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Optical Coherence Tomography Angiography

and En Face Optical Coherence Tomography


Features of Paracentral Acute Middle
Maculopathy
JAYANTH SRIDHAR, ABTIN SHAHLAEE, EHSAN RAHIMY, BRYAN K. HONG, M. ALI KHAN,
JOSEPH I. MAGUIRE, JAMES P. DUNN, SONIA MEHTA, AND ALLEN C. HO
To characterize the optical coherence tomography (OCT) angiography, en face OCT, and microperimetry features of paracentral acute middle
maculopathy in both the acute phase and after resolution,
and to propose a classification of distinct subtypes of this
entity.
! DESIGN: Retrospective observational case series.
! METHODS: Clinical histories, high-resolution digital
color imaging, spectral-domain OCT images, fluorescein
angiography, OCT angiography images, and en face
OCT images of 16 patients with paracentral acute middle
maculopathy were evaluated. Microperimetry was available in 6 patients.
! RESULTS: The most common referring diagnoses were
isolated branch retinal arterial occlusion (5/16), combined central retinal vein and cilioretinal artery occlusion
(4/16), and isolated central retinal vein occlusion (4/16).
All patients demonstrated hyperreflective plaque-like
lesions at the level of the inner nuclear layer on
spectral-domain OCT, with no fluorescein angiographic
correlate. OCT angiography demonstrated variable areas
of capillary dropout within the superficial and deep retinal
capillary plexi in these areas. En face OCT highlighted
confluent areas of middle retina hyperreflectivity corresponding to these lesions. Three distinct en face OCT patterns were observed: arteriolar, fern-like, and globular.
Microperimetry demonstrated relative scotomas mapping
to the area of middle retinal hyperreflectivity seen on en
face OCT.
! CONCLUSIONS: Paracentral acute middle maculopathy
may be best evaluated with the use of en face OCT imaging, which corresponds to subjective and objective visual
field defects. En face OCT appearance may be used to
classify paracentral acute maculopathy into distinct
subtypes. (Am J Ophthalmol 2015;-:--.
! 2015 by Elsevier Inc. All rights reserved.)
! PURPOSE:

ARACENTRAL ACUTE MIDDLE MACULOPATHY IS A

recently characterized presentation of deep retinal


capillary ischemia, manifesting as hyperreflective
bands within the middle retina on spectral-domain
optical coherence tomography (OCT) imaging.1,2 While
the initial description detailed lesions occurring in
isolation, subsequent reports have observed this finding
in conjunction with other retinovascular conditions,
including branch (BRAO) and central (CRAO) retinal
arterial occlusion, central retinal vein occlusion
(CRVO), diabetic retinopathy, sickle cell retinopathy,
and
Purtscher
retinopathy.35
Most
recently,
Christenbury and associates described the first case of
paracentral acute middle maculopathy imaged with
OCT angiography, demonstrating attenuation of the
deep capillary plexus in the area of involvement.6 Taken
together, these observations further support a vasoocclusive origin for these lesions.
The purpose of the current study was to describe the
natural evolution of paracentral acute middle maculopathy in 16 additional cases evaluated with OCT angiography, and to better elucidate the involvement of
the adjacent retinal capillary plexuses, which to date
have been unable to be adequately assessed with traditional fluorescein angiography. Furthermore, these findings were correlated to en face OCT imaging, which
has not been previously reported for this condition,
and microperimetry, when available. A new classification of distinct subtypes of paracentral acute middle
maculopathy is then proposed based on en face OCT
appearances.

METHODS
INSTITUTIONAL REVIEW BOARD APPROVAL WAS OBTAINED

Accepted for publication Sep 10, 2015.


