Comment to: 'Ahuja AS et al: Paracentral Acute Middle Maculopathy as a Manifestation of Giant Cell Arteritis'

Letters to the Editor Comment to: “Ahuja AS et al: Paracentral Acute Middle Maculopathy as a Manifestation of Giant Cell Arteritis” strongly hints at the presence of an underlying systemic disorder, GCA being at the top of this list in the elderly population. Francesco Pellegrini, MD Ophthalmology Department, “Santo Spirito” Hospital, Pescara, Italy W e enjoyed reading the paper by Ahuja AS et al entitled: “Paracentral Acute Middle Maculopathy as a Manifestation of Giant Cell Arteritis” (1). In their interesting paper, Ahuja and coworkers described 2 cases of Paracentral Acute Middle Maculopathy (PAMM), a focal retinal ischemic disorder of the inner nuclear layer, in which a definite diagnosis of giant cell arteritis (GCA) was later done through temporal artery biopsy (TAB). The first patient presented optical coherence tomography (OCT) findings suggestive of PAMM associated to cotton wool spots, whereas in the second case, PAMM was found in association with optic disc edema and peripapillary hemorrhage. They state that their “series is the first in which PAMM has been described in biopsy-proven GCA.” We would like to point out that in 2018 we already reported 2 cases of PAMM in biopsy-proven GCA (2). Among 53 eyes of 53 patients with cilioretinal artery occlusion (CILRAO), we found 2 patients with PAMM in whom TAB confirmed the suspect of GCA. As for Ahuja et al' cases, we also found PAMM not as an isolated finding, but associated to other manifestations of retinal ischemia, namely CILRAO. The clinical value of Ahuja and coworkers' paper, however, remains unchanged. In fact, they correctly highlighted the importance of obtaining OCT imaging in patients with retinal ischemia. They also correctly pointed out that the identification of ischemia affecting 2 separate vascular beds Pellegrini et al—“Reply to: Paracentral Acute Middle Maculopathy as a Manifestation of Giant Cell Arteritis”: Response W e appreciate the interest of Pellegrini et al in our recent article, “Paracentral Acute Middle Maculopathy as a Manifestation of Giant Cell Arteritis” (1), and we are glad that they agree with our conclusions about the utility of identifying multifocal ischemia on spectraldomain optical coherence tomography (SD-OCT) as a red flag for the possibility of giant cell arteritis (GCA). We would, however, like to respond to their assertion that paracentral acute middle maculopathy (PAMM) as a manifestation of biopsy-proven GCA was described in their previous publication on the topic of cilioretinal artery occlusions (2). Their large retrospective series of 53 cases of cilioretinal artery occlusion is very informative and offers striking SD-OCT images of PAMM in the distribution of Letters to the Editor: J Neuro-Ophthalmol 2022; 42: e533-e538 Emanuela Interlandi, MD, PhD Ophthalmology Department, “Ospedale del Mare,” Naples, Italy Francesco Pichi, MD Eye Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates The authors report no conflicts of interest. REFERENCES 1. Ahuja AS, El-Dairi MA, Hadziahmetovic M, Gospe SM III. Paracentral acute middle maculopathy as a manifestation of giant Cell arteritis. J Neuroophthalmol. 2021;41:e153– e156. 2. Pichi F, Fragiotta S, Freund KB, Au A, Lembo A, Nucci P, Sebastiani S, Gutierrez Hernandez JC, Interlandi E, Pellegrini F, Dolz-Marco R, Gallego-Pinazo R, Orellana-Rios J, Adatia FA, Munro M, Abboud EB, Ghazi N, Cunha Souza E, Amer R, Neri P, Sarraf D. Cilioretinal artery hypoperfusion and its association with paracentral acute middle maculopathy. Br J Ophthalmol. 2019;103:1137–1145. the cilioretinal artery. However, in their article, the authors report that it is their 51 non–GCA-related cases that demonstrate PAMM on SD-OCT, manifesting as a hyperreflective band in the inner nuclear layer with variable extension into the inner plexiform layer, but no involvement of the inner-most retinal layers. Conversely, in their 2 cases of cilioretinal artery occlusions in patients with biopsyproven GCA, the SD-OCT images demonstrate infarction of the middle and inner retina together; this is akin to what would be seen in a typical central retinal artery occlusion, where all but the outer-most retinal layers are hyperreflective and thickened. In fact, in their Discussion, the authors explicitly state that in their 2 cases of complete occlusion of the cilioretinal artery in the setting of GCA, ‟PAMM lesions were not identified with SD-OCT.” Ultimately, any claim to the first identification of PAMM as a manifestation of GCA is of less importance than the understanding that this pathological feature demands urgent and thorough workup to identify underlying etiologies that may put patients at risk of further vision loss. e533 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.