Surgical management of two cases with macular exudation from retinal macroaneurysms refractory to focal photocoagulation.

Purpose: To report two cases of macular exudations resulting from retinal arterial macroaneurysms (MaAs) refractory to focal photocoagulations that were treated with a new surgical technique including subretinal balanced saline solution (BSS) injection to dilute lipid-rich subretinal fluid (SRF) and facilitate absorption of the SRF, intentional retinal hole formation to direct SRF into the vitreous cavity, and laser photocoagulation posterior to the MaAs to prevent intraretinal fluid and SRF from reaching the fovea. Observations: A 70-year-old man with macular edema (ME) refractory to anti-vascular endothelial growth factor (VEGF) therapy was referred to our hospital. Fundus examination showed retinal arterial MaAs and hard exudations. He underwent laser photocoagulation, sub-Tenon injections of triamcinolone acetonide (STTA), and anti-VEGF therapies; the ME recured despite all treatments. Subretinal lipid-rich exudatoins from retinal arterial MaAs involved the macula, which led to severe vision loss. Therefore, vitrectomy with the new technique was planned to flush out the lipid-rich SRF and prevent new exudations from reaching the macula. Postoperatively, the SRF resolved completely and the ME has not reccured until 59 months postoperatively at his latest visit. The second patient was a 77-year-old woman with an epiretinal membrane and ME with sarcoidosis. She underwent anti-VEGF therapy, STTA injection, and focal laser photocoagulation. The vision-threatening ME persisted. She underwent vitrectomy with the new technique, and the macular exudation resolved promptly. The ME has not recurred 27 months postoperatively. Conclusions: Vitrectomy with this technique may be considered in cases with vision-threatening ME due to retinal MaAs resistant to combined multiple conventional treatments.