From Mid Atlantic Retina, The Retina Service of Wills Eye Hospital,
Thomas Jefferson University, Philadelphia, Pennsylvania.
Inquiries to Allen C. Ho, Mid Atlantic Retina, The Retina Service of
Wills Eye Hospital, Thomas Jefferson University, Philadelphia, PA
19107; e-mail: acho@att.net
0002-9394/$36.00
http://dx.doi.org/10.1016/j.ajo.2015.09.016

2015 BY

through the Wills Eye Hospital, Philadelphia, Pennsylvania, for a retrospective observational case series. Research
adhered to the tenets of the Declaration of Helsinki and
was conducted in accordance with regulations set forth
by the Health Insurance Portability and Accountability
Act (HIPAA).

ELSEVIER INC. ALL

RIGHTS RESERVED.

2
TABLE 1. Patient Demographics, Examination Findings, and Imaging in Paracentral Acute Middle Maculopathy
Age
(Years)

Sex

Eye

1
2
3
4
5

41
56
82
65
17

M
F
M
M
M

OS
OD
OD
OS
OD

Vision loss
Vision loss
Field cut
Vision loss
Vision loss

CRVO/CR
CRAO
BRAO
BRAO
BRAO

6
7

73
52

M
F

OS
OS

Field cut
Vision loss

BRAO
CRVO/CR

75

OD

Paracentral scotoma

BRAO

9
10
11
12
13

60
76
93
52
21

F
M
M
M
F

OS
OD
OD
OD
OU

Paracentral scotoma
Vision loss
Vision loss
Vision loss
Vision loss

BRAO
CRVO/CR
CRVO/CR
CRVO
BRAO OU

14
15

34
26

F
F

OS
OS

Vision loss
Paracentral scotoma

BRAO
BRAO

16

21

OU

Vision loss

BRAO

Patient

Symptom

Referring
Diagnosis

Deep Capillary Plexus


OCT-A Findings

Middle Retina En Face


OCT Pattern

AMERICAN JOURNAL OF OPHTHALMOLOGY

Associated Condition

VA Presentation

Beta thalassemia
HSV uveitis
HTN
HTN, chiropractic procedure
Prepapillary vascular loop,
trauma
HTN, carotid occlusion
Transcontinental flight/
dehydration
HTN, post-cardiac
catheterization
HTN, DM
HTN
HTN
Amyloidosis
Sickle cell disease,
dehydration on cruise ship
Cosmetic facial filler injection
Mechanical heart valve on
anticoagulation
Post-viral illness, Purtscherlike

20/20
CF
20/25
20/25
20/40

Normal flow
Capillary dropout
Normal flow
Normal flow
Capillary dropout

Arteriolar
Arteriolar
Arteriolar
Arteriolar
Arteriolar

20/40
20/60

Capillary dropout
Normal flow

Arteriolar
Arteriolar

20/25

Normal flow

Arteriolar

Capillary dropout
Normal flow
Normal flow
Normal flow
Capillary dropout OU

Arteriolar
Arteriolar
Arteriolar/fern-like
Fern-like
Multifocal globular

Paracentral scotoma
N/A
N/A
Paracentral scotoma
N/A

Capillary dropout
Normal flow

Focal globular
Focal globular

N/A
Paracentral scotoma

Normal flow OU

Multifocal globular

Paracentral scotoma

20/40
20/40
20/40
20/25
20/25 OD
20/200 OS
HMa
20/30
CF OU

Microperimetry Findings

N/A
N/A
N/A
N/A
N/A
Altitudinal field cut
Altitudinal field cut
N/A

BRAO branch retinal artery occlusion; CF count fingers; CR cilioretinal artery occlusion; CRAO central retinal artery occlusion; CRVO central retinal vein occlusion; DM diabetes
mellitus; HSV herpes simplex virus; HTN hypertension; N/A not available; OCT optical coherence tomography; OCT-A optical coherence tomography angiography; OD right eye; OS
left eye; OU both eyes; VA (Snellen) visual acuity.
a
Patient with concurrent ischemic optic neuropathy.

