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Last Month’s Blink

Sub-Internal Limiting Membrane Dehemoglobinized Hemorrhage

Written by Danny A. Mammo, MD, and Sandra R. Montezuma, MD, University of Minnesota, Department of Ophthalmology & Visual Neurosciences, Minneapolis. Photo by Drew Miller, University of Minnesota.

A 32-year-old man with acute myeloid leukemia presented with a one-month history of a large central scotoma of the left eye. His visual acuity was 20/25 in the right eye and count fingers at 2 feet in the left. Posteri­or segment exam of both eyes demonstrated no anterior vitreous cells, few posterior pigmented vitreous cells, multiple areas of Roth spots, pre­retinal hemorrhages, and intraretinal hemorrhag­es. The left fundus also had a white foveal lesion (Fig. 1). On fundus autofluorescence imaging, the lesion was dramatically hyperautofluores­cent (Fig. 2). On OCT, it was hyperreflective and was found to be beneath the internal limiting membrane (ILM), consistent with a diagnosis of sub-ILM dehemoglobinized hemorrhage. The patient’s hemorrhages are secondary to his severe leukemia-induced anemia (hemoglobin, 7.2 g/dL) and thrombocytopenia (9). Although hemor­rhage is classically hypoautofluorescent on fundus autofluorescence, sub-ILM dehemoglobinized hemorrhage is thought to be hyperautofluorescent because of buildup of fluorophorescent bilirubin due to hemoglobin degradation.

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