Myopic Simple Hemorrhage Presenting as Radial Hemorrhage in Henle’s Fiber Layer

Abstract

This case report describes a simple hemorrhage (SH) presenting as radial hemorrhage in Henle’s fiber layer (HFL) in a patient with high myopia. A 26-year-old girl with high myopia was referred to our center for sudden onset of decreased vision and a central scotoma in the right eye (OD). Best corrected visual acuity (BCVA) was 20/100 OD. Fundus examination showed a stellate intraretinal hemorrhage in the fovea of the OD. The hemorrhage was organized in a peculiar petaloid pattern with feathery distal edges, suggesting localization within the radially oriented HFL. The presence of both choroidal neovascularization and microvascular abnormalities consistent with macular telangiectasia type 2 (MacTel 2) were excluded. Based on these findings, a diagnosis of myopic SH was made. At 4-month follow-up BCVA OD spontaneously improved to 20/40, without any treatment been ever administered to the patient. Spectral-domain optical coherence tomography OD showed reabsorption of the hemorrhage and almost complete restoration of the foveal architecture. The intraretinal location and spread of the hemorrhage into the HFL in our patient are an unusual presentation of SH, which vividly highlights the anatomy of the fovea. Since fibers in HFL are quite delicate and loosely arranged, this layer is very susceptible to deposition of transudates, exudates, hemorrhage, and other products. Radial hemorrhage in HFL has been originally reported in 4 patients as complication of MacTel 2. It has been previously postulated that it may represent a characteristic finding in MacTel 2 that may develop as a result of microvascular abnormalities of the deep retinal capillary plexus. On the contrary, our data suggest that radial hemorrhage in the HFL does not represent a characteristic finding of MacTel 2, but must rather be considered a non-specific sign with multiple possible etiologies.

Central Bouquet Hemorrhage. Clinical and multimodal imaging features.

“…10 Notably, cases of CBH in highly myopic eyes have been reported in the literature, although the interpretation of blood localization on OCT is inconsistent. [12][13][14] Abnormal hemodynamic forces resulting from choroidal leakage and disruption of the foveal ELM may contribute to the anterograde tracking of blood within the CB. 9 This mechanism is supported by the high prevalence of subretinal fluid/hemorrhage (80%) and pre-existent outer retinal disruption (e.g., nAMD, pathological myopia, angioid streaks) seen in this subgroup in our study.…”

“…In the existing literature, instances of CBH have been documented. [12][13][14] However, as far as we know, there has been no elucidation of the anatomical basis of this pattern nor a differentiation between HFL hemorrhage cases with and without CBH.…”