--- 2015

FIGURE 1. Optical coherence tomography angiography and en face optical coherence tomography features of paracentral acute middle maculopathy. Patient 10 was a 76-year-old man who presented with an inferior field cut in the setting of central retinal vein occlusion. Spectral-domain optical coherence tomography (OCT) demonstrated superior graying on near-infrared reflectance (Top left)
with middle retinal hyperreflectivity in the corresponding area (Top right). Fluorescein angiography (Bottom left) showed areas of
blockage reflecting preretinal and intraretinal heme and intact perfusion to superior macula. En face OCT (Bottom right, top row)
at the level of the superficial (left), middle (middle), and outer (right) retina demonstrated band-like hyperreflectivity at the level
of the middle retina. OCT angiography at the same levels (Bottom right, bottom row) is notable for absence of deep capillary plexus
dropout at the level of the middle retina.

Clinical records and imaging were reviewed to identify all cases with spectral-domain OCT imaging
showing paracentral acute middle maculopathy lesions
at a single academic private-practice office location
from January 1, 2015 to July 30, 2015. Available en
face OCT and OCT angiogaphy imaging cases were
identified. OCT angiography and en face OCT was
performed using the Avanti RTVue XR (Optovue,
Fremont, California, USA), which obtains volumetric
data from horizontal and vertical acquisitions that can
be automatically segmented to specific depths. Using
these data, side-by-side OCT angiography and en face
OCT images can be generated at the levels of the superficial capillary plexus, the deep capillary plexus, the
normally avascular outer retina, and the choriocapillaris.7,8 Baseline and follow-up demographic, clinical,
laboratory, and imaging data were extracted from
patient charts. High-resolution digital color photography, fluorescein angiography, and red-free photography were included in review, when available, for
each patient. Microperimetric examination using the
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Macular Integrity Assessment (MAIA; CenterVue,


Padova, Italy) was available and reviewed for 6 patients.

RESULTS
THE PATIENT DEMOGRAPHIC, OCULAR EXAMINATION, IM-

aging, and microperimetry findings (when available) are


summarized in Table 1. The mean age at presentation
was 53 years, and 9 of the 16 patients (56%) were male.
Ten individuals (63%) presented with acute-onset nonspecific visual loss, 3 (19%) reported a paracentral scotoma,
and 3 (19%) described an altitudinal field cut. Of the 10 patients with sudden vision loss, 2 (20%) experienced a partial resolution of symptoms within 30 minutes of onset.
The most common referring diagnoses were isolated
BRAO (5/16, 31%), combined CRVO with cilioretinal artery occlusion (4/16, 25%), and isolated CRVO (4/16,
25%). Seven patients had known histories of hypertension;
1 of these patients also had diabetes mellitus, 1 patient

OCT ANGIOGRAPHY OF PARACENTRAL ACUTE MIDDLE MACULOPATHY

FIGURE 2. Optical coherence tomography angiography and en face optical coherence tomography features of paracentral acute middle maculopathy, arteriolar pattern. Patient 9 was a 60-year-old woman who presented with a paracentral scotoma in the setting of a
branch retinal arterial occlusion proven on fluorescein angiography (Top row). Spectral-domain optical coherence tomography
(OCT; Second row, left) demonstrated nasal middle retinal hyperreflectivity approaching the fovea. Montage OCT angiography at
the level of the superficial plexus (Second row, right) disclosed multiple areas of capillary dropout. Review of en face OCT (Third
row) and OCT angiography (Bottom row) demonstrated a large area of middle retinal hyperreflectivity in an arteriolar distribution
with more extensive capillary dropout at the level of the deep plexus. Microperimetry (Bottom right) confirmed a superior altitudinal
defect in the same distribution.

