Question of the Week

A 78-year-old female with a history of HTN, coronary artery disease, prior CVA, and CKD presents with a new, painless central blind spot in the left eye, first noticed several weeks earlier and has been stationary since onset. She denies flashes, curtain-like visual field defect, headache, or trauma, though she does report a recent bout of constipation with straining around the time her symptoms began. She also reports that her systolic blood pressure was in the 180s around symptom onset.

Visual acuity is 20/30 OD and count fingers at 1 foot OS. Dilated fundus examination of the left eye reveals trace vitreous hemorrhage along with a raised area of subretinal hemorrhage near the fovea, extending inferiorly. The retinal periphery is flat, retinal vessels appear of normal caliber, and the optic nerve appears healthy. The right eye is unremarkable aside from a few peripheral drusen.

Over the following weeks, serial examinations show the hemorrhage gradually organizing into fibrosis that continues to extend toward the fovea despite conservative monitoring. Follow-up exams also reveal mild arteriolar tortuosity, vascular nicking, and a streak of hemorrhage tracking along a retinal arteriole adjacent to the area of blood. OCT of the left eye is shown below.

What is the most likely diagnosis?

A. Ruptured retinal arterial macroaneurysm

B. Valsalva retinopathy

C. Neovascular age-related macular degeneration (wet AMD)

D. Retinal vein occlusion

E. Proliferative diabetic retinopathy with vitreous hemorrhage

Answer

Answer: A

The pattern of hemorrhage here is the key clue — blood spanning multiple retinal layers (vitreous, subretinal, and by implication intraretinal) in an older, hypertensive patient is classic for a ruptured RAM, which is an acquired focal dilation of a retinal arteriole that can present through hemorrhage, exudation, or both. The vascular findings that emerge on follow-up — arteriolar tortuosity, nicking, and a hemorrhage streak tracking along a single arteriole — point directly to a focal vascular lesion rather than a diffuse process, and the continued extension of fibrosis toward the fovea despite conservative management is typical of an organizing macroaneurysm-related hemorrhage.

B. Valsalva retinopathy: The key distractor given the straining history, but classic Valsalva hemorrhage is preretinal or sub-internal limiting membrane, from a sudden rise in intraocular venous pressure. It does not typically produce a multilayered, subretinal pattern, and it would not be expected to progress over weeks in the way this hemorrhage did.

C. Neovascular AMD: Reasonable in an elderly patient with subretinal blood, but there is no drusen, pigment epithelial detachment, or classic choroidal neovascular membrane in the affected eye, and the hemorrhage is more extensive and multilayered than typical for a CNV bleed.

D. Retinal vein occlusion: Would be expected to produce diffuse, flame-shaped hemorrhages in a venous distribution with widespread vascular dilation and tortuosity, rather than a focal multilayered hemorrhage centered at the macula with a single affected arteriole.

E. Proliferative diabetic retinopathy with vitreous hemorrhage: One of the most common causes of sudden vision loss from intraocular hemorrhage overall, but the vignette gives no history of diabetes and no exam evidence of retinal neovascularization or other diabetic changes.