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Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 142-145

Multimodal imaging in a case of acute idiopathic maculopathy

Department of Vitreo-Retina services, Aditya Birla Sankara Nethralaya, Kolkata, West Bengal, India

Date of Submission29-Jul-2021
Date of Acceptance04-Sep-2021
Date of Web Publication07-Jan-2022

Correspondence Address:
Dr. Rupak Roy
Department of Vitreo-Retina, Aditya Birla Sankara Nethralaya, 147, Mukundapur, EM Bypass, Kolkata - 700 099, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_2001_21

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Bacillary layer detachment (BLD) is an optical coherence tomography (OCT) finding depicting split within the inner segment of myoids. We present a case of acute idiopathic maculopathy in a young female who presented with sudden painless diminution of vision in the left eye without a prodromal viral illness. On the OCT splitting of ellipsoid and myoid zone of rod, inner segments were noted suggestive of BLD, whereas optical coherence tomography angiography showed flow void areas on choriocapillaris slab. BLD in acute idiopathic maculopathy occurs due to poor choroidal perfusion leading to stress and splitting of bacillary layer. However, once choroidal perfusion improves, BLD resolves and hence no treatment is required.

Keywords: Acute idiopathic maculopathy, bacillary layer detachment, choroidal perfusion

How to cite this article:
Kothari A, Chugh M, Saurabh K, Roy R. Multimodal imaging in a case of acute idiopathic maculopathy. Indian J Ophthalmol Case Rep 2022;2:142-5

How to cite this URL:
Kothari A, Chugh M, Saurabh K, Roy R. Multimodal imaging in a case of acute idiopathic maculopathy. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Aug 14];2:142-5. Available from: https://www.ijoreports.in/text.asp?2022/2/1/142/334925

The term “bacillary layer” was introduced to literature first by Polyak in 1941 as the retinal photoreceptor layer, which consists of the inner and outer photoreceptor segments.[1]

Recently, Mehta et al.[2] introduced the term bacillary layer detachment (BLD) to describe the separation of the bacillary layer from the remaining retinal layers resulting from an intraphotoreceptor split immediately posterior to the external limiting membrane within the photoreceptor inner segment myoids in a case of toxoplasma chorioretinitis.

BLD is a novel optical coherence tomography (OCT) finding which is also found in variety of diseases that affect the choroidal and retinal pigment epithelium perfusion such as Vogt-Kayanagi-Harada disease, blunt ocular trauma, Peripapillary pachychoroid syndrome, acute idiopathic maculopathy.

Acute idiopathic maculopathy was first described by Yannuzzi et al.[3] in 1991 in a series of patients who had common clinical presentation of acute, severe visual loss, macular serous detachment, and central scotoma. It typically affects healthy young adults who have prodromal viral flu like illness. Viral etiology for the same is proposed, but the pathophysiology is not fully understood. The prognosis of acute idiopathic maculopathy is generally good with spontaneous resolution within several weeks to months with a characteristic Bulls eye pattern of pigmentary changes at macula.[4]

In our report, we present one case of unilateral acute idiopathic maculopathy (UAIM) manifesting as BLD.

  Case Report Top

A 40-year-old female came to our OPD on July 7, 2021 with chief complaints of distortion of images and sudden, painless diminution of vision in the left eye since 1 week. The patient was not suffering from any prodromal viral flu like illness. The patient had no similar complaints in past. The patient was suffering from hypertension, rheumatoid arthritis, and depression for which she was on regular medications.

On presentation, best-corrected visual aquity was 6/6 in the right eye and 6/15 in the left eye; near vision in the right eye was N6 and N18 in the left eye. The intraocular pressure in both eyes was normal. Slit-lamp examination showed that the anterior segment was within normal limits in both eyes. The fundus examination of the right eye was within normal limits and the left eye showed the presence of subretinal fluid over the posterior pole. No peripheral treatable lesions were noted [Figure 1]. Further, the patient was advised to undergo optical coherence tomography angiography (OCTA) and fundus fluorescein angiography (FFA). The FFA of the right eye showed a normal study and the left eye showed the pooling of dye corresponding to the subretinal fluid pocket [Figure 1].
Figure 1: (a) Color fundus photograph of the left eye with area of subretinal fluid infero-temporal to fovea seen as a yellowish lesion (arrow). (b) Multicolor composite image of the left eye shows greenish discoloration of fovea (arrow). (c) Photograph of the early phase of fluorescein angiogram of the left eye shows no abnormality. (d and e) Mid and late phases of fluorescein angiogram showing hyperfluorescence (arrow) in the foveal avascular zone suggestive of pooling

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OCT showed a normal study in the right eye, and the left eye showed a smooth convex elevation involving the outer retina and neurosensory detachment with a nonhomogeneous center composed of multiple hyperreflective dots and clumps involving the apical side of retinal pigment epithelium (RPE). The splitting of ellipsoid and myoid zone of rod inner segment was noted at the margin of the lesion s/o BLD [Figure 2]. OCTA showed flow void areas in choriocapillaries slab [Figure 3].
Figure 2: SD-OCT section of the left eye at the level of macula. (a) Section taken at the suprafoveal level. (b) Magnified view of the suprafoveal section, showing neurosensory detachment (NSD) (*). (c) Section taken at the level of the fovea. (d) Magnified view of the foveal section, temporal to NSD is bacillary layer detachment (BLD). BLD is seen as disruption of hyporeflective myoid zone (MZ). MZ is seen along with hyperreflective external limiting membrane (ELM) anterior to the disruption. Hyperreflective ellipsoid zone (EZ) along with hyporeflective interdigitation zone (IZ) is seen posterior the detachment, attached to retinal pigment epithelium (RPE). (**) shows fibrin deposits and degenerated photoreceptor outer layer material within the intraretinal split

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Figure 3: (a–c) Infrared picture of the left eye along with the SD-OCT section of macula. (d) OCTA at the level of superficial plexus which is unremarkable. (e) OCTA at the level of deep plexus shows no abnormality. (f) OCTA at the level of Chorio-capillaris, which shows flow voids (arrow)

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After reviewing the imaging modalities, a diagnosis of UAIM was made. As the condition is self-resolving, no treatment was advised and the patient was asked to review after 1 month.