presented after cardiac catheterization, and another lost


vision 1 hour after a chiropractic procedure. Associated
conditions in the remaining 9 patients included recent
cosmetic facial filler injection, post-viral illness, amyloidosis, beta thalassemia, presumed herpes simplex uveitis,
prepapillary vascular loop with trauma, sickle cell anemia
with dehydration on a cruise ship, mechanical heart valve
on anticoagulation, and transcontinental flight with dehydration.
Snellen best-corrected visual acuity (BCVA) on presentation ranged from 20/20 to hand motions. Two individuals
(13%) had bilateral vision loss; vision in these cases was

finger count OU and 20/25 OD and 20/200 OS, respectively. The patient with hand motions visual acuity had
concurrent ischemic optic neuropathy.
All patients demonstrated hyperreflective plaque-like
lesions at the level of the inner nuclear layer on
spectral-domain OCT, consistent with paracentral acute
middle maculopathy (Figure 1 top). Fluorescein angiography did not consistently reveal any correlate to these lesions (Figure 1 bottom left). En face OCT highlighted
confluent areas of middle retina hyperreflectivity corresponding to the lesions (Figure 1 bottom right). OCT angiography demonstrated variable areas of capillary dropout

AMERICAN JOURNAL OF OPHTHALMOLOGY

--- 2015

TABLE 2. Patterns of Middle Retina En Face Optical Coherence Tomography Hyperreflectivity in Paracentral Acute Middle
Maculopathy
Pattern

Appearance

Presumed Mechanism

Arteriolar
Fern-like
Globular

Band-like areas in distribution of major arteriole


Multilobulated central area tracking along veins
Ovoid focal or multifocal areas

Transient or true arterial occlusion


Perivenular capillary ischemia
Distal precapillary or capillary ischemia

within the superficial and deep retinal capillary plexi in the


area corresponding to the paracentral acute middle maculopathy lesions (Figure 1, bottom right, bottom row). Microperimetry disclosed relative scotomas mapping to the area
of middle retinal hyperreflectivity as seen on en face
OCT (Figure 2).
Three distinct patterns of these areas on en face OCT
were observed: arteriolar, globular, and fern-like
(Table 2). The arteriolar pattern was seen in 11 patients
(63%) and showed a characteristic band-like middle retina
hyperreflectivity mirroring the distribution of a large
retinal arteriole (Figure 2). The globular pattern was noted
in 4 patients (25%) with either a focal ovoid patch or
multifocal ovoid patches of middle retina hyperreflectivity
(Figure 3). The fern-like pattern was observed in 2 patients
(13%) in the setting of CRVO with multilobulated parafoveal middle retina hyperreflectivity (Figure 4). Of note, 1
patient with a combined CRVO and cilioretinal artery occlusion had both the arteriolar and fern-like pattern.
On follow-up en face OCT, areas of middle retina hyperreflectivity showed resolution, with variable areas of hyporeflectivity representing middle retinal atrophy (Figure 5).
OCT angiography of the deep capillary plexus showed
capillary dropout in the same areas.

DISCUSSION
ONLY

RECENTLY

RECOGNIZED,

PARACENTRAL

ACUTE

middle maculopathy, or PAMM for short, was initially


described as a presumed variant of acute macular neuroretinopathy.1,9 It has since been established that these lesions can
be associated with a multitude of retinal vascular disease
processes, including CRVO, CRAO, BRAO, and diabetic
retinopathy, among others.3,4,10 Chen and associates
recently described paracentral acute middle maculopathy
occurring in the setting of disparate vascular conditions,
such as sickle cell crisis, Purtscher retinopathy, hypertensive
retinopathy, and postupper respiratory infection.5
Owing to the OCT localization of these lesions at the
level of the inner nuclear layer, they have been postulated
to represent an ischemic insult of the adjacent intermediate
and deep capillary plexuses.3 It is well established that the
retina has a multilayered capillary network consisting of
the superficial plexus at the level of the ganglion cell layer
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and the intermediate and deep plexuses at the superficial


