BASICS

DESCRIPTION

An uncommon unilateral or bilateral swelling of the optic disc seen in diabetics of all ages. The optic disc edema is transient and usually resolves over the course of a few months. Impairment of optic nerve function is usually mild. It is important to differentiate between diabetic papillopathy and proliferative diabetic retinopathy with neovascularization on the optic disc.

EPIDEMIOLOGY

Incidence

• Although more common in juvenile diabetics, diabetic papillopathy has been reported in patients as old as 79 years.

• Sexes are equally affected.

RISK FACTORS

• Poor glucose control

• Duration of diabetes

GENERAL PREVENTION

All diabetics should be counseled on the importance of strict blood glucose control.

PATHOPHYSIOLOGY

• The pathophysiology of disc swelling is unclear.

• Some consider this as being a vasculopathy of the superficial layers of the disc capillaries.

COMMONLY ASSOCIATED CONDITIONS

• Diabetic retinopathy

• Macular edema

DIAGNOSIS

HISTORY

• Painless decrease in vision

• Visual field defect (most common is an enlarged blind spot)

PHYSICAL EXAM

• Visual acuity can be normal

• Minimal or no afferent pupillary defect

• Dyschromatopsia is mild or absent

• Enlarged blind spot or mild arcuate defect on visual field

• Hyperemic swelling of the optic disc with dilated, radially oriented superficial telangiectatic vessels (1)[A]

• Background diabetic retinopathy

• Macular edema

• Small optic disc ratio in fellow eye if only one eye affected

DIAGNOSTIC TESTS & INTERPRETATION

Lab

• May have an elevated Hb A1c

• Blood pressure

• CBC

• ANA

• ACE

• Lyme titer

• RPR

• ESR

Imaging

MRI brain and orbits with and without gadolinium to rule out demyelination and/or a compressive lesion.

Diagnostic Procedures/Other

Intravenous fluorescein angiography (IVFA). Follow up IVFA can show capillary nonperfusion and rule out neovascularization.

Pathological Findings

• IVFA shows focal or diffuse optic disc hyperfluorescence

• Leakage from telangiectatic vessels

• Need to differentiate this disc swelling from disc neovascularization where fluorescein is leaked into the vitreous in the latter (2)[A].

DIFFERENTIAL DIAGNOSIS

• NAION

• Papilledema

• Hypertensive retinopathy

• Proliferative diabetic retinopathy

• Optic Neuritis (Papillitis)

• Inflammatory optic neuropathies

TREATMENT

MEDICATION

• No medication for treatment

• Self-limited

• May require laser photocoagulation for diabetic retinopathy and/or macular edema

ADDITIONAL TREATMENT

General Measures

May need retinal photocoagulation after the disc edema has resolved to treat diabetic retinopathy and/or macular edema

Issues for Referral

Follow up with neuro-ophthalmologist or retinal specialist 2 weeks after initial diagnosis is made

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

• Every 2–3 weeks to look for resolution of edema and assess optic nerve function (color vision, visual field, and pupillary exam)

• Need to confirm there is no proliferative diabetic retinopathy

• Need to reconsider the diagnosis if severe optic nerve dysfunction noted at presentation (this remains a diagnosis of exclusion).

DIET

Diabetic diet

PATIENT EDUCATION

The importance of strict blood glucose control must be stressed.

PROGNOSIS

Good clinical outcome, however, there may be mild permanent visual field defects and morbidity from associated macular edema.

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