Paramacular Acute Middle Maculopathy Associated with Glyceryl Trinitrate

Abstract

An unusual case of nitroglycerin-induced Paracentral Acute Middle Maculopathy (PAMM) is presented. A 50-year-old patient with sudden vision loss and scotoma was followed up with swept-source optical coherence tomography (SS-OCT), optical coherence tomography-angiography (OCT-A), and fluorescein angiography (FA). An anal fissure treated with glyceryl trinitrate (GTN) 0.2% ointment with headache and dizziness after application was reported. Fundoscopy OS revealed mild retinal venous dilatation and tortuosity with scattered blot hemorrhages and subtle, parafoveal, whitish lesions in the outer retina. SS-OCT revealed diffuse, hyperreflective lesions in the inner plexiform (IPL), inner nuclear (INL), and outer plexiform layers (OPL). OCT-A revealed focal dropout in the deep capillary plexus. FA showed masking due to blot hemorrhages and early punctuate leakage in the inner retina. This entity was identified as nitroglycerin-induced PAMM. Over the following 8 months, after discontinuation of the ointment application, the patient was symptom-free with stable visual acuity. OCT revealed INL/OPL thinning and confirmed complete lesion resolution. This first report of retinal vascular abnormalities due to nitrite ointment provides an insight into an unknown side effect of nitroglycerin ointment use. A dose-dependent correlation between GTN application and retinal vascular abnormalities remains to be confirmed.

Figure 1

Fundus photo OD with no evidence of pathology (a). Fundus photo OS with mild retinal venous dilatation and tortuosity with scattered blot hemorrhages (b). Fundus autofluorescence does not reveal hyperfluorescent lesions or RPE changes (c, d) apart from the masking effect from blot hemorrhages OS (d). Optical coherence tomography-angiography demonstrates a focal, small area of capillary dropout in the deep capillary plexus (f). Superficial capillary plexus, outer retina, and choriocapillaris appear normal (e, g, h). Fundus photo OS, 1 month after presentation with fewer blot hemorrhages (i). Fundus photo after 6 months of OS shows complete resolution of the hemorrhages (j).

Figure 2

Swept-source- (SS-) OCT imaging of the left eye. Horizontal scans are presented on the left column and vertical ones on the right one (lines 1 and 6 on DRI OCT Triton, SS-OCT, respectively). OCT scans on presentation demonstrated diffuse, hyperreflective lesions at the level of the inner plexiform layer, inner nuclear layer, and outer plexiform layer (a, b). Partial resolution (one month later) (c, d) and complete resolution (six months later) (e, f) of the lesions are observed along with thinning of the inner retina.

Figure 3

Fluorescein angiography (FA) images OS shows a masking effect due to blot hemorrhages and early punctuate leakage in the upper retina: (b) 1.09 min, (c) 1.19 min, (d) 1.29 min, (e) 1.38 min, and (f) 4.30 min.