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Diabetes

A 47-Year-Old Woman Urgently Referred for Proliferative Diabetic Retinopathy Management

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.

1 Credit CME

JAMA Ophthalmology

Published Online: January 28, 2021

JAMA Ophthalmology Clinical Challenge

Article Information and Disclosures

Tianyu Liu, MD¹;

Ayman G. Elnahry, MD, PhD²;

Benjamin J. Kim, MD¹

Author Affiliations

¹Scheie Eye Institute, University of Pennsylvania, Philadelphia
²Department of Ophthalmology, Faculty of Medicine, Cairo University, Cairo, Egypt

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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 A_1c 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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Diabetic papillopathy

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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Article Information

Corresponding Author: Benjamin J. Kim, MD, Scheie Eye Institute, University of Pennsylvania, 51 N 39th St, Philadelphia, PA 19104 (benjamin.kim@pennmedicine.upenn.edu).

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.

References

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Mansour AM , El-Dairi MA , Shehab MA , Shahin HK , Shaaban JA , Antonios SR . Periocular corticosteroids in diabetic papillopathy. Eye (Lond). 2005;19(1):45-51. doi:10.1038/sj.eye.6701418 PubMed Google Scholar Crossref

Al-Hinai AS . Diabetic papillopathy with macular edema treated with intravitreal bevacizumab. Oman J Ophthalmol. 2012;5(2):138-139. doi:10.4103/0974-620X.99389 PubMed Google Scholar Crossref

Chin EK , Almeida DR , Sohn EH . Sustained and expedited resolution of diabetic papillopathy with combined PRP and bevacizumab. Can J Ophthalmol. 2015;50(5):e88-e91. doi:10.1016/j.jcjo.2015.05.020 PubMed Google Scholar Crossref

Elnahry AG , Elnahry GA . Unilateral papilledema revealing an intracanalicular optic nerve sheath meningioma. Neuroophthalmology. 2018;43(2):123-125. doi:10.1080/01658107.2018.1482359 PubMed Google Scholar Crossref

Lubow M , Makley TA Jr . Pseudopapilledema of juvenile diabetes mellitus. Arch Ophthalmol. 1971;85(4):417-422. doi:10.1001/archopht.1971.00990050419004 PubMed Google Scholar Crossref

Ostri C , Lund-Andersen H , Sander B , Hvidt-Nielsen D , Larsen M . Bilateral diabetic papillopathy and metabolic control. Ophthalmology. 2010;117(11):2214-2217. doi:10.1016/j.ophtha.2010.03.006 PubMed Google Scholar Crossref

Hirano T , Hoshiyama K , Hirabayashi K , et al. Vitreretinal interface slab in OCT angiography for detecting diabetic retinal neovascularization. Ophthalmol Retina. 2020;4(6):588-594. doi:10.1016/j.oret.2020.01.004 Google Scholar Crossref

Hayreh SS , Zimmerman MB . Incipient nonarteritic anterior ischemic optic neuropathy. Ophthalmology. 2007;114(9):1763-1772. doi:10.1016/j.ophtha.2006.11.035 PubMed Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.