Asteris Petros, Stergiopoulos Georgios, Bagli Eleni, Kalogeropoulos Chris
Department of Ophthalmology, University Hospital of Ioannina, Ioannina, GRC.
Cureus. 2025 Aug 20;17(8):e90605. doi: 10.7759/cureus.90605. eCollection 2025 Aug.
An 80-year-old woman presented with sudden, profound vision loss in her left eye. Initial fundus examination showed only mild disc hyperemia, a few retinal hemorrhages, and venous dilation, findings insufficient to explain the severity of visual loss on their own. Optical coherence tomography (OCT) revealed hyperreflective bands in the inner nuclear layer consistent with paracentral acute middle maculopathy (PAMM), while en face OCT angiography demonstrated a fern-like perivenular pattern. A relative afferent pupillary defect (RAPD) was also noted at the 48-hour follow-up. Given the clinical-imaging discrepancy, fluorescein angiography, performed at the 48-hour follow-up, showed delayed arterial and venous filling, macular capillary dropout, and late optic disc leakage. Fundus autofluorescence revealed marked hypoautofluorescence in ischemic regions. Despite initial apparent anatomical resolution, vision remained poor, and the RAPD persisted. On the last follow-up, retinal atrophy had developed. Systemic evaluation identified previously undiagnosed atrial fibrillation, implicating microembolic retinal ischemia as the likely etiology. No emboli were visualized, but imaging suggested occlusion of small-caliber retinal vessels. No visual recovery was observed at follow-ups. To our knowledge, reports linking fern-like PAMM to newly discovered atrial fibrillation with this degree of vision loss are uncommon. This case underscores that profound vision loss may result from microvascular ischemia in the absence of overt fundus signs. It highlights the importance of multimodal imaging and cardiovascular assessment in unexplained acute visual loss.
一名80岁女性因左眼突然出现严重视力丧失前来就诊。初次眼底检查仅显示轻度视盘充血、少量视网膜出血和静脉扩张，这些表现本身不足以解释视力丧失的严重程度。光学相干断层扫描（OCT）显示内核层有高反射带，符合黄斑中心旁急性中层病变（PAMM），而OCT血管造影正面成像显示静脉周围呈蕨类样图案。在48小时随访时还发现了相对传入性瞳孔障碍（RAPD）。鉴于临床影像表现不一致，在48小时随访时进行的荧光素血管造影显示动脉和静脉充盈延迟、黄斑毛细血管缺失以及晚期视盘渗漏。眼底自发荧光显示缺血区域有明显的低自发荧光。尽管最初解剖结构看似恢复，但视力仍很差，且RAPD持续存在。在最后一次随访时，出现了视网膜萎缩。全身评估发现此前未诊断出的心房颤动，提示微栓塞性视网膜缺血可能是病因。未观察到栓子，但影像学提示小口径视网膜血管闭塞。随访期间未观察到视力恢复。据我们所知，将蕨类样PAMM与新发现的心房颤动及这种程度的视力丧失联系起来的报告并不常见。该病例强调，在没有明显眼底体征的情况下，微血管缺血可能导致严重视力丧失。它突出了多模态成像和心血管评估在不明原因急性视力丧失中的重要性。
