Recurrent Vitreous Hemorrhage from an Optic Nerve Retinal Arterial Macroaneurysm

To report a case of recurrent vitreous hemorrhage from an optic nerve retinal arterial macroaneurysm (ONRAM) successfully treated with intraoperative endolaser.

A 92-year-old woman on oral aspirin and warfarin anticoagulation for atrial fibrillation developed three episodes of dense vitreous hemorrhage from an ONRAM. Due to failure of the vitreous hemorrhage to clear spontaneously, a total of three pars plana vitrectomy (PPV) procedures were performed along with a 1.25-mg intravitreal bevacizumab injection after the third episode of hemorrhage. During the third PPV procedure, a 25-gauge 532-nm green diode laser endoprobe was used to deliver low-power (100 mW) and long-duration (500 ms) laser spots directly on the ONRAM to induce intraoperative shrinkage of the ONRAM.

After the endolaser treatment, the macroaneurysm showed involution due to fibrosis without any adverse effects on retinal circulation or visual field defect. No recurrence of vitreous hemorrhage was noted after 2 years of follow-up.

Oral anticoagulant use may have been responsible for the atypical clinical course in our patient. Laser photocoagulation, including intraoperative endolaser photocoagulation, may be considered in selected cases of symptomatic ONRAMs.