Retinal Macroaneurysm MCQ Examination for Retina Fellowship Board
Question 1
A 68-year-old hypertensive woman presents with sudden painless vision loss. Fundus examination reveals a large intraretinal hemorrhage in the superotemporal arcade. What is the most common location for retinal arterial macroaneurysms?
A. Within the optic disc margin
B. Within the first three orders of arterial bifurcation
C. At arteriovenous crossing points
D. In the peripheral retina beyond the equator
Answer: B
Explanation: Retinal arterial macroaneurysms are acquired saccular or fusiform dilatations that occur within the first three orders of bifurcation of the central retinal artery, typically in the posterior pole 1, 2. This distinguishes them from peripheral vascular abnormalities and makes them accessible to clinical examination and treatment.
Question 2
Which demographic group has the highest incidence of retinal arterial macroaneurysms?
A. Young hypertensive men
B. Elderly hypertensive women
C. Middle-aged diabetic men
D. Young women with autoimmune disease
Answer: B
Explanation: Retinal arterial macroaneurysms occur most commonly in elderly women with systemic vascular conditions such as hypertension and arteriosclerotic disease 1. The association with female gender and advanced age is well-established in the literature 3, 4.
Question 3
What is the most commonly reported presenting symptom of retinal arterial macroaneurysm?
A. Eye pain
B. Photopsia
C. Sudden vision loss
D. Gradual vision decline
Answer: C
Explanation: The primary reported symptom is sudden loss of vision, typically due to hemorrhage (subretinal, intraretinal, preretinal, or vitreous) or macular edema with associated lipoprotein exudation 3, 1. Many patients may be asymptomatic if the macula is not involved 3.
Question 4
A patient with a retinal macroaneurysm presents with counting fingers vision. Fluorescein angiography shows a focal hyperfluorescent lesion with late leakage. What is the most appropriate initial management?
A. Immediate panretinal photocoagulation
B. Intravitreal anti-VEGF injection
C. Observation with systemic hypertension control
D. Vitrectomy
Answer: C
Explanation: Most retinal arterial macroaneurysms regress spontaneously without treatment and without causing decreased visual acuity 1. Observation is often adequate treatment, with the critical step being identification and co-management with primary care for hypertension control 2. Treatment is reserved for cases with macular threat or involvement 2.
Question 5
Which systemic condition is MOST strongly associated with retinal arterial macroaneurysms?
A. Diabetes mellitus
B. Systemic hypertension
C. Hyperlipidemia
D. Chronic kidney disease
Answer: B
Explanation: Retinal arterial macroaneurysms are strongly associated with systemic hypertension and arteriosclerotic disease 3, 1, 4. While other cardiovascular risk factors may coexist, hypertension is the predominant systemic association requiring workup and management 2.
Question 6
What type of hemorrhage pattern is characteristic of a ruptured retinal arterial macroaneurysm?
A. Flame-shaped hemorrhages only
B. Dot-blot hemorrhages only
C. Multilevel retinal hemorrhage (subretinal, intraretinal, preretinal, and/or vitreous)
D. Isolated vitreous hemorrhage
Answer: C
Explanation: Retinal arterial macroaneurysms can cause multilevel retinal hemorrhage involving subretinal, intraretinal, preretinal, or vitreous spaces 3, 4. This multilevel pattern is characteristic and helps distinguish macroaneurysms from other causes of retinal hemorrhage 4.
Question 7
A 72-year-old woman with a retinal macroaneurysm has 20/200 vision due to subfoveal hemorrhage. What is the most likely long-term visual outcome predictor?
A. Size of the macroaneurysm
B. Presence of subfoveal hemorrhage and foveal exudates
C. Patient age
D. Duration of hypertension
Answer: B
Explanation: Poor visual outcome may occur secondary to foveal exudates and subfoveal hemorrhage 1. These complications directly affect the foveal architecture and are the primary determinants of final visual acuity, whereas most macroaneurysms without these complications have good prognosis 1, 2.
Question 8
When is direct laser photocoagulation indicated for retinal arterial macroaneurysm?
A. In all cases at diagnosis
B. Only when central vision is reduced or threatened
C. When the macroaneurysm is larger than 500 microns
D. When systemic hypertension is uncontrolled
Answer: B
Explanation: Laser photocoagulation may be applied directly to the macroaneurysm or to affected retinal capillary beds if central vision is reduced or threatened 3. Since most lesions spontaneously involute without visual consequence, treatment is reserved for cases with macular involvement or threat 3, 2.
Question 9
What is the natural history of untreated retinal arterial macroaneurysms?
A. Progressive enlargement requiring treatment
B. Spontaneous involution without visual consequence in most cases
C. Conversion to neovascularization
D. Development of retinal detachment
Answer: B
Explanation: Most retinal arterial macroaneurysms spontaneously involute without treatment and without causing decreased visual acuity 3, 1. This favorable natural history supports observation as the primary management strategy in cases without macular threat 2.
Question 10
A patient presents with sudden vision loss and multilevel hemorrhage. Fluorescein angiography is planned. What is the key diagnostic finding on FA for retinal macroaneurysm?
A. Capillary non-perfusion
B. Focal hyperfluorescent lesion with late leakage
C. Diffuse retinal vascular leakage
D. Choroidal neovascular membrane
Answer: B
Explanation: Fluorescein angiography demonstrates a focal hyperfluorescent lesion corresponding to the macroaneurysm with characteristic late leakage 4. This finding confirms the diagnosis and helps differentiate macroaneurysms from other causes of retinal hemorrhage 4, 2.
