Paracentral acute middle maculopathy following physical exertion: A case report

To report a case of paracentral acute middle maculopathy (PAMM) after physical exertion and to explore possible underlying microvascular mechanisms.

A 42-year-old Caucasian man presented with a persistent, unilateral, painless paracentral scotoma that appeared after an intense ski session seven days earlier. His medical history included an 11-year course of migraine with aura and recurrent transient scotomas in either eye, lasting from minutes to days, often triggered by fatigue, exertion, or altitude. At presentation, best-corrected visual acuity was 1.6 Snellen equivalent bilaterally (20/12), with unremarkable slit lamp and fundoscopy examination. Optical coherence tomography (OCT) revealed a focal hyperreflective band in the inner nuclear layer of the right eye, consistent with PAMM. Fundus autofluorescence revealed a hyperautofluorescent spot in the same area. Microperimetry confirmed a localized scotoma in the corresponding area. At follow-up, clinical examination before and after moderate exertion (90 minutes of cycling) showed no new scotomas or clinical abnormalities. However, en face OCT angiography (OCTA) of the deep capillary plexus revealed multifocal variations in capillary density, with some areas demonstrating reduced perfusion after exercise.

PAMM is an OCT finding of focal retinal ischemia associated with various vascular disorders. Migraine has also been reported as a risk factor. In this case, physical exertion may have contributed to transient hemodynamic changes, potentially unmasking an underlying retinal microvascular vulnerability. The multifocal post-exercise decrease in perfusion on OCTA despite stable symptoms emphasizes the dynamic, subclinical nature of microvascular injury.Multimodal imaging combining structural and functional assessment is critical for the early detection of ischemic retinal events, even in patients without classic vascular risk factors.