and deep edges of the inner nuclear layer, respectively.1113
The middle retina including the inner nuclear layer and
outer plexiform layer is felt to be a watershed zone that
may be most vulnerable to ischemia of the deeper
capillary plexuses.14
OCT angiography represents a relatively new technology with the ability to not only noninvasively image the superficial capillary plexus traditionally seen on fluorescein
angiography but also to capture the flow of the deeper capillary plexuses.7,8,15 There have been significant publications
describing OCT angiography findings in healthy subjects,
juxtafoveal telangiectasia, and choroidal neovascular
membranes in exudative age-related macular degeneration,
central serous chorioretinopathy, and other diseases.1620
De Carlo and associates recently demonstrated the ability
to capture wide-field OCT angiography montage images
extending anterior to the major arcades.21
OCT angiography has only previously been described for
1 case of paracentral acute middle maculopathy in the
setting of CRAO.6 That case showed severe hypoperfusion
of the deep capillary plexus; however, the images were obtained weeks after the onset of symptoms. While some of
the cases in the current series demonstrated capillary
dropout acutely, the majority demonstrated apparently
normal flow in the deeper capillary plexuses, despite the
supposition that the lesions represent ischemia at that
level. The authors suggest that in these cases with normal
flow initially there was likely a transient hypoperfusion of
the deeper plexuses that resulted in the functional abnormality in the absence of acute structural change on OCT
angiography. In the absence of a true occlusive event
(ie, CRAO or BRAO), the retina may also have the ability
to autoregulate flow to the deeper plexi so that OCT angiography initially reflects normal flow.
Over time, there was pruning and dropout of the deeper
plexuses on OCT angiography matching the middle retinal
atrophy, typical of paracentral acute middle maculopathy
lesions in other series.1,3,5 Given the initial normal flow
seen in conjunction with the spectral-domain OCT lesions, there is the strong possibility that reperfusion injury
plays a role in the subsequent development of atrophy. It is
well known in cases of cerebral, myocardial, and spinal cord
ischemia, for example, that reperfusion after an ischemic
event actually may accelerate damage owing to increased
levels of oxygen-derived free radicals and inflammatory

OCT ANGIOGRAPHY OF PARACENTRAL ACUTE MIDDLE MACULOPATHY

FIGURE 3. Optical coherence tomography angiography and en face optical coherence tomography features of paracentral acute middle maculopathy, globular pattern. Patient 15 was a 26-year-old woman who presented with sudden-onset paracentral scotoma.
Spectral-domain optical coherence tomography (OCT; Top row) disclosed an inferotemporal area of middle retinal hyperreflectivity.
Fundus color and red-free photography (Second row) showed a small patch of retinal whitening in the same area. En face OCT at the
level of the middle retina (Third row, left) demonstrated a globular area of hyperreflectivity. Microperimetry (Third row, right)
showed a corresponding paracentral scotoma. Review of en face OCT (Fourth row) and OCT angiography (Bottom row) demonstrated sparing of other retinal levels with intact superficial and deep capillary flow.

AMERICAN JOURNAL OF OPHTHALMOLOGY

--- 2015

FIGURE 4. Optical coherence tomography angiography and en face optical coherence tomography features of paracentral acute middle maculopathy, fern-like pattern. Patient 12 was a 52-year-old man who presented with a central retinal vein occlusion and foveal
blunting in the right eye (Top row, left). Microperimetry showed paracentral scotomas (Top row, middle). En face optical coherence
tomography (OCT) at the level of the middle retina (Top row, right) showed a fern-like pattern of perivenular hyperreflectivity. Review of en face OCT (Middle row) and OCT angiography (Bottom row) demonstrated sparing of other retinal levels with normal superficial and deep capillary plexus flow.

