A 47-year-old woman with a history of hypertension and type 2 diabetes for more than 15 years was referred for proliferative diabetic retinopathy management. Her chief complaint was acute onset of blurry vision in the right eye. She described intermittent foggy vision and the appearance of “a hair moving across the vision of her right eye” for the past few weeks. Her most recent hemoglobin A1c level was 8.3%, and 2 months prior to her visit, she had restarted diabetes medications. Her medications included metformin and glimepiride. Her corrected visual acuity was 20/20 OU. Her pupil, color vision, and anterior segment examinations had normal results bilaterally. A posterior segment examination of the right eye showed mild temporal elevation of the optic disc with blurred margins, mild peripapillary hemorrhages, a small amount of preretinal hemorrhage, and small-caliber branching vessels at the temporal disc with no fibrosis (Figure 1A). The left eye showed a normal optic disc, a cup-disc ratio of 0.1, and some microaneurysms at the macula. There were a few scattered dot-blot hemorrhages bilaterally. Fluorescein angiography of the right eye showed mild leakage from the abnormal vessels at the temporal optic disc (Figure 1B).
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A. Maintain observation
Diabetic papillopathy is an uncommon condition found among patients with type 1 or 2 diabetes that can be mistaken for neovascularization of the disc (NVD). Diabetic papillopathy can classically be differentiated from NVD by its radially oriented telangiectasias, which do not extend into the vitreous, while NVD has a random branching pattern and can extend into the vitreous.1,2 Diabetic papillopathy has a favorable prognosis, and most cases resolve spontaneously within 4 to 8 months.1,2 Small observational studies have reported improvement of optic disc edema with intravitreal or periocular steroids,3 vascular endothelial growth factor inhibitors (choice C),4 or panretinal photocoagulation (choice D).5 However, there appear to be no strong data for such treatments, and diabetic papillopathy can typically be observed. Magnetic resonance imaging of the brain (choice B) can be considered if compressive optic neuropathy or papilledema is suspected; unilateral papilledema cases have been reported but are uncommon.6 While it is not unreasonable to rule out these conditions with imaging, the absence of an afferent pupillary defect or other neurological deficits make these diagnoses less likely.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Corresponding Author: Benjamin J. Kim, MD, Scheie Eye Institute, University of Pennsylvania, 51 N 39th St, Philadelphia, PA 19104 (email@example.com).
Published Online: January 28, 2021. doi:10.1001/jamaophthalmol.2020.4670
Conflict of Interest Disclosures: Dr Kim reported having been a consultant for Allergan. No other disclosures were reported.
Additional Contributions: We thank the patient for granting permission to publish this information.
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