Spontaneous Rupture and Involution of a “Macro–Microaneurysm” in Diabetic Retinopathy

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Unusually large microaneurysms (MAs) are a common finding in Coats disease but may also occur in various other retinal vascular disorders including retinal vein occlusion and diabetic retinopathy.1,2 Most very large microaneurysms are found in the peripheral retina, but some may present in the macula where they have been whimsically termed “macro-microaneursyms.” (Personal communication, Lawrence A. Yannuzzi, MD). Herein, we present the multimodal imaging findings of a retinal macro–microaneurysm related to diabetic retinopathy that showed spontaneous involution after rupture.
A 73-year-old man was referred for management of diabetic macular edema. Funduscopic examination showed retinal hemorrhages and edema surrounding a single MA in his left eye (Figure 1A). Despite treatment with intravitreal aflibercept (2.0 mg/0.05 mL), the lesion continued to enlarge, reaching a maximal diameter of 510 μ (Figure 1A, inset, upper right). En face and cross-sectional optical coherence tomography angiography (OCT angiography) (Figure 1A, middle and right) showed individual capillaries feeding and draining the aneurysm with minimal flow detected within the lesion itself. Seventeen months after presentation, the patient reported a sudden change in vision associated with spontaneous rupture (Figure 1B, left). En face OCT angiography and structural OCT with flow overlay showed nearly absent flow within the lesion and in surrounding intraretinal hyperreflective material representing hemorrhage (Figure 1B, middle and right). The loss of flow signal may have been partly related to shadowing from the hemorrhage. Treatment was discontinued, and 2 months later, examination and imaging showed near-complete resolution of hemorrhage and edema related to involution of the aneurysm (Figure 1C).
Recent studies have shown the use of OCT angiography in the study of capillary dropout and neovascularization occurring in diabetic retinopathy.3,4 Our case further demonstrates how OCT angiography can provide highly detailed images of retinal blood flow which improves our ability to study the microvascular remodeling occurring in diabetic retinopathy and other retinal vascular diseases.
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