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An Unexpected Improvement
Hooshmand J, Moore P, McKay D, Vote BJ. Paracentral acute middle maculopathy associated with severe vision loss following vitrectomy for vitreous haemorrhage. Clinical & Experimental Ophthalmology. 2018 Aug;46(6):706-8.
A 70 year-old woman with a with history of mild asymptomatic mitral valve prolapse, hypertension and stable glaucoma presented to us with fundus obscuring vitreous haemorrhage in the left eye on the background of previous retinal tears on the same side. Her visual acuity in the affected eye at the time of presentation was hand movement (down from 6/6, 7 months earlier) with an intraocular pressure of 16mmHg.
She underwent a routine vitrectomy to clear the haemorrhage. The haemorrhage was determined to have most likely arisen from a bridging vessel at the site of the previous tear. Laser photocoagulation and air–fluid exchange were carried out during the procedure. period. Immediately after the procedure (patch off), the patient described a dense paracentral scotoma despite improved peripheral vision. Visual acuity on day 1 was hand movements with normal pupillary response. Three weeks postoperatively, her vision remained poor in the left eye at counting fingers. She was noted to have significant cataract. Retinal examination was unremarkable apart from evidence of previous laser around a superotemporal tear. Optical coherence tomography (OCT) demonstrated hyperreflective band-like lesions in the middle layer of the retina involving the entire inner nuclear layer. Visual field testing revealed markedly constricted field and a visual field index of 16%.
Given the significant lens opacity, standard phacoemulsification surgery was performed 10 weeks following the initial operation. By 2 weeks after cataract surgery, her visual acuity had recovered to 6/30 with an associated increase in visual field index to 85%. Our patient underwent a straight forward vitrectomy preceded by a routine sub-tenon’s anaesthesia. Her visual acuity was noted to have significantly deteriorated following the operation from her baseline pre-morbid level of 6/6 despite a subsequent uncomplicated cataract surgery, an otherwise clear media and a normal fundus examination.
A diagnosis of paracentral acute middle maculopathy (PAMM) was made based on pathognomonic OCT findings which remained consistent in early phase with hyper-reflective lesions in the inner nuclear layer (INL) through to late phase of the disease with generalized retinal atrophy. Our patient showed an unexpected improvement in visual acuity with a corresponding improvement in visual fields at 3 months postoperatively. This has not been observed in cases of PAMM before.