cytokines.2225 In the case of myocardial ischemia, for


example, an ongoing challenge is that percutaneous
coronary intervention may paradoxically further damage
myocytes in the first minutes after reperfusion.26 Given
the similarities between retinal tissue and myocardial and
neural tissue, an identical process at the level of the middle
retina could result in cellular apoptosis and capillary
dropout over time. Rat models of retinal ischemia and
reperfusion injury have previously demonstrated the role
of both free radical damage and apoptosis with caspase activation in inner retinal loss.27,28 Schmid and associates
demonstrated that induced ischemia in a rat model
affected inner retinal cells more than outer retinal cells,
with an increase in apoptotic cells in both the ganglion
cell and inner nuclear layers.29 As a result, they hypotheVOL. -, NO. -

sized that owing to reperfusion there may be a delayed


degeneration mediated by apoptosis occurring more than
2 weeks after the original ischemic insult. While further
study at the cellular level would be necessary to prove
that this is the exact mechanism in paracentral acute middle maculopathy, it suggests the potential of therapy to
reduce reperfusion injury, such as pharmacologic options
or induced hypothermia, to alter the inner retinal remodeling process. Rey-Funes and associates described that exposure of a rat retinal model to asphyxia in normothermic
conditions resulted in high levels of expression of angiogenic and gliotic factors when compared to asphyxic exposure in hypothermic conditions.30
In contrast to OCT angiography, en face OCT has
existed for nearly a decade since its original description.31

OCT ANGIOGRAPHY OF PARACENTRAL ACUTE MIDDLE MACULOPATHY

FIGURE 5. Optical coherence tomography angiography and en face optical coherence tomography features of paracentral acute middle maculopathy, evolution on follow-up. Serial en face optical coherence tomography (OCT; Top panels) and OCT angiography
(Middle panels) at the level of the middle retina (Bottom panels) show the evolution of paracentral middle maculopathy for Patient
10. Initial imaging (left column) demonstrated band-like superior hyperreflectivity on en face OCT with normal capillary flow. By
3 weeks (middle column) hyperreflectivity had disappeared on en face OCT with early patchy capillary dropout. By 8 weeks (right
column) there was hyporeflectivity at the level of the middle retina due to atrophy and there was more pronounced deep capillary
plexus pruning.

However, technological advances allow current en face


OCT images to be captured at specific retinal layers, allowing for several potential clinical applications. Sakimoto
and associates and Imai and associates used en face OCT
to show retinal nonperfusion and inner retinal thinning,
respectively, in branch retinal vein occlusion.32,33Alasil
recently reported the use of en face imaging of the
choroid in polypoidal choroidal vasculopathy.34
Rahimy and associates previously described the en face
appearance of paracentral acute middle maculopathy lesions on near-infrared reflectance as dark-gray areas.3
While those images showed more subtle changes, the en
8

face OCT middle retina cuts in the current series show


obvious well-demarcated areas of hyperreflectivity. This allows for the separation of paracentral acute middle maculopathy lesions into the 3 different subtypes based on
morphologic appearance, which may have implications
on the underlying disease mechanism. The band-like arteriolar pattern simulates the distribution of a BRAO. Even
in the absence of a true BRAO, we presume that transient
occlusion of a large retinal arteriole with rapid restoration
of normal flow could induce ischemia in the watershed zone
of the middle retina while sparing the nerve fiber and ganglion cell layers. In contrast, the smaller, oval patches of

AMERICAN JOURNAL OF OPHTHALMOLOGY

--- 2015

hyperreflectivity seen in the focal and multifocal globular


patterns likely represent distal ischemic events in smaller
terminal retinal arterioles, precapillaries, and capillaries.
Thus, the patients with the globular pattern had suspected
microembolic events, whether due to sickling of red blood
cells (Patient 13), iatrogenic emboli (Patient 14),
suspected emboli from mechanical heart valve (Patient
15), or Purtscher-like retinopathy with presumed complement activation (Patient 16). Finally, the fern-like pattern
seen in 2 patients with CRVO had been previously
observed both as perivenular whitening on examination
and as perivenular graying on near-infrared reflectance.3,3537 This is presumably due to the high density of
capillaries, including deep plexus ones, in the perivenular
distribution.38 Of note, 4 patients in this series had
CRVO with concomitant cilioretinal artery occlusion. In
prior series of paracentral middle maculopathy in the
setting of CRVO, 40% of patients had cilioretinal artery
occlusion.3 The presumed mechanism is the elevated intraluminal pressure of the central retinal vein transmitting
across the cilioretinal artery system and causing transient
occlusion.39
Microperimetry using macular integrity assessment offers eye-tracking technology allowing for measurement
of visual function with structural correlation and has
become rapidly popular as a detector of macular dysfunction.40 Only 1 case of microperimetry in the setting of
deep capillary ischemia had been previously reported.41
In the 6 patients with microperimetry available, the scotomas measured correlated directly with the areas of the
retina with the paracentral acute middle maculopathy

