Evolution of sub-internal limiting membrane hemorrhage on multimodal imaging

Purpose To describe the evolving near-infrared (NIR) imaging findings and cross-sectional optical coherence tomography (OCT) features in a patient with a resolving sub-internal limiting membrane (sub-ILM) hemorrhage. Observations An 85-year-old man presented with an ‘egg-shaped’ scotoma in the left eye with sudden onset 5 weeks ago. Examination revealed a large dome-shaped sub-ILM hemorrhage, as well as subhyaloid and subretinal hemorrhage due to a ruptured retinal macroaneurysm. The sub-ILM hemorrhage demonstrated hyporeflectivity on NIR and corresponding hyperreflectivity on OCT, which is brighter inferiorly, and results in less OCT signal transmission to the underlying retinal layers. By 11 weeks after onset, the sub-ILM hemorrhage was smaller with a superior serous and an inferior mixed hemorrhagic and dehemoglobinized component. The hemorrhage has become more hyperreflective on NIR in both superior and inferior components, compared to prior. OCT scans continued to show a hyperreflective signal from blood, which was brighter inferiorly, but there was greater OCT signal transmission to the underlying retinal layers. Conclusions and Importance These changes on NIR and OCT appear to follow the Beer-Lambert law and may illustrate the evolution of hemoglobin from to its degradation products.