LAUSR

© BMJ Publishing Group Limited 2021. No commercial reuse. See rights and permissions. Published by BMJ. DESCRIPTION We herein report a case of bilateral acuteonset scotoma following SARSCoV-2 infection in a 19yearold girl attributed to the presence of paracentral acute middle maculopathy (PAMM). She was tested positive for SARSCoV-2 infection 2 weeks prior by reverse transcription PCR testing and radiologically. Her medical reports revealed a raised Ddimer levels (1.23 μg/mL), for which she was started on intravenous steroids and enoxaparin by the treating physician. Her presenting visual acuity was 20/40, N6 and 20/125, N6 in the right (RE) left eye (LE), respectively. Dilated fundus evaluation exhibited the presence of cotton wool spots along the vascular arcades along with subtle white lesions at macula bilaterally ([figure 1A,B). Optical coherence tomography (OCT) showed presence of focal hyperreflective change in the inner and outer plexiform layers (IPL, OPL) with inner nuclear layer (INL) volume loss parafoveally (figure 1C,D) features consistent with PAMM. On review after 4 weeks, her visual acuity improved to 20/20 in RE and 20/25 in LE, repeat Ddimer levels were normal. OCT showed thinning of INL with the irregularity of IPL and OPL along with the resolution of the cotton wool spots (figure 2A–D). Sarraf et al first described PAMM to be a spectraldomain OCT manifestation of a thickened hyperreflective band at the level of the OPL and INL. PAMM has been attributed to the acute phase of ischaemia of intermediate and deep capillary plexuses which may herald presence of underlying secondary conditions like retinal vascular diseases. Ddimer, commonly elevated in coronavirus disease 2019 (COVID-19) patients, is a fibrindegradation product which is increased in thrombotic events, indicating fibrinolysis. Raised Ddimer values, lead to activation of coagulation cascade secondary to systemic inflammatory response syndrome, correlate to the disease severity and high mortality in such patients. Virgo and Mohamed interestingly reported two cases of PAMM and acute macular neuroretinopathy following SARSCoV-2 infection, possibly under the umbrella of ‘paediatric inflammatory multisystem syndrome temporally associated with SARSCoV-2 infection’. We hypothesise that the retinal capillary plexus ischaemia leading to PAMM could be secondary to a thrombotic milieu which is translated in the form of raised blood Ddimer levels. Routine ocular fundus examination and ordering Ddimer assay in patients with COVID-19 presenting with PAMM is extremely crucial as prompt anticoagulation is mandated in these patients. 12 In supposition, the relationship of Ddimer levels with PAMM in patients with COVID-19 warrants further attention before a meaningful conclusion can be drawn. Figure 1 (A, B) Colour fundus picture of right and left eye, respectively, shows subtle whitish perifoveal lesions along with cotton wool spots along the vascular arcades; (C, D) Swept source optical coherence tomography of right and left eye passing through macula shows focal area of patchy perifoveal hyperreflectivity in the inner and outer plexiform layers with inner nuclear layer volume loss consistent with paracentral acute middle maculopathy. Figure 2 First month followup (A, B) Colour fundus picture of right and left eye, respectively, shows resolving perifoveal whitish lesions and cotton wool spots; (C, D) Swept source optical coherence tomography of right and left eye passing through macula shows reduced hyperreflectivity with the irregularity of inner and outer plexiform layers and thinning of inner nuclear layer perifoveally.