Ruptured Retinal Arterial Macroaneurysms Associated with Hemorrhagic Bacillary Layer Detachments

Abstract

Background/Purpose: Bacillary layer detachments (BALAD) are a recently recognized form of retinal detachment involving a splitting of photoreceptors at the inner segment myoid zone, with separation of the external limiting membrane and ellipsoid zone on optical coherence tomography (OCT). A growing number of disease processes are recognized to cause BALAD, and here we present three of the first cases of hemorrhagic retinal artery macroaneurysms that resulted in BALAD.Methods: A retrospective review of three patients who presented for acute, painless, monocular vision loss was performed. Multimodal imaging including fundus photography and OCT are included in this analysis.Results: Three elderly female patients, all with a history of hypertension, presented with ruptured macroaneurysms involving the macula. All three patients had evidence of BALAD on OCT. Various management strategies were used.Conclusion: Hemorrhagic retinal arterial macroaneurysms can be associated with BALAD, observed best on OCT. This is most likely secondary to the rapid accumulation of intraretinal fluid during the hemorrhage, which leads to an avulsion at the inner segment myoid zone-a site of inherent structural weakness in the photoreceptors. Visual recovery may be improved in instances of hemorrhagic macroaneurysms associated with BALAD, similar to other disease entities where BALAD occurs, although further research is needed.

Haemorrhagic bacillary layer detachment secondary to retinal artery macroaneurysm

“…Few cases of RAM with haemorrhagic BALAD have been described which resolved with observation, intravitreal tissue plasminogen activator or vitrectomy 10. Here, we describe the first report of RAM-associated BALAD resolving with focal laser.…”

Central Bouquet Hemorrhage. Clinical and multimodal imaging features.

“…26 The hemorrhagic variant of BALAD was first described by Ramtohul et al in a case of proliferative macular telangiectasia Type 2, and subsequent studies reported this OCT finding in nAMD and ruptured retinal arterial macroaneurysms. [27][28][29] On OCT, hemorrhagic BALAD is characterized by accumulation of hyperreflective blood within the cavity formed by the BALAD (i.e., split at the level of the photoreceptor inner segment myoids). 26,27 Its anterior border is marked by the ELM, and the posterior border is represented by a faint EZ corresponding to residual inner and outer segments remaining adherent to the retinal pigment epithelium/Bruch membrane complex.…”