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Paracentral acute middle maculopathy following internal carotid artery stenting
Joseph B Alsberge1, H Richard McDonald2,3
1Department of Ophthalmology, Northwest Permanente, Vancouver, WA, USA.
Purpose:
To report a case of paracentral acute middle maculopathy (PAMM) that presented after internal carotid artery stenting despite the use of a filter embolic protection device.
Observations:
A 74-year-old man presented one week following transfemoral stenting of the right internal carotid artery for high-grade stenosis. A filter-type embolic protection device was used during the stenting procedure to prevent distal embolization of atherosclerotic debris. Dilated examination of the right eye revealed a parafoveal gray lesion in the macula and optical coherence tomography showed a corresponding placoid hyperreflective band at the level of the inner nuclear layer consistent with PAMM. The patient was asymptomatic. At 10 weeks follow up the PAMM lesion was resolved.
Conclusions:
PAMM occurred following internal carotid artery stenting despite the use of a filter embolic protection device, likely due to embolic debris passing through the filter device or debris released while the filter was in a collapsed state. The PAMM lesion was small and resolved without visual sequelae.
Insights
Paracentral acute middle maculopathy (PAMM) can occur after carotid artery stenting, even with embolic protection filters. This case highlights potential filter bypass or debris release issues, though the PAMM lesion resolved without vision loss.
Area of Science:
- Ophthalmology
- Vascular Neurology
- Interventional Cardiology
Background:
- Internal carotid artery stenting (ICAS) is a common procedure for high-grade stenosis.
- Embolic protection devices (EPDs) are used during ICAS to minimize distal embolization.
- Paracentral acute middle maculopathy (PAMM) is a retinal condition affecting the macula.
Observation:
- A 74-year-old male developed PAMM one week post-ICAS despite using a filter-type EPD.
- Ocular examination revealed a parafoveal gray lesion, confirmed by OCT as a hyperreflective band in the inner nuclear layer.
- The patient was asymptomatic, and the PAMM lesion resolved within 10 weeks.
Findings:
- PAMM occurred despite the use of a filter-type EPD during ICAS.
- Potential causes include embolic debris passing through the filter or debris released during filter deployment/retraction.
- The observed PAMM lesion was asymptomatic and fully resolved.
Implications:
- This case suggests that current filter-type EPDs may not completely prevent embolic events leading to PAMM.
- Further research into EPD efficacy and PAMM pathogenesis after ICAS is warranted.
- Ophthalmologists should consider ICAS as a potential trigger for PAMM in relevant patient populations.
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