A Case of Bilateral Diabetic Papillopathy Related to Rapid Hemoglobin A1c Decrease in Type I Diabetes Mellitus

PURPOSE: To report a case of bilateral diabetic papillopathy related to rapid hemoglobin A1c (HbA1c) decrease in a type I diabetic patient. CASE SUMMARY: A 39-year-old female who was diagnosed with type I diabetes mellitus for the first time at this hospital was presented to our clinic for evaluation of diabetic retinopathy. There were no subjective symptoms, including blurred vision or visual defect. Her best corrected visual acuity in both eyes was 1.0, but her fundus resembled mild nonproliferative diabetic retinopathy. When diagnosed with type I diabetes mellitus, her HbA1c was 15.3%. She used insulin to control her blood glucose and her HbA1c reached 7.3% two months after controlling the blood glucose. Three months after her diabetic diagnosis, there were no differences in subjective symptoms and best corrected visual acuity. Fundus examination showed optic disc swelling in both eyes. To evaluate for the etiology of optic disc swelling, we did the examinations of the optic disc, fundus, and brain magnetic resonance imaging. No specific signs were observed. We diagnosed diabetic papillopathy and observed the patient without any treatments. Her optic disc swelling showed gradual improvement. CONCLUSIONS: This case shows that the rapid HbA1c decrease in type I diabetes mellitus is related to the occurrence of bilateral diabetic papillopathy. This supports previous studies that estimated that the rapid HbA1c decrease in type I diabetes mellitus in response to insulin treatment is one of the risk factors for bilateral diabetic papillopathy.

Two Cases of Long-Term Changes in the Retinal Nerve Fiber Layer Thickness after Intravitreal Bevacizumab for Diabetic Papillopathy

PURPOSE: To report long-term changes in the average retinal nerve fiber layer (RNFL) thickness in 2 patients who had intravitreal bevacizumab (IVB) injection for diabetic papillopathy. CASE SUMMARY: A 36-year-old patient with diabetes complained of decreased visual acuity (20/200) in the right eye. The fundus examination showed optic disc swelling in both eyes. The average RNFL thickness based on optical coherence tomography (OCT) increased to 278 microm and Goldmann perimetry showed nasal visual field defect in the right eye. The IVB was injected into the right eye. Three weeks after the IVB injection, RNFL thickness decreased to 135 microm and visual acuity improved to 20/25 in the right eye. However, RNFL thickness increased from 126 to 207 microm and visual acuity decreased to 20/32 in the left eye. Thus, IVB was injected into the left eye. In week 3, RNFL thickness decreased to 147 microm and visual acuity improved to 20/20 in the left eye. At 12 months after IVB injection, RNFL thickness was 87 microm in the right eye and 109 microm in the left eye. A 57-year-old patient with diabetes complained of decreased visual acuity (20/200) and showed optic disc swelling in the right eye. The average RNFL thickness increased to 252 microm and Goldmann perimetry showed an enlarged blind spot in the right eye. IVB was injected into the right eye. After 3 weeks, RNFL thickness decreased to 136 microm and visual acuity improved to 20/70 in the right eye. Six months after IVB injection, RNFL thickness was 83 microm in the right eye. CONCLUSIONS: Visual acuity progressively improved within 3 weeks and RNFL thickness measured by spectral domain OCT showed progressive thickness reduction in 2 cases of diabetic papillopathy patients who had IVB injections.

Intravitreal Bevacizumab Injection in Diabetic Papillopathy

PURPOSE: To report a case where intravitreal bevacizumab injection was an effective treatment for diabetic papillopathy in a type 2 diabetic patient. CASE SUMMARY: A 47-year-old male with a 10-year history of diabetes mellitus type 2 presented to our clinic for evaluation of diabetic retinopathy. There were no subjective symptoms including blurred vision or visual defect, and best corrected visual acuity (BCVA) was 20/20 in the right eye and 20/30 in the left eye. Fundus examination showed hyperemic optic disc swelling with telangiectatic new vessels, and fluorescein angiography leakage from the optic disc with neovascularization. The patient underwent fractionated panretinal photocoagulation. Ten days later, he complained of painless blurred vision with significant optic nerve head swelling and BCVA was 20/80 in the left eye. Intravitreal bevacizumab injection was administered, optic disc swelling was significantly decreased and BCVA improved to 20/30 after two months. CONCLUSIONS: Diabetic papillopathy with severe decreased visual acuity can be treated with intravitreal bevacizumab injection.

Bilateral Diabetic Anterior Ischemic Optic Neuropathy

PURPOSE: To evaluate the clinical findings of diabetic patients with bilateral anterior ischemic optic neuropathy. METHODS: Three diabetic patients with bilateral anterior ischemic optic neuropathy showed different clinical findings. One eye developed AION and the contralateral eye was diagnosed with diabetic papilloapthy with a subclinical disc swelling in Case I. The contralateral eye with diabetic papillopathy progressed to AION 3 months after showing the initial symptoms. In Case II, one eye developed AION, which continued in the contralateral eye after 6 months. In Case III, AION developed in both eyes simultaneously. RESULTS: A fundus examination revealed an edema of the optic disc in all cases. Prominent leakage of fluorescein dye from the capillaries of the optic disc was demonstrated on fluorescein angiography. Different field patterns including central scotoma, paracentral scotoma, an enlarged physiologic blind spot, and the constriction of the peripheral field of the visual field were revealed on Goldmann perimetry. The visual evoked cortical potential showed decreased amplitude and a prolonged latency. The visual acuity of the five eyes improved after administering high dose methylprednisolone. However, visual acuity of one eye with diabetic papillopathy did not improve. CONCLUSIONS: The clinical findings of the anterior ischemic optic neuropathies in the diabetic patients vary, and their prognosis is fair in most cases.