Paracentral acute middle maculopathy and hemodynamically significant patent foramen ovale

Purpose: To report a possible association between paracentral acute middle maculopathy (PAMM) and hemodynamically significant patent foramen ovale (PFO), and to propose a cardiovascular screening strategy for patients with unexplained isolated PAMM. Design: Retrospective multicenter case series. Methods: Electronic medical records and multimodal retinal imaging findings of consecutive patients with PAMM and hemodynamically significant PFO presenting at Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico and Ophthalmic Hospital, ASST Fatebenefratelli Sacco between January 2019 and December 2024. Initial spectral domain optical coherence tomography (SD-OCT) showed a band-like hyperreflective lesion at the inner nuclear layer (INL) in all cases. Results: A total of five patients (three males; mean age 62 years, range 54–71) with PAMM were found to have a hemodynamically significant PFO. Four out of five had isolated PAMM and were included in this series. In three cases the PFO was discovered after the cardiologist referral; one patient was known for PFO and Factor V Leiden mutation. In all cases PFO was the only embolic source identified after an extensive workup. Management included surgical or percutaneous closure or antithrombotic therapy. Over a mean 12-month follow-up (range: 6–21), SD-OCT showed progressive attenuation and thinning of the INL; visual acuity improved or remained stable. None of the patients experienced recurrent retinal or cerebral ischemic events during follow-up. Conclusions: Our series suggests that isolated PAMM is possibly linked to hemodynamically significant PFO, supporting the need for a targeted cardiovascular assessment, including bubble contrast echocardiography.