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Year : 2022  |  Volume : 2  |  Issue : 2  |  Page : 453

Commentary: A thesaurus for aneurysms - Anomalous exudative complexes, capillary macroaneurysms, TelCaps, macro- microaneurysms

1 Department of Vitreo Retina, Sankara Eye Hospital, Shimoga, India
2 Department of Vitreo Retina and Ocular Oncology, Sankara Eye Hospital, Bangalore, India
3 Department of Vitreoretina, M M Joshi Eye Institute, Hubballi, Karnataka, India

Date of Web Publication13-Apr-2022

Correspondence Address:
Apoorva Ayachit
Department of Vitreoretina, M. M. Joshi Eye institute, Gokul Road, Hosur, Hubballi - 580 021, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_2900_21

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How to cite this article:
Sagar P, Shanmugam M, Ayachit G, Joshi S, Ayachit A. Commentary: A thesaurus for aneurysms - Anomalous exudative complexes, capillary macroaneurysms, TelCaps, macro- microaneurysms. Indian J Ophthalmol Case Rep 2022;2:453

How to cite this URL:
Sagar P, Shanmugam M, Ayachit G, Joshi S, Ayachit A. Commentary: A thesaurus for aneurysms - Anomalous exudative complexes, capillary macroaneurysms, TelCaps, macro- microaneurysms. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Aug 17];2:453. Available from: https://www.ijoreports.in/text.asp?2022/2/2/453/342986

The authors have submitted a well-documented case of a large, perifoveal aneurysm in diabetic retinopathy (DR).[1] Aneurysms of the retinal circulation usually involve arterioles or capillaries: microaneurysms affecting capillaries and macroanueryms affecting arterioles. It is well-known that in some eyes with diabetic macular edema (DME), there may be larger-than-usual aneurysms that are larger than microaneurysms and smaller than arterial macroaneurysms. These aneurysms arising from capillaries have a hyalinized appearance and show the presence of a white rim on color photographs (in some cases, the whitening can cover the entire aneurysm, as in this case). They typically have a hyperreflective wall on optical coherence tomography (OCT). As these are aneurysmal dilatations, they are ubiquitous, and may be present in other vascular retinopathies such as vein occlusions and even present in eyes with no evidence of DR or any other retinal vascular disease.[2] AA showed such a lesion in prepapillary arterial loops.[3] In a retrospective study, P. S. noted that DME due to such larger aneurysms shows a poor response to anti-Vascular endothelial growth factor (VEGF) agents and shows a better response to intravitreal steroids (unpublished data). Targeted photocoagulation of these larger aneurysms (enough to cause occlusion of these aneurysms) results in better resolution of macular edema in DME and RVO (unpublished data). In the present report, the authors report good response to dexamethasone implant which is concurrent with our observation.

Spaide et al. described retinal capillary macro aneurysms (RCM) as large, solitary, and persistent in eyes without other retinal vascular disease. The aneurysms in their series were >200 microns in size.[2] Lopez Luppo et al. found a difference in basement membrane and pericytes in small versus large microaneurysms. In larger aneurysms, there was increased matrix metalloproteinase (MMP)-9, which breaks down basement membrane proteins. MMPs decrease the integrity of the basement membrane and thus cause an aneurysmal expansion.[4] Based on this, Spaide et al. postulated that the expansion and exudation from these larger aneurysms may not be necessarily VEGF-dependent. This may explain the suboptimal response to anti-VEGF and better response to laser.

Farias. et al. described an even more generic term called telangiectatic capillaries (TC) to denote large aneurysms (>150 microns) in DR which showed up better on indocyanine green angiography (ICGA) owing to late and persistent staining.[5] To add to the existing descriptors, the term macro-microaneurysm was coined in a report by Gilani et al.[6]

Perifoveal exudative vascular anomalous complex (PEVAC) is a descriptive term rather than a disease entity and would be a misnomer. The large aneurysms are not always perifoveal and are a capillary dilatation, not an “anomalous complex.” Some larger aneurysms may not show exudation; thus, PEVAC does not cover those lesions.

A consensus has to be reached to define and use a single nomenclature to describe larger capillary aneurysms to avoid confusion. Interestingly, the debate about the terminology is illustrated in the letter to the editor by Sacconi (who elaborated on PEVAC) and the reply by Spaide.[7],[8] There is a continuum rather than any categorical distinction between microaneurysms, macro-microaneurysms, RCM, TC, and finally PEVAC. At best, these terms are descriptive entities for findings on imaging and are not meant to be diagnoses.

Our vote is for retinal capillary macroaneurysm because it is the least ambiguous.

  References Top

Nataraj A, Sheth J, Soman M, Nair U. Refractory perifoveal exudative vascular anomalous complex like lesion responding to intravitreal dexamethasone implant: A therapeutic challenge. Indian J Ophthalmol Case Rep 2022;2:449-52.  Back to cited text no. 1
  [Full text]  
Spaide RF, Barquet LA. Retinal capillary macroaneurysms. Retina 2019;39:1889-95.  Back to cited text no. 2
Ayachit AG, Sacconi R, Ayachit GS, Joshi S, Querques G. Perifoveal exudative vascular anomalous complex-like lesion as a complication of prepapillary arterial loops. Ophthalmic Surg Lasers Imaging Retina 2018;49:974-8.  Back to cited text no. 3
López-Luppo M, Nacher V, Ramos D, Catita J, Navarro M, Carretero A, et al. Blood vessel basement membrane alterations in human retinal microaneurysms during aging. Invest Ophthalmol Vis Sci 2017;58:1116-31.  Back to cited text no. 4
Castro Farías D, Matsui Serrano R, Bianchi Gancharov J, de Dios Cuadras U, Sahel J, Graue Wiechers F, et al. Indocyanine green angiography for identifying telangiectatic capillaries in diabetic macular oedema. Br J Ophthalmol 2020;104:509-13.  Back to cited text no. 5
Gilani F, Gal-Or O, Freund KB. Spontaneous rupture and involution of a “macro–microaneurysm” in diabetic retinopathy. Retina 2017;37:e73.  Back to cited text no. 6
Sacconi R, Cohen SY, Borrelli E, Bandello F, Souied EH, Querques G. Correspondence. Retina 2019;39:e48-9.  Back to cited text no. 7
Spaide RF. Reply. Retina 2019;39:e49-50.  Back to cited text no. 8


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