Optical Coherence Tomography Angiography Features and Flow-Based Classification of Retinal Artery Macroaneurysms

<b>Objectives:</b> We propose a flow-signal-based classification of retinal artery macroaneurysms (RAMs) using Optical Coherence Tomography Angiography (OCTA) and compare the findings with fundus fluorescein angiography (FFA). <b>Methods:</b> A retrospective review of 49 RAM cases observed over 6 years (October 2017-March 2023) at a medical retina clinic at the University Hospital Southampton, UK. Electronic clinical records, FFA, and OCTA images (en face and B-scan) were reviewed to identify pathology and assess RAM flow profiles. <b>Results:</b> In total, 30 eyes from 30 patients were included. The mean age of the patients was 76 years (range 49-91), with 17 females and 13 males. All eyes underwent OCTA, enabling classification of RAMs into three flow signal types: high (9 eyes), low (10 eyes), and absent (9 eyes), while 2 eyes had haemorrhage-related artefacts. A subgroup of 13 eyes also underwent FFA, allowing direct comparison, which showed flow profiles similar to those of OCTA: high (4 eyes), low (6 eyes), and absent (2 eyes), with 1 ungradable case due to subretinal haemorrhage masking. A discrepancy in flow was observed in one case where FFA indicated flow, but OCTA did not. Despite this, FFA and OCTA generally agreed on the flow levels, with a Spearman correlation of r = 0.79 (<i>p</i> = 0.004). <b>Conclusions:</b> OCTA flow profiles were directly comparable to FFA. OCTA effectively identified different levels of blood flow signal behaviour in RAMs. The proposed flow-based RAM classification may aid in prognosis, treatment indications, follow-up, and safe repeat imaging in clinical practice without systemic risk to the patient.