Discordant Visual Outcome after Premium IOL Implantation: Unveiling Paracentral Acute Middle Maculopathy on OCT

Background: Premium intraocular lenses (IOLs), including extended depth of focus (EDOF) designs, provide excellent functional outcomes. However, unexplained postoperative visual dissatisfaction requires thorough evaluation, particularly of the macula. Case presentation: We report a 60-year-old patient who underwent sequential cataract surgery with implantation of an EDOF IOL (Vivity). The first eye achieved 10/10 postoperatively. The second eye had a preoperative acuity of 9/10 but remained limited to 4/10 postoperatively despite proper IOL positioning and clear media. Fundus examination was unremarkable. Macular OCT revealed hyper reflectivity of the inner nuclear layer, consistent with paracentral acute middle maculopathy (PAMM). Conclusion: PAMM is a rare but relevant cause of unexplained visual loss after cataract surgery. OCT is essential in such cases to avoid misattributing poor outcomes to IOL performance.