  Discussion Top

Historically, BLD has been described in infectious diseases like ocular toxoplasmosis and ocular tuberculosis, inflammatory diseases like Vogt-Koyanagi Harada disease, acute posterior multifocal placoid pigment epitheliopathy, virus-induced acute idiopathic maculopathy, malignant conditions like bilateral diffuse uveal melanocytic proliferation, vascular conditions like peripapillary pachychoroid syndrome, and even following blunt trauma with choroidal rupture. In all these diseases, there is primary involvement of the choroid and RPE, either due to pachychoroid disease or choroidal inflammation or infiltration. Hence, considering the unilaterality, clinical appearance, imaging features and the self-limiting nature of the disease in our case, the final diagnosis in our case was narrowed down to UAIM. However, there was no prodromal illness in our case as is reported in literature.

UAIM is an uncommon macular inflammatory disease of the RPE that affects young healthy males and was first reported by Yannuzzi et al.[3] in 1991. Patients with UAIM often present with sudden and severe unilateral visual loss, following a flu-like illness. RPE thickening with associated exudative neurosensory retinal detachment and the presence of hyperreflective material underneath the detachment have been reported in literature.[5] The natural course of UAIM is a spontaneous recovery over a period of several weeks to months with a good visual recovery and no recurrence of the acute manifestations. However, the improvement in visual acuity corresponded to ellipsoid zone restoration. Sparing of the photoreceptor cell bodies with isolated involvement of the photoreceptor outer segments has been demonstrated by the adaptive optics technology and may explain the recovery of the photoreceptor outer segments and the good visual prognosis of UAIM.[6] Recently, BLD as a presenting feature in acute idiopathic maculopathy has been reported in three cases in literature.[7],[8]

The etiopathogenesis of UAIM is still not clear, although inflammation of the RPE leading to its thickening and edema is the most common mechanism. However, choroidal inflammation secondary to a viral etiology has also been reported.[6] Even in our cases, flow void areas were noted on OCT-angiography in the choriocapillaris segment. The mechanism of BLD in UAIM could be due to the underlying poor choroidal perfusion leading to the stress and splitting of the bacillary layer. The BLD resolves once the inflammation subsides and the choroidal perfusion improves.

  Conclusion Top

To conclude, BLD in UAIM is not a commonly reported SDOCT finding and can serve as an imaging biomarker.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Polyak SL. The retina: The anatomy and the histology of the retina in man, ape and monkey, including the consideration of visual functions, the history of physiological optics and the histological laboratory technique. JAMA 1942;118:1337.  Back to cited text no. 1
Mehta N, Chong J, Tsui E, Duncan JL, Curcio CA, Freund KB, et al. Presumed foveal bacillary layer detachment in a patient with toxoplasmosis chorioretinitis and pachychoroid disease. Retin Cases Brief Rep 2021;15:391-8.  Back to cited text no. 2
Yannuzzi LA, Jampol LM, Rabb MF, Sorenson JA, Beyrer C, Wilcox LM. Unilateral acute idiopathic maculopathy. Arch Ophthalmol 1991;109:1411-6.  Back to cited text no. 3
Rosar AP, Casalino G, Cozzi M, Pellegrini M, Bottoni F, Dell'Arti L, et al. Acute idiopathic maculopathy: A proposed disease staging based on multimodal imaging. Retina 2021. doi: 10.1097/IAE.0000000000003247  Back to cited text no. 4
Freund KB, Yannuzzi LA, Barile GR, Spaide RF, Milewski SA, Guyer DR. The expanding clinical spectrum of unilateral acute idiopathic maculopathy. Arch Ophthalmol 1996;114:555-9.  Back to cited text no. 5
Ooto S, Hangai M, Yoshimura N. Photoreceptor restoration in unilateral acute idiopathic maculopathy on adaptive optics scanning laser ophthalmoscopy. Arch Ophthalmol 2011;129:1633-5.  Back to cited text no. 6
Venkatesh R, Reddy NG, Pulipaka RS, Mahendradas P, Yadav NK, Jayadev C. Bacillary layer detachment in unilateral acute idiopathic maculopathy: A report of 2 cases. Ocul Immunol Inflamm 2021;1-4. doi: 10.1080/09273948.2021.1903934. Online ahead of print.  Back to cited text no. 7
Fernández-Avellaneda P, Breazzano MP, Fragiotta S, Xu X, Zhang Q, Wang RK, et al. Bacillary layer detachment overlying reduced choriocapillaris flow in acute idiopathic maculopathy. Retin Cases Brief Rep 2019. doi: 10.1097/ICB.0000000000000943. Online ahead of print.  Back to cited text no. 8


  [Figure 1], [Figure 2], [Figure 3]


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