Question 11
Which laser wavelength was specifically studied and shown effective for treating retinal macroaneurysms?
A. Argon green (514 nm)
B. Yellow dye (577 nm)
C. Red diode (810 nm)
D. Micropulse (577 nm)
Answer: B
Explanation: The yellow (577 nm) wavelength of an ophthalmic tunable dye laser was studied in twelve patients with retinal macroaneurysms, achieving obliteration of the macroaneurysm with resolution of hemorrhage, exudate, edema, or serous macular detachment in all cases, with visual improvement in eight of twelve cases and no complications 5.
Question 12
What is the appropriate systemic workup for a patient newly diagnosed with retinal arterial macroaneurysm?
A. Hypercoagulability panel
B. Blood pressure monitoring and cardiovascular risk assessment
C. Carotid duplex ultrasound
D. Echocardiography
Answer: B
Explanation: Given the high incidence of associated systemic disease, particularly hypertension and arteriosclerotic disease, proper systemic workup focuses on blood pressure control and cardiovascular risk assessment 4. Co-management with primary care for hypertension control is crucial 2.
Question 13
A 59-year-old hypertensive man presents with counting fingers vision and multilevel hemorrhage from a retinal macroaneurysm. At 6-month follow-up after observation alone, what is the expected visual outcome?
A. No improvement expected
B. Improvement to 20/200 or better
C. Improvement to 20/40 or better
D. Progressive vision loss
Answer: C
Explanation: In the reported case of a similar patient with counting fingers vision at presentation, hemorrhage resolved without treatment and visual acuity returned to 20/25 by the 6-month follow-up visit 4. This demonstrates the favorable natural history with spontaneous resolution in many cases 1, 4.
Question 14
Which of the following is NOT a typical sequela of retinal arterial macroaneurysm?
A. Retinal hemorrhage
B. Macular edema
C. Retinal neovascularization
D. Serous macular detachment
Answer: C
Explanation: The sequelae of retinal macroaneurysms include retinal hemorrhage, exudate, edema, and serous detachment of the macula 5. Retinal neovascularization is not a characteristic complication of macroaneurysms, distinguishing them from ischemic retinal vascular occlusions 3, 1.
Question 15
What is the morphologic classification of retinal arterial macroaneurysms?
A. Capillary or venous
B. Saccular or fusiform
C. Proliferative or non-proliferative
D. Ischemic or non-ischemic
Answer: B
Explanation: Retinal arterial macroaneurysms are acquired saccular or fusiform dilatations of the large arterioles of the retina 1. This morphologic classification helps characterize the lesion and distinguish it from other vascular abnormalities 2.
Question 16
A patient with a retinal macroaneurysm has lipoprotein exudation threatening the fovea but no hemorrhage. What is the mechanism of vision loss in this scenario?
A. Ischemia
B. Macular edema with exudation
C. Vitreous traction
D. Epiretinal membrane formation
Answer: B
Explanation: Vision loss may occur as a result of macular edema with associated lipoprotein exudation, in addition to hemorrhage 3. Foveal exudates are one of the causes of poor visual outcome 1.
Question 17
What is the primary reason retinal arterial macroaneurysms have many differential diagnoses?
A. They are extremely rare
B. The clinical presentation is highly variable
C. They only occur in young patients
D. They always present with pain
Answer: B
Explanation: The clinical presentation of a retinal arterial macroaneurysm is highly variable, making initial diagnosis difficult and differentials many 2. This variability in presentation requires thorough investigation to distinguish macroaneurysms from retinal and systemic diseases 3.
Question 18
In a patient with retinal macroaneurysm treated with yellow dye laser, what was the treatment endpoint?
A. Complete vessel occlusion
B. Obliteration of the macroaneurysm
C. Reduction in hemorrhage only
D. Improvement in visual acuity
Answer: B
Explanation: In all treated cases, the macroaneurysm was "obliterated" with resolution of hemorrhage, exudate, edema, or serous macular detachment 5. Obliteration of the lesion is the treatment goal, which then leads to resolution of secondary complications 5.
Question 19
Which additional systemic vascular finding is associated with retinal arterial macroaneurysms?
A. Retinal emboli
B. Carotid stenosis
C. Atrial fibrillation
D. Peripheral vascular disease
Answer: A
Explanation: Retinal arterial macroaneurysms are associated with systemic hypertension, arteriosclerosis, retinal emboli, and cardiovascular disease 3. The presence of retinal emboli suggests shared embolic or atherosclerotic pathophysiology 3.
Question 20
What is the most important reason for optometrists and ophthalmologists to be familiar with retinal arterial macroaneurysms?
A. They require immediate surgical intervention
B. They frequently manifest as isolated phenomena but require investigation for systemic disease
C. They always cause permanent vision loss
D. They are the most common cause of retinal hemorrhage
Answer: B
Explanation: While retinal arterial macroaneurysms frequently manifest as isolated phenomena with few symptoms, their differential diagnosis includes retinal and systemic diseases that require thorough investigation 3. Identification is crucial to appropriately co-manage with primary care for hypertension control 2, and proper knowledge of necessary systemic workup is critical given the high incidence of associated systemic disease 4.