lesions on en face OCT. As such, microperimetry may


be a useful adjunct to spectral-domain OCT, OCT
angiography, and en face OCT in the detection of subtle
paracentral scotomas in patients with paracentral acute
middle maculopathy. Recently, however, the test-retest
repeatability of microperimetry in the detection of deep
scotoma borders has come into question.42 Future investigation is warranted to continue to evaluate the applications of this technology in the setting of deep capillary
ischemia.
Limitations of this study include its retrospective nature
and the relatively small number of patients included. Much
like prior series, this series relies on a theorized and unproven mechanism of deep retinal capillary ischemia as
the cause of paracentral acute middle maculopathy. In
addition, a study with long-term follow-up of the chronic
appearance of paracentral acute middle maculopathy lesions on OCT angiography and en face OCT would be useful.
In conclusion, paracentral acute middle maculopathy
may be best evaluated with the use of OCT angiography
and en face OCT imaging, with microperimetry as an
adjunct test to map out correlative paracentral scotomas.
En face OCT may not only help the ophthalmologist to
recognize this unique presentation more easily than standard OCT, but it may also allow for its subclassification
into clinically distinct subtypes. As more cases of paracentral acute middle maculopathy are reported, our understanding of the role of the intermediate and deep
capillary plexus in this entity will be improved by a multimodal imaging approach.

FUNDING/SUPPORT: THE AUTHORS HAVE NO FUNDING OR SUPPORT TO DISCLOSE FOR THIS PUBLICATION. A.C.H. HAS
received research grant funding in the past from Alcon, Allergan, Avalanche, Genentech, Iconic, Janssen/Johnson & Johnson, NEI/NIH, Ophthotech,
PanOptica, Regeneron, Second Sight, and Thrombogenics. Financial Disclosures: J.M. is a speaker for Regeneron and Genentech and on the advisory
board for Genentech. A.C.H. is a scientific advisor for Aerpio, Alcon, Allergan, DigiSight, Beaver EndoOptiks, Janssen, Genentech, ONL, Ophthotech,
Optovue, PanOptica, PRN, Regeneron, Second Sight, and Thrombogenics. The other authors have no disclosures, nor do they have any proprietary or
financial interest in any of the work discussed in this manuscript. All authors attest that they meet the current ICMJE requirements to qualify as authors.

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AMERICAN JOURNAL OF OPHTHALMOLOGY

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Biosketch
Dr Jayanth Sridhar received his undergraduate and medical degrees from the University of Miami, FL. He completed his
residency training at the Bascom Palmer Eye Institute and is currently a senior vitreoretinal surgical fellow and clinical
instructor at Wills Eye Hospital and Thomas Jefferson University in Philadelphia, PA. His research interests include
applications of novel imaging techniques to retinal disease and utilizing new technology to improve the quality of
medical student and resident education.

VOL. -, NO. -

OCT ANGIOGRAPHY OF PARACENTRAL ACUTE MIDDLE MACULOPATHY

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Biosketch
Abtin Shahlaee, MD, is a post-doctoral research fellow at Wills Eye Hospital. He received his medical degree from Tehran
University of Medical Sciences and was was a former research assistant at the Department of Ophthalmology at the Medical
University of Vienna. His current research projects focus on retinal imaging and diseases of the retina. His career goals
include training in ophthalmology in an academic setting with a long-term plan of becoming a successful clinician scientist.

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AMERICAN JOURNAL OF OPHTHALMOLOGY

--- 2015

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