between RAM and cerebral aneurysm has been
reported.
[10]
Hence, we postulate that the pathophysiologic
mechanism of radiation induced RAM is likely to resemble
that of radiation-induced cerebral aneurysm, in which initial
endothelial injury caused by radiation results in aneurysmal
change.
Our patients did not have proliferative disease and vitreous
hemorrhage was secondary to the RAM. These cases
highlight the importance of careful review of past radiation
history of an isolated RAM found in one eye of the patient.
The treatment of radiation-induced RAM is same as that of
other RAM, but patients should be followed up closely to
Figure 4: (a) Right eye optical coherence tomography (OCT) showing hyperreflective membrane in vitreoretinal interface suggestive of preretinal
hemorrhage and intraretinal hyperreflectity suggestive of retinal artery macroaneurysm (RAM) with subretinal fluid (SRF), (b) OCT 1 month post-op
showing cystoid macular edema (CME) and RAM with SRF, (c) OCT 1 month after intravitreal triamcinolone acetonide showing resolved CME and
completely involuted RAM.
Mishra, et al.: Retinal artery macroaneurysm
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check for the development of macular edema and
proliferative disease due to radiation.
CONCLUSION
In our cases, patients with history of radiotherapy, in the
absence of other systemic illnesses, clinical and imaging
characteristics, rendered RAM secondary to radiation a
likely diagnosis. RAM as sequel of radiotherapy and its
management is not been reported before in literature.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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