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Feng

Hemorrhagic Bacillary Layer Detachment in

Macular Telangiectasia Type 2
Fig. 1. Multimodal imaging features of hemorrhagic
bacillary layer detachment. A. Color fundus photogra-
phy shows typical features of macular telangiectasia
Type 2 including retinal graying, crystalline deposits,
ectatic capillaries, and hyperpigmentation foci. There is
an active yellowish neovascular membrane (white
arrowhead) with subretinal hemorrhages. B. Optical
coherence tomography angiography segmented from
the outer retina to the choriocapillaris shows a sub-
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retinal neovascular membrane (white arrowhead). The

inset shows segmentation lines of the en face optical
coherence tomography angiography image with red
flow signal overlay. C–E. The (C) is a magnified view
of the BLD on OCT as illustrated in (E). The intra-
retinal split occurs at the level of the hyporeflective
myoid zone (green arrowheads). The ellipsoid zone
(orange arrowhead) of the attached retina is continuous
with a faint hyperreflective line (orange arrowhead) that
likely represents split photoreceptor inner segments and
outer segments remaining adherent to the retinal pig-
ment epithelium/Bruch membrane complex (yellow
arrowhead). The external limiting membrane (blue
arrowheads) is visible over the top of the BLD (withe
arrowhead). Note the dense hyperreflective material
within the BLD that corresponds to heme accumulation
and may interfere with accurate delineation of the outer
retinal layers. The (D) is the near infrared reflectance
image with the green line indicating the position of the
OCT scan. Vertical OCT scan (E) shows parafoveal
outer retinal cyst consistent with BLD (white arrow-
head) and adjacent subretinal fluid (asterisk). F and G.
Eye-tracked follow-up near infrared reflectance image
(F) and OCT scan (G) performed 1 month after an in-
travitreal injection of ranibizumab shows dramatic resolution of the BLD. The external limiting membrane is intact. Note the persistent focal atten-
uations of the ellipsoid and interdigitation zones (between red arrowheads).

M acular telangiectasia Type 2 (MacTel 2) is a occurrence of subretinal neovascularization in Mac-

bilateral disease characterized by neurodegener-
ative and vascular changes affecting the fovea.1 The
From the Department of ophthalmology, Centre Hospitalier Uni-
versitaire de l’Hôpital Nord, chemin des Bourrely, Marseille, France.
None of the authors has any financial/conflicting interests to disclose.
Authorship: all authors attest that they meet the current ICMJE
criteria for authorship.
Patient consent: the patient consented to publication of the case
orally.
This is an open-access article distributed under the terms of the
Creative Commons Attribution-Non Commercial-No Derivatives
License 4.0 (CCBY-NC-ND), where it is permissible to download
and share the work provided it is properly cited. The work cannot
be changed in any way or used commercially without permission
from the journal.
Reprint requests: Prithvi Ramtohul, MD, Department of ophthal-
mology, Centre Hospitalier Universitaire de L’Hôpital Nord, chemin
des Bourrely, 13015 Marseille, France; e-mail: pramtohul@me.com
Tel 2 is rather rare but constitutes a vision-
threatening complication.2 We describe longitudinal
multimodal imaging features of a novel variant of
bacillary layer detachment (BLD, outer retinal split
at the level of the photoreceptor inner segment my-
oid)3 and termed “hemorrhagic BLD” in a case of
subretinal neovascularization associated with MacTel
2. This report followed the tenets of the Declaration
of Helsinki.
A 55-year-old woman presented with proliferative
MacTel 2. Fundus photography showed active
yellowish neovascular membrane with subretinal
hemorrhages (Figure 1A). Optical coherence tomog-
raphy (OCT) angiography segmented at the level of
the outer retina confirmed subretinal neovasculariza-
tion (Figure 1B). Optical coherence tomography

e42
 PHOTO ESSAY
disclosed a parafoveal outer retinal cyst consistent
with BLD and adjacent subretinal fluid (Figure 1, C–
E). The higher optical intensity in the BLD com-
pared with that of subretinal fluid and its colocaliza-
tion with subretinal hemorrhage on fundus
photography suggested heme accumulation in the
BLD. Eye-tracked follow-up OCT performed one
month after a single intravitreal injection of ranibi-
zumab (0.5 mg/0.05 mL) demonstrated significant
regression of the BLD (Figure 1, F and G). Persis-
tent focal attenuations of the ellipsoid and interdig-
itation zones were noted.
To the best of our knowledge, hemorrhagic BLD
has not been associated with proliferative MacTel 2,
although similar findings coined “atypical outer retinal
fluid accumulation” have been reported in neovascular
age-related macular degeneration.4 Intense leakage of
fluid from the subretinal neovascularization and mod-
ulation of the adherence between photoreceptor outer
segments and retinal pigment epithelium by the sub-
retinal hemorrhage may have induced BLD develop-
ment.5 In fact, fibrin interdigitation between
photoreceptor outer segments has been documented
after experimental subretinal hemorrhages and may
explain the presumed photoreceptor fracture under
hydrostatic pressure effect.
Key words: MacTel, macular telangiectasia, multi-
modal imaging, optical coherence tomography, subre-
tinal fluid, subretinal hemorrhage.
PRITHVI RAMTOHUL, MD
ALBAN COMET, MD
DANIÈLE DENIS, MD PHD
PIERRE GASCON, MD
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References
1. Gass JD, Oyakawa RT. Idiopathic juxtafoveolar retinal telangi-
ectasis. Arch Ophthalmol 1982;100:769–780.
2. Tzaridis S, Hess K, Friedlander M, Holz FG. Optical coherence
tomography-angiography for monitoring neovascularisations in
macular telangiectasia type 2. Br J Ophthalmol 2020. doi:
10.1136/bjophthalmol-2020-316021. Epub ahead pf print.
3. Ramtohul P, Denis D, Gascon P. Bacillary layer detachment in
acute posterior multifocal placoid pigment epitheliopathy: a
multimodal imaging analysis. Retina 2020;41:e12–e14.
4. Liakopoulos S, Keane PA, Ristau T, et al. Atypical outer retinal
fluid accumulation in choroidal neovascularization: a novel OCT
finding. Ophthalmic Surg Lasers Imaging Retina 2013;44:S11–S18.
5. Toth CA, Morse LS, Hjelmeland LM, Landers MB. Fibrin
directs early retinal damage after experimental subretinal hem-
orrhage. Arch Ophthalmol 1991;109:723–729.
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