Periretinal Hemorrhage Due to Retinal Arterial Macroaneurysm: The Role of ICG Angiography in Solving a Diagnostic Dilemma

A 65-year-old woman presented with sudden visual loss of 2 weeks’ duration in her right eye. She had a 20-year long history of systemic hypertension, ischemic heart disease and coronary artery angioplasty. Best-corrected visual acuity was counting fingers at 1m in her right eye and 20/30 in the left with trace positive relative afferent pupillary defect in the right eye. The only remarkable slitlamp finding was mild bilateral nuclear cataracts, intraocular pressure was 12 mmHg in both eyes. Fundus examination revealed 1+ media haziness secondary to mild vitreous hemorrhage in the right eye, normal optic disc, and a dense premacular hemorrhage with a subretinal component superiorly (Figures 1, 2). Funduscopy in the left eye disclosed signs of dry type age-related macular degeneration (AMD) manifesting as moderate-sized hard drusen and mild pigmentary derangement. Retinal vascular tortuosity and arterial narrowing due to hypertensive retinopathy and arteriolar sclerosis were noted in both eyes. Differential diagnoses of the condition included retinal vascular accidents such as branch retinal vein occlusion (BRVO), choroidal neovascularization (CNV) due to neovascular AMD, and retinal arterial macroaneurysm (RAM). Indocyanine green angiography (ICGA) with HRA2 (Heidelberg Retina Angiograph 2) demonstrated a macroaneurysm in the superior temporal arterial branch which had been obscured by preretinal hemorrhage on funduscopy. Other angiographic findings included blockage of retinal vessels due to layering subhyaloid hemorrhage and blockage of choroidal vessels due to subretinal hemorrhage superior to the former. The involved artery had focal tortuosity in the form of a Z-shaped kink near the aneurysm (Figures 3-5).