Review on day one post uneventful phacoemulsification surgery is no longer standard practice due to the infrequency of complications when using modern cataract removal techniques. Clinicians are therefore likely to be unfamiliar with the potential causes of reduced vision when presented with a patient in the immediate postoperative period. The purpose of this review is to discuss the various differential causes of early visual loss, for the benefit of clinicians presented with similar patients in emergency care, with the use of an illustrative clinical case of paracentral acute middle maculopathy (PAMM), which recently presented to the authors. A thorough literature search on Google Scholar was conducted, and only causes of visual loss that would manifest within 24 h postoperatively were included. Complications are inherently rare in this period; however, various optical, anterior segment, lens-related and posterior segment causes have been identified and discussed. Front-line clinicians should be aware of these differentials with different mechanisms. PAMM remains to be the only cause of unexpected visual loss within this time frame that may have no abnormal findings on clinical examination.

/pdf/unexpected-poor-vision-within-24-h-of-uneventful-2xm9ah2p.pdf

Unexpected Poor Vision within 24 h of Uneventful Phacoemulsification Surgery—A Review

https://doi.org/10.1016/j.ajoc.2023.101857

The spectrum of COVID-19-associated chorioretinal vasculopathy

Purpose: To present a case of sequential paracentral acute middle maculopathy (PAMM) in a middle-aged woman with no cardiovascular risk factors. Methods: A single case was evaluated. Results: A 53-year-old woman with a history of PAMM resulting from perfused central retinal artery occlusion in the left eye presented with PAMM in the right eye 3 years later. The patient had a medical history of treated anemia, stress disorder, and insomnia. Examination of the right eye showed a superior parafoveal crescent of translucent retina without associated edema or hemorrhage. Optical coherence tomography (OCT) showed hyperreflective band-like areas in the superior parafoveal and perifoveal regions. Fluorescein angiography revealed normal arterial filling. OCT angiography showed patchy filling of the middle capillary plexus with normal perfusion of the superficial capillary plexus in the right eye. Conclusions: Although bilateral sequential PAMM is rare, close monitoring in a case of PAMM in 1 eye should be considered.

Sequential Bilateral Paracentral Acute Middle Maculopathy in a Middle-Aged Woman

Purpose: To review the demographic and clinical profile of patients developing acute macular neuroretinopathy (AMN) or paracentral acute middle maculopathy (PAMM) after receiving coronavirus disease-2019 (COVID-19) vaccination or infection. Methods: In this review article, the published literature was searched to determine cases developing either AMN or PAMM after COVID-19 vaccinations or infections. Data, including demographic profile, presenting features, symptoms, diagnosis, and clinical outcomes, were extracted from the selected publications. These parameters were compared between the two groups, i.e., patients developing AMN/PAMM either after vaccination or infection. Results: After the literature review, 57 patients developing either AMN (n = 40), PAMM (n = 14), or both (n = 3) after COVID-19 infection (n = 29) or vaccination (n = 28) were included (mean age: 34.9 ± 14.4 years; n = 38; 66.7% females). In 24.6% patients, the diagnosis of COVID-19 infection was preceded by the development of ocular disease. There were no significant differences in the age or gender between the patients developing AMN or PAMM after vaccination or infection (p > 0.13). Among the vaccination group, the highest number of patients developing AMN/PAMM were after the Oxford-AstraZeneca (n = 12; 42.9%). Patients with vaccination had a significantly early onset of AMN/PAMM compared to those with infection (11.5 ± 17.6 days versus 37.8 ± 43.6 days; p = 0.001). Conclusions: Both AMN and PAMM are reported to be associated with COVID-19 infections and in persons receiving vaccination against COVID-19. While COVID-19 infections and vaccinations may have a contributory role, other risk factors such as oral contraceptive pills may also play a role in the development of the disease.

/pdf/acute-macular-neuroretinopathy-and-paracentral-acute-middle-31dt4rxa.pdf

Acute Macular Neuroretinopathy and Paracentral Acute Middle Maculopathy during SARS-CoV-2 Infection and Vaccination

This cross-sectional study aimed to investigate the hypothesis that permanent capillary damage may underlie the long-term COVID-19 sequela by quantifying the retinal vessel integrity. Participants were divided into three subgroups; Normal controls who had not been affected by COVID-19, mild COVID-19 cases who received out-patient care, and severe COVID-19 cases requiring intensive care unit (ICU) admission and respiratory support. Patients with systemic conditions that may affect the retinal vasculature before the diagnosis of COVID-19 infection were excluded. Participants underwent comprehensive ophthalmologic examination and retinal imaging obtained from Spectral-Domain Optical Coherence Tomography (SD-OCT), and vessel density using OCT Angiography. Sixty-one eyes from 31 individuals were studied. Retinal volume was significantly decreased in the outer 3 mm of the macula in the severe COVID-19 group (p = 0.02). Total retinal vessel density was significantly lower in the severe COVID-19 group compared to the normal and mild COVID-19 groups (p = 0.004 and 0.0057, respectively). The intermediate and deep capillary plexuses in the severe COVID-19 group were significantly lower compared to other groups (p < 0.05). Retinal tissue and microvascular loss may be a biomarker of COVID-19 severity. Further monitoring of the retina in COVID-19-recovered patients may help further understand the COVID-19 sequela. 

/pdf/retinal-tissue-and-microvasculature-loss-in-covid-19-1lof58y8.pdf

Retinal tissue and microvasculature loss in COVID-19 infection

A 28-year-old man was admitted to hospital for surgical repair of a distal femur fracture sustained during a road traffic accident. Recovery was complicated by a pulmonary embolism. Two days later, his respiratory status declined, and he was transferred to intensive care unit (ICU) for ventilatory support due to confirmed SARS-CoV-2 infection.

He reported bilateral reduced vision after being discharged from ICU. Visual acuities were 6/18 right and 6/12 left. Dilated funduscopy revealed bilateral cotton wool spots and small, sparse mid-peripheral intraretinal haemorrhages (figure 1). Discrete areas of retinal pallor involving the fovea were consistent with paracentral acute middle maculopathy (PAMM), confirmed on optical coherence tomography (OCT) (figure 2).



Figure 1 
Fundus autofluorescence of the right eye (A) and left eye (B) showing bilateral cotton wool spots …

https://pmj.bmj.com/content/postgradmedj/early/2021/06/30/postgradmedj-2021-140500.full.pdf

Theodora Gkika

Papers

Bilateral paracentral acute middle maculopathy in a SARS-CoV-2-positive patient.