Paracentral Acute Middle Maculopathy Following Acute Primary Angle Closure and Acute Primary Angle Closure Glaucoma

Figures & data

Figure 1 SD-OCT characteristics of different stages of PAMM lesions in APAC or APACG eyes. Stage I (edema): hyper-reflective lesions involving the INL (white arrow) along with the shadowing effect they created (black arrow) and some lesions extended into IPL and OPL. Stage II (edema resolution): severe attenuating OPL thickness (white arrow) along with the corresponding shadow partially resolved. Stage III (atrophy): a legacy of INL thinning and irregular, attenuated OPL (white arrow) along with hyper-reflective lesions resolved.

Abbreviations: PAMM, paracentral acute middle maculopathy; APAC, acute primary angle closure; APACG, acute primary angle closure glaucoma; INL, inner nuclear layer; IPL, inner plexiform layer; OPL, outer plexiform layer; SD-OCT, spectral domain optical coherence tomography.

Table 1 Demographic Characteristics and Ocular Findings of Patients with APAC or APACG (N = 781)

	Total (N=781)	Control Group (N=759)	PAMM Group (N=22)	P value^†
Age, years, mean (SD)	62.07 (8.91)	62.22 (8.76)	57.14 (12.27)	0.067
Gender, n (%)
Male	202 (25.9%)	198 (26.1%)	4 (18.2%)	0.404
Female	579 (74.1%)	561 (73.9%)	18 (81.8%)
Included eye, n (%)
Right	461 (59.0%)	447 (58.9%)	14 (63.6%)	0.656
Left	320 (41.0%)	312 (41.1%)	8 (36.4%)
TST, days, median (IQR)	3 (9.0)	3 (9.0)	3.5 (8.5)	0.952
Baseline BCVA, logMAR, mean (SD)	0.69 (0.90)	0.68 (0.91)	0.96 (0.68)	0.148
MD, dB, median (IQR)	−7.12 (14.57)	−7.12 (14.42)	−10.11 (20.86)	0.513
PSD, dB, median (IQR)	3.51 (4.90)	3.48 (4.91)	4.13 (4.33)	0.255
AL, mm, mean (SD)	22.37 (0.80)	22.39 (0.79)	21.89 (0.78)	0.004
ACD, mm, mean (SD)	1.78 (0.27)	1.78 (0.27)	1.70 (0.31)	0.159
SFCT, μm, mean (SD)	290.42 (108.42)	289.16 (108.08)	333.41 (113.98)	0.059
mRNFLT, μm, mean (SD)	108.73 (39.25)	108.83 (39.16)	105.24 (43.12)	0.679

Notes: ^†Control and PAMM group differences in demographic characteristics were evaluated by the independent sample T test, Mann–Whitney U-test, Chi-square and Fisher’s exact tests as appropriate. Bold means statistically significant (P < 0.05).

Abbreviations: APAC, acute primary angle closure; APACG, acute primary angle closure glaucoma; PAMM, paracentral acute middle maculopathy; TST, time from symptoms to treatment; BCVA, best-corrected visual acuity; MD, mean deviation; PSD, pattern standard deviation; AL, axial length; ACD, anterior chamber depth; SFCT, subfoveal choroidal thickness; mRNFLT, mean retinal nerve fiber layer thickness; SD, standard deviation; IQR, interquartile range; logMAR, logarithm of the minimum angle of resolution.

Table 2 Systemic Associations of Patients with APAC or APACG (N = 781)

	Total (N=781)	Control Group (N=759)	PAMM Group (N=22)	P value^†
CHOL, mmol/L, mean (SD)	5.15 (1.03)	5.16 (1.03)	4.82 (1.27)	0.126
TG, mmol/L, mean (SD)	1.56 (0.92)	1.57 (0.93)	1.42 (0.62)	0.439
GLU, mmol/L, mean (SD)	5.58 (1.07)	5.58 (1.07)	5.63 (0.94)	0.838
SBP, mmHg, mean (SD)	130.88 (18.42)	130.85 (18.35)	131.77 (21.18)	0.818
DBP, mmHg, mean (SD)	76.80 (9.39)	76.79 (9.40)	77.14 (9.18)	0.866
BMI, kg/m^2, mean (SD)	22.30 (3.49)	22.32 (3.47)	21.76 (4.23)	0.491
Hypertension, n (%)	138 (17.7%)	132 (17.4%)	6 (27.3%)	0.253
Type 2 diabetes, n (%)	59 (7.6%)	55 (7.2%)	4 (18.2%)	0.077
Hyperlipidemia, n (%)	448 (57.4%)	435 (57.3%)	13 (59.1%)	0.868

Notes: ^†Control and PAMM group differences in demographic characteristics were evaluated by the independent sample T test, Mann–Whitney U-test, Chi-square and Fisher’s exact tests as appropriate.

