Question of the Week

A 79 year old woman with a long history of poorly controlled hypertension presents with acute, painless decreased vision in her right eye. Visual acuity is 20/100 OD and 20/40 OS. Fundus examination of the right eye reveals a round, saccular dilation along a second order retinal arteriole in the superotemporal arcade, associated with surrounding intraretinal hemorrhage, hard exudates, and macular edema. There is no neovascularization. Optical coherence tomography confirms center involving macular edema with subretinal fluid. Fluorescein angiography shows early focal hyperfluorescence with late leakage from the arteriole lesion.

Which of the following is the most appropriate management to address this patient’s vision loss?

A. Observation with strict systemic blood pressure control only
B. Panretinal photocoagulation
C. Focal laser photocoagulation to the arteriole lesion
D. Immediate pars plana vitrectomy
E. High dose systemic corticosteroids

Answer

Correct answer: C. Focal laser photocoagulation to the arteriole lesion

This patient has a leaking arteriole aneurysmal lesion along a second order retinal artery with center involving macular edema, hard exudates, and late leakage on fluorescein angiography, all of which indicate active exudation causing vision loss. In this setting, observation alone is inappropriate because ongoing leakage places the fovea at risk for persistent edema and permanent visual impairment.

Focal laser photocoagulation directed to the aneurysmal lesion or applied perilesionally is the preferred treatment for symptomatic, exudative lesions with macular involvement, as it promotes thrombosis and involution of the aneurysm, reduces vascular leakage, and facilitates resolution of macular edema. This approach has been shown to improve or stabilize visual acuity in patients with vision threatening exudation.

Panretinal photocoagulation is reserved for ischemic retinal diseases with neovascularization and does not address focal arterial leakage. Pars plana vitrectomy is indicated for nonclearing vitreous hemorrhage rather than exudative macular disease. Systemic corticosteroids do not treat the underlying focal arterial pathology.