1. Acute Macular Neuroretinopathy
Henry J Kaplan, MD
Evans Professor of Ophthalmology
Chair, Department of Ophthalmology & Visual Sciences
Director, Kentucky Lions Eye Center
University of Louisville
25th Congress of Ophthalmology 2015

2. AMN
Rare condition that produces transient or permanent visual impairment.
Typical cases have acute onset multifocal scotomas that correspond precisely with reddish, flat, or depressed circumscribed lesions in the macula. These lesions are wedge- shaped and generally point toward the fovea.

3. AMN
The pathophysiology of AMNR is unclear, the causes are uncertain, and there is no specific treatment for this condition.
Review of literature
Gass and colleagues:
Surv Ophthalmol 48:1–11, 2003.

4. Gass Review
First described by Bos and Deutman in 1975, who thought that the lesions involved the inner retina, thus the name AMNR.
SD-OCT imaging studies revealed that is not true.
Presents several days or later after the development of multiple, paracentral scotomata in one or both eyes.
Scotomas correspond precisely with the round or oval retinal lesions, that are depressed or flat, causing Gass to believe they represent defects in ONL photoreceptors.
Best seen with red-free light
FA is usually normal with ocassional hypofluorescence of lesions.

5. Gass Review Etiology unknown in review of 73 cases
Associated with oral contraceptives, epinephrine, flu-like illness, contrast imaging agents, trauma – coughing, straining, migraine headache, postpartum hypotension, and hypotensive shock.
Presents in young women, child-rearing age
VA is normal or mildly decreased

6. Variation in Presentation
Dark petal-like oval/round lesions
Occasional superficial hemorrhage

7. AMN Variation in Presentations
Small dark reddish-brown spots
Located in the outer retina

8. 9 patients,5 female & 4 male(mean age,47.6years;range, 21-65 years).
Sarraf D et al. Paracentral Acute Middle Maculopathy:A New Variant of Acute Macular Neuroretinopathy Associated With Retinal Capillary Ischemia. JAMA Ophthalmol. 2013;131(10):
9 patients,5 female & 4 male(mean age,47.6years;range, years).
All patients presented with an acute paracentral scotoma and a classic dark gray paracentral lesion.
Visual acuity ranged from 20/15 to 20/30.
Six eyes (5 patients) had type 1 SD-OCT lesions (above INL), ie paracentral acute middle maculopathy; 5 eyes (4 patients), type 2 SD-OCT lesions (below INL).
Type 1 lesions lead to inner nuclear INL thinning; type 2, ONL thinning.

9. Paracentral Acute Middle Maculopathy
Type 2 lesions associated with significant outer macular defects (disruption of IS/OS and OS/RPE bands0; type 1 lesions spared the outer macula.
Propose that each of these lesions may be explained by occlusion of either the superficial capillary plexus (type 1) or deep capillary plexus (type 2) located in the innermost and outermost portion of the INL, respectively.

10. Location of SCP and DCP

11. AMN Variant

12. Type 1 Lesion
b=red free, cf, = near IR

13. Type 2 Lesion
EH 8 weeks later

14. Conclusion AMN is a rare disorder, predominant in women
As in most disorders of the retina this disease has a variable phenotype on clinical presentation (i.e. prodromal symptoms), clinical appearance and imaging analysis.
There is very likely a spectrum of AMN whose features with regard to etiology and presentation will be further clarified in the future.