Intraretinal Sclero-Choroidal Vessels in Eyes with Severe Chorioretinal Thinning: Hypothesis on Bruch’s Membrane Failure

Purpose: To describe the multimodal imaging features of intraretinal sclero-choroidal vessels (ISCVs) in eyes with severe chorioretinal thinning. Methods: A retrospective observational case series. We examined 6 eyes of 6 patients with advanced chorioretinal thinning presenting to the Doheny UCLA Eye Centers (pathologic myopia with posterior staphyloma, iatrogenic staphyloma, chronic anti-VEGF exposure, or non-myopic macular atrophy). All patients underwent structural optical coherence tomography (OCT), and when available, eyes were additionally imaged with OCT angiography (OCTA). Clinical records, fundus photography, and OCT scans were reviewed to assess vessel morphology, anatomical location and course, relationship to BM, and associated chorioretinal changes. Results: In all six cases, a large-caliber, non-exudative sclero-choroidal vessel was observed entering into the neurosensory retina. OCT consistently showed a hyperreflective tubular wall with a hyporeflective lumen, often occupying more than 50% of the retinal thickness at the point of entry. All vessels emerged at sites of focal BM disruption, typically within zones of marked choroidal thinning, posterior staphyloma, or atrophic remodeling. OCTA when available confirmed intraluminal flow, with no evidence of surrogate biomarkers of leakage or neovascular proliferation. Accurate identification required careful multimodal assessment to distinguish these ISCVs from mimicking conditions. Conclusions: ISCVs represent a novel structural finding characterized by passive migration of a sclero-choroidal vessel into the retina through areas of BM disruption. ISCVs are non-proliferative and clinically stable, and should be distinguished from more typical exudative lesions on structural OCT. Recognition of ISCVs avoids misdiagnosis and unnecessary treatment.