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.

Keywords: Eye disease; Henle fiber layer hemorrhage; Imaging; Macula/retina/vitreous; Maculopathy; Myopia; Myopic hemorrhage; Ophthalmoscopy; Radial hemorrhage; Retina; Simple hemorrhage.

Fig. 1

Baseline multimodal imaging. a Color fundus photography displays macular hemorrhage in a characteristic radial pattern. b, c Spectral-domain optical coherence tomography shows an elevated hyper reflective lesion in the outer retina, with areas of shadowing of the underlying retinal pigment epithelium and accumulation of fluid within the outer plexiform layer adjacent to the lesion. d Optical coherence tomography angiography shows no sign of choroidal neovascularization nor microvascular abnormalities consistent with macular telangiectasia type 2. e En face optical coherence tomography reveals radial hyperreflectivity at the level of the outer plexiform layer. f Cross-sectional optical coherence tomography displays intraretinal hyper reflective material radiating in the outer plexiform layer.

Fig. 2

One-month and 4-mo, nth follow-up. a One-month follow-up. Spectral-domain optical coherence tomography shows partial reabsorption of the intraretinal hemorrhage. Hyper reflective material is still present in the subfoveal region, with disruption of the outer retinal layers. b Four-month follow-up. Spectral-domain optical coherence tomography shows intraretinal hyperreflective signs perpendicular to the retinal pigmented epithelium in the foveal region, with subtle disruption of the inner segment/ outer segment layer.