Diabetic Papillopathy

Diabetic Papillopathy
SYMPTOMS Mild decrease in vision but less commonly may also be asymptomatic
SIGNS Can be unilateral or bilateral
Mild optic nerve edema, Optic nerve hyperemia, Loss of the cup, Blurring of the optic disc margins, Obscurations of the small vasculature at or around the optic nerve, Thickened and edematous retinal nerve fiber layer, Opacification of the retinal nerve fiber layer, Loss of sharp light reflexes around the optic disc, Splinter retinal hemorrhages, Cotton wool spots, Marked capillary telangiectasia on the optic disc
Ultimately there may be mild optic nerve pallor with cupping following resolution of diabetic papillopathy or if diabetic papillopathy is chronic
Other signs of diabetic retinopathy will be present
WORK-UP Pupils (decrease in direct light response and an APD in the eye with diabetic papillopathy), EOMs, Color vision (typically abnormal), Visual field (enlarged blind spot/visual field defect is not always present), Blood pressure evaluation (in order to rule out malignant hypertension), Slit lamp examination, Dilated retinal exam, Fundus photos, OCT, Fluorescein angiography (presence of optic disc staining more so than leakage)
OCT (Optic nerve analysis with EDI and RNFL analysis): *Elevation of the neuroretinal rim thickness *Smooth optic nerve contour *Elevation of the optic disc with involvement of the retinal nerve fiber layer with a smooth, hill-like appearance *Anterior displacement of the Bruch's/RPE complex especially near the Bruch's membrane opening *Presence of peripapillary hyper-reflective ovoid-mass like structures (PHOMS) which represent bulging optic nerve axons *Presence of subretinal fluid (presence of “lazy V sign” especially at the Bruch’s membrane opening) *Thickening of the of the RNFL with typically the nasal side being > 86 microns, temporal side being > 97 microns, superior side being > 149 microns, and inferior side being > 165 microns (Nasal RNFL thickening has the greatest specificity and sensitivity) *Subretinal hyporeflective space between the optic disc and Bruch's membrane opening (SHYPS) is >464 microns
TREATMENT Refer to a neuro-ophthalmologist/ER STAT for additional testing and treatment (diabetic papillopathy is a diagnosis of exclusion)
There is no effective treatment for diabetic papillopathy. It typically resolves on its own within 2-10 months
FOLLOW-UP After resolution of diabetic papillopathy, patient should be followed-up every 4-6 months
ADDITIONAL LAB | TESTS Testing will typically be ordered through the neuro-ophthalmologist/ER: MRI of the brain and orbits with and without contrast, Lumbar puncture, ESR with C-reactive protein (will typically be normal), CBC with differential, PT/TT/BT/PTT/INR, Fasting blood sugar, HbA1c, Blood pressure evaluation, Sleep study
ETIOLOGY Unclear but thought to be due to impaired blood flow or ischemia to the optic nerve
DIFFERENTIAL DX Papilledema, Hypertensive optic neuropathy, Optic neuritis, Ischemic optic neuropathy, Infiltrative optic neuropathy
NOTES Diabetic papillopathy is typically seen in patients with Type 1 diabetes
Diabetic papillopathy does not correlate to any specific stage of diabetic retinopathy
OCT will go from showing swelling of the RNFL to thinning of the RNFL as optic atrophy develops
Once diabetic papillopathy resolves, vision usually returns to normal (75% of patients see 20/40 or better)
Diabetic papillopathy increases the risk of developing an NAION
Diabetic Papillopathy https://www.opticianonline.net/cpd-archive/5935

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