Abbreviations: APAC, acute primary angle closure; APACG, acute primary angle closure glaucoma; PAMM, paracentral acute middle maculopathy; CHOL, cholesterol; TG, triglycerides; GLU, glucose; SBP, systolic blood pressure; DBP, diastolic blood pressure; BMI, body mass index; SD, standard deviation.

Table 3 BCVA Comparison Between the Three Stages

Parameters	Stage I	Stage II	Stage III	P value
Baseline BCVA, logMAR, mean (SD)	0.99 (0.56)	1.16 (0.70)	0.97 (0.86)	0.874*
Final BCVA, logMAR, median (IQR)	0.40 (0.30)	0.90 (1.10)	1.60 (2.20)	0.087^†
BCVA improvement, lines, mean (SD)	4.00 (3.90)	1.20 (2.39)	−0.67 (0.82)	0.012^††

Notes: *One-way analysis of variance; ^†Kruskal–Wallis H-test; ^††Welch test; Bold means statistically significant (P < 0.05). Stage I: edema, Stage II: edema resolution, Stage III: atrophy.

Abbreviations: BCVA, best-corrected visual acuity; logMAR, logarithm of the minimum angle of resolution; SD, standard deviation; IQR, interquartile range.

Figure 2 Boxplots showing the distribution of PAMM patients’ time from symptoms to treatment (TST, days) for the three stages. Whiskers mean values from minimum to maximum. ** P < 0.01. Stage I: edema, Stage II: edema resolution, Stage III: atrophy.

Abbreviation: PAMM, paracentral acute middle maculopathy.

Figure 3 Bar charts showing the PAMM group patients’ characteristics. Error bars are standard deviations. (A) Inner retinal thickness among the three stages. (B) Full retinal thickness among the three stages. (C) The highest recorded IOP among the three stages. (D) BCVA improvement from baseline at final visit, lines. ** P < 0.01, *** P < 0.001, **** P < 0.0001. Stage I: edema, Stage II: edema resolution, Stage III: atrophy.

Abbreviations: PAMM, paracentral acute middle maculopathy; IOP, intraocular pressure; BCVA, best-corrected visual acuity; ns, not significant.

Table 4 The Pearson or Spearman Correlations Between BCVA and Other Factors in PAMM Eyes

Parameters	Factors	R	P
Baseline BCVA	TST	−0.173	0.441^†
	Inner retinal thickness	0.157	0.485^†
	Full retinal thickness	0.144	0.524*
Final BCVA	TST	0.325	0.140^†
	Inner retinal thickness	−0.369	0.091^†
	Full retinal thickness	−0.413	0.056*
BCVA improvement	TST	−0.513	0.015^†
	Inner retinal thickness	0.498	0.018^†
	Full retinal thickness	0.504	0.017*

Notes: ^†Spearman correlation test; *Pearson correlation test; Bold means statistically significant (P < 0.05). Baseline BCVA refers to the BCVA at the first visit; Final BCVA refers to the BCVA obtained at a follow-up time of 3 months or more; BCVA improvement refers the lines of vision change for final BCVA versus baseline BCVA.

Abbreviations: PAMM, paracentral acute middle maculopathy; BCVA, best-corrected visual acuity; TST, time from symptoms to treatment, days.

Figure 4 A female ages 65–75 years old with hypertension presented with acute vision loss and periocular pain in the right eye. Visual acuity was no light perception (logMAR equivalent, 3.0) at presentation, and the IOP was 63 mmHg; SD-OCT displayed the development of PAMM lesions in an APACG patient. (A) Distinct hyper-reflective lesions at INL extended into IPL and OPL (stage I, edema); (B) Distinct attenuating OPL thickness (stage II, edema resolution); (C) Severe INL thinning (stage III, atrophy). The white / black arrow represents the full / inner retinal thickness (µm) at the thickest part of stage I lesion and the thinnest part of stage II or III lesions.

Abbreviations: IOP, intraocular pressure; SD-OCT, spectral domain optical coherence tomography; PAMM, paracentral acute middle maculopathy; APACG, acute primary angle closure glaucoma; INL, inner nuclear layer; IPL, inner plexiform layer; OPL, outer plexiform layer; logMAR, logarithm of the minimum angle of resolution.

Figure 5 Univariable and multivariable binary logistic regression of factors associated with PAMM following APAC or APACG.

Notes: Odds ratios were obtained by binary logistic regression; Bold means statistically significant (P < 0.05). *Age, gender and the variables from the univariable analysis with a P value < 0.10 were included in the model 1 analysis. Adjusted for age and gender only. Male and no type 2 diabetes are the references. ^†Age, gender and the variables from the model 1 analysis with a P value < 0.10 were included in the model 2 for multivariable analysis. Male and no type 2 diabetes are the references.

Abbreviations: PAMM, paracentral acute middle maculopathy; APAC, acute primary angle closure; APACG, acute primary angle closure glaucoma; AL, axial length; SFCT, subfoveal choroidal thickness; OR, odds ratio; CI, confidence interval.