Type of publication:
Conference abstract
Author(s):
*Nayak D.; *Kirtley F.; *Williams K.; *Husain S.;
Citation:
Eye (Basingstoke). Conference: The Royal College of Ophthalmologists Annual Congress 2025. Liverpool United Kingdom. 39 (pp 224-225), 2025. Date of Publication: 01 Jun 2025.
Abstract:
Introduction: Sudden loss of vision, especially when accompanied by loss of colour vision, a relative afferent pupillary defect (RAPD), and visual acuity dropping below 6/60, is an alarming symptom that often leads clinicians to suspect optic neuropathy, particularly conditions like Anterior Ischemic Optic Neuropathy (AION) or Posterior Ischemic Optic Neuropathy (PION). However, retinal conditions such as Paracentral Acute Middle Maculopathy (PAMM) and Acute Macular Neuroretinopathy (AMN), especially Type 2 AMN, can present with similar symptoms, causing diagnostic confusion. This poster explores classic findings on Optical Coherence Tomography (OCT) and OCT Angiography (OCTA) along with visual fields that can aid in distinguishing between optic neuropathy and retinal diseases, guiding appropriate management and treatment. Method(s): The study included 10 patients with a mean age of 62 years, ranging from 47 to 75 years, with an equal gender distribution (5 males and 5 females). The average initial visual acuity was 5/60, ranging from 1/60 to 6/60. All patients presented with sudden vision loss, and 9 (90%) had a relative afferent pupillary defect (RAPD). Seven patients (70%) reported loss of colour vision, and many had a history of hypertension, hyperlipidaemia, or were on statins. The initial differential diagnosis included PION in 3 patients, AION in 4 patients, and demyelination in 3 patients. Some patients were treated with high-dose steroids (60 mg/day) for suspected(GCA) or as stroke cases due to vascular risk factors. OCT and OCTA findings revealed characteristic differences between the conditions. Result(s): The final diagnoses confirmed that 4 patients had PAMM, identified by hyperreflective lesions in the inner retinal layers on OCT, particularly in the parafoveal region. 3 patients were diagnosed with AMN, based on outer retinal hyperreflective lesions and macular ischemia identified on OCTA. The remaining 3 patients were diagnosed with optic neuropathy, 2 with PION and 1 with AION, based on OCT and OCTA findings, which did not show the characteristic retinal findings of PAMM or AMN. Regarding treatment, 5 patients were started on high-dose steroids (60 mg/day) for suspected GCA, but there was no significant improvement in the PAMM and AMN patients, where retinal ischaemia, rather than optic nerve ischemia, was the underlying issue. All patients were on statins, with 8 (80%) on increased doses due to hyperlipidaemia, and 7 (70%) were on antihypertensive therapy. Patients diagnosed with PAMM and AMN were managed conservatively with observation and treatment for underlying conditions, such as controlling hypertension and hyperlipidaemia, and did not require systemic steroids or biologics. Follow-up at 6 months showed that 6 out of 7 patients with PAMM and AMN had stable or slightly improved vision, with one patient showing slight worsening but remaining stable overall. Conclusion(s): OCT and OCTA imaging provide critical diagnostic information, revealing characteristic findings of retinal ischemia in PAMM and AMN. High-dose steroids, initially prescribed for suspected giant cell arteritis (GCA) or ischemic optic neuropathies, were ineffective for PAMM and AMN, as these conditions are driven by retinal ischemia rather than optic nerve ischemia. This underscores the importance of accurate diagnosis to avoid unnecessary treatments and potential harm, as steroids can worsen PAMM by increasing blood pressure. Patients with PAMM and AMN, when managed conservatively with observation and treatment for underlying conditions, demonstrated stable or improved visual outcomes. This contrasts with optic neuropathy patients who showed minimal improvement with steroids, highlighting the significance of early differentiation for optimal management. Additionally, this study emphasizes the cost-effectiveness of OCT and OCTA. These imaging techniques provide a less expensive, non-invasive alternative to MRI and CT scans, offering quicker and more accurate diagnoses. By reducing the need for more costly imaging and unnecessary treatments, OCT and OCTA contribute to both improved clinical outcomes and reduced healthcare costs. Therefore, their use in diagnosing acute onset retinal conditions mimicking optic neuropathy can significantly enhance patient care while ensuring cost savings for healthcare systems.
DOI: 10.1038/s41433-025-03831-0
