As far as we know, we report the first case of macular subretinal bleeding on macular LCs in a highly myopic patient in immediate post partum.
LCs are uncommon findings in the posterior pole of highly myopic eyes, with a prevalence of 4.2 % to 15,7 % [6, 7].
They seem to be associated to higher refractive error, worse visual prognosis, longer axial length, and decreased choroidal thickness [8]. They are described in younger patients, with mean age of 45 years [3]. With time, they are believed to increase in number and width [3].
Morphologically, they appear as fine, irregular, yellow lines, often branching and criss-crossing all over the posterior fundus [9]. LCs correspond to mechanical breaks in the RPE-BM-CC complex and are supposed to be the result of stretching of these tissues secondary to progressive posterior segment elongation [9].
LCs location at the temporal edge of macula is the most frequently described [3]. They must be differentiated from angioid streaks (AS) and myopic stretch lines which are two distinct conditions affecting Bruch membrane [10, 11]. However, these lesions present with distinctive features on multimodal imaging [10,11,12]. Few studies described the histopathologic features of lacquer cracks [7, 13, 14]. Querques et al. [13] found an association between the position of perforating scleral vessels and lacquer cracks in pathologic myopia. The authors hypothesized that scleral expansion at the site of the perforating scleral vessels could play a role in the formation of lacquer cracks. LCs are often found simultaneously with subretinal hemorrhages [14], as in the present case. It has been suggested that subretinal bleeding may precede the development of a new rupture of Bruch’s membrane and choriocapillaris complex in eyes with pathologic myopia [7, 14]. Subretinal hemorrhages secondary to LCs typically have good prognosis, with complete resorption of the subretinal bleeding in few months [15].
However, a close follow up is required because of the risk of choroidal neovascularization or the occurrence of patchy chorioretinal atrophy [3, 15].
For many years it was thought that increased effort during labor would increase the risks of rhegmatogenous retinal detachment in highly myopic patients [4, 5, 16]. Nonetheless, subsequent studies revealed no evidence of association between vaginal delivery and rhegmatogenous retinal detachment or retinal degeneration [4, 5].
In this case, the macular subretinal bleeding may be explained by a sudden increase of intraocular pressure due to the Valsalva maneuvers in a mechanically weakened area of the globe. Also, we cannot exclude this subretinal bleeding as the natural course of pathologic myopia.
The timelapse of 2 days between the delivery and the ophthalmologic examination may be attributed to the immediate post partum context and delayed access to ophtalmologic emergencies.
Some cases of traumatic lacquer cracks have been reported following photodynamic therapy [17] or laser treatment of choroidal neovascularization [18].
Therefore, we can only speculate that traumatic events like a Valsalva maneuver occurring during labour in this case could explain the pathogenesis of acute subretinal hemorrhage secondary to lacquer cracks.
However, no association between LC and uncomplicated vaginal delivery is described in the medical literature. The macular hemorrhage could be simply the natural evolution of the disease. No causal relationship with delivery can be proven from this sequence of events. The sudden loss of BCVA and therefore a prompt diagnosis may be explained by the foveal location of the LC in our patient.