Diabetic papillopathy and its relation to optic nerve ischemia. Optom Vis Sci. 2009;86:e395-e403. [PMID: 19225435 DOI: 10.1097/opx.0b013e318198927c]

NAION or not NAION? A literature review of pathogenesis and differential diagnosis of anterior ischaemic optic neuropathies

PURPOSE

To offer a comprehensive review of the available data regarding non-arteritic anterior ischaemic optic neuropathy and its phenocopies, focusing on the current evidence to support the different existing aetiopathogenic hypotheses for the development of these conditions.

CONCLUSIONS AND IMPORTANCE

Due to the limited array of responses of the neural tissue and other retinal structures, different aetiopathogenic mechanisms may result in a similar clinical picture. Moreover, when the insult occurs within a confined space, such as the optic nerve or the optic nerve head, in which different tissues (neural, glial, vascular) are highly interconnected and packed together, determining the primary noxa can be challenging and may lead to misdiagnosis. Anterior ischaemic optic neuropathy is a condition most clinicians will face during their everyday work, and it is important to correctly differentiate among resembling pathologies affecting the optic nerve to avoid unnecessary diagnostic procedures. Combining a good clinical history and multimodal imaging can assist diagnosis in most cases. The key remains to combine demographic data (e.g. age), with ophthalmic data (e.g. refractive error), systemic data (e.g. comorbidities and medication), imaging data (e.g. retinal OCT) with topographic signs (e.g. focal neurology).

METHODOLOGY

Papers relevant for this work were obtained from the MEDLINE and Embase databases by using the PubMed search engine. One author (MPMG) performed the search and selected only publications with relevant information about the aetiology, pathogenic mechanisms, risk factors as well as clinical characteristics of phenocopies (such as vitreopapillary traction, intrapapillary haemorrhage with adjacent peripapillary subretinal haemorrhage or diabetic papillopathy) of non-arteritic anterior ischaemic optic neuropathy (NAION). The terms "non-arteritic ischaemic optic neuropathy/NAION", "vitreopapillary traction", "vitreopapillary traction AND non-arteritic ischaemic optic neuropathy/NAION", "posterior vitreous detachment AND non-arteritic ischaemic optic neuropathy/NAION", "central retinal vein occlusion AND non-arteritic ischaemic optic neuropathy/NAION", "disc oedema/disc oedema", "diabetes mellitus AND non-arteritic ischaemic optic neuropathy/NAION" and "diabetic papillopathy" were searched on PubMed. From each of these searches, publications were selected based on their title, obtaining a total of 115 papers. All papers not written in English were then excluded, and those whose abstracts were not deemed relevant for our review, according to the aforementioned criteria. Subsequent scrutiny of the main text of the remaining publications led us (MPMG, AP, ZS) to include references which had not been selected during our first search, as their titles did not contain the previously mentioned MeSH terms, due to their significantly relevant contents for our work. A total of 62 publications were finally consulted for our review. The literature review was last updated on 24-Aug-2022.

Papilledema: A Review of the Pathophysiology, Imaging Findings, and Mimics

Increased intracranial pressure is the most common cause of papilledema. Multiple etiologies such as cerebral edema, hydrocephalus, space occupying lesions, infection, and idiopathic intracranial hypertension among others should be considered. Imaging plays a critical role in the detection of pathologies that can cause papilledema. MRI with contrast and CE-MRV, in particular, are key for the diagnosis of idiopathic intracranial hypertension. This review will focus in common and infrequent causes of papilledema, the role of imaging in patients with papilledema as well as its potential mimickers.

Combined therapy with intravitreal aflibercept and subtenon corticosteroids in eyes with severe diabetic papillopathy: two case reports

Background

Diabetic papillopathy is a rare diagnosis of exclusion characterized by unilateral or bilateral optic disc edema with variable degrees of visual loss. Although the visual prognosis has been generally reported as favorable, the presence of severe disc edema associated with macular edema prompts the need for treatment. We present a specific and unreported therapeutic approach consisting of intravitreal aflibercept and subtenon triamcinolone acetonide injections in two patients with evidence of diabetic papillopathy and macular edema.

Case presentation

In the first case, a 60-year-old Caucasian woman affected by type II diabetes mellitus presented with fundoscopic evidence of sequential bilateral optic disc edema associated with acute severe visual loss in both eyes. The second patient, a diabetic 57-year-old Caucasian male, presented with sudden painless visual loss in his left eye. Multimodal imaging and systemic findings correlated towards an infrequent diagnosis of diabetic papillopathy. In a period of 5–7 weeks after treatment, both patients experienced almost full visual and anatomical recovery. A steady situation was observed at 12 months of follow-up.

Conclusions

Both our cases displayed a severe grade of optic disc edema, which was optimally reversed with intravitreal aflibercept and subtenon triamcinolone acetonide leading to a relatively rapid and safe improvement in visual acuity.

Regional brain changes in patients with diabetic optic neuropathy: a resting-state functional magnetic resonance imaging study

Background

To evaluate functional connection density (FCD) in patients with diabetic optic neuropathy (DON) using the resting functional connectivity (FC) method, and to determine the abnormal areas of brain activity.

Methods

Patients with DON (n=22; 10 male, 12 female) and healthy controls (HCs; n=22; 10 male, 12 female) were included in the study. The basic characteristics of the groups were matched. Functional magnetic resonance imaging (fMRI) was conducted with participants at rest, and long- and short-range FCD (long FCD and IFCD, respectively) were measured. Receiver operating characteristic (ROC) curve analysis was also conducted to determine whether DON and HC participants could be distinguished using fMRI indicators.

Results

Compared with HCs, the long FCD values of the left lingual gyrus, right lingual gyrus, right fusiform gyrus, and medial and lateral cingulate gyri were decreased in patients with DON. Further, the IFCD values of the left superior temporal gyrus, left inferior temporal gyrus, right inferior temporal gyrus, left cerebellar area 8, and right cerebellar Crus2 area were higher in patients with DON than in the HCs.

Conclusions

DON is associated with abnormal spontaneous brain activity. Our findings contribute to elucidating the mechanisms underlying the neuropathology of DON, and provide direction for further clinical research.

The evaluation of patients with optic disc edema: A retrospective study

OBJECTIVE:

Optic disc edema is among major problems that neuro-ophthalmology clinics encounter. We intended to analyze patients with optic disc edema in this article.

METHODS:

Data related to the main complaint, associated systemic disease, visual acuity, characteristics of optic disc swelling, other ocular findings, topical or systemic drugs, treatment methods, follow-up examination, and related data of the patients were obtained retrospectively.

RESULTS:

There were 77 female and 23 male patients in the study. Optic disc edema was detected bilaterally in 65 patients, unilaterally in 35 patients. The duration of the symptoms until the first application was 19.82±17.18 (0–90) days. There were no systemic disorders in 74 patients but diabetes mellitus in 11 patients, hypertension in four patients, coronary artery disease in three patients, urticaria in two patients, lymphoma in one, multiple sclerosis in one patient, mastoiditis in one patient, scleroderma in one, and pregnancy in two patients were detected. While 93 patients had no additional ocular findings, 2 had uveitis, 1 had corneal dystrophy, 1 had keratoconus, 1 had cataract, 1 had previous cataract surgery, and 1 had peripheral retinal degenerations. The major etiology of the optic disc edema was idiopathic intracranial hypertension, which was detected in 44 patients. In all these patients, bilateral optic disc edema was observed and 43 patients were given oral acetazolamide and one patient oral topiramate.

CONCLUSION:

The presence of optic nerve edema should be absolutely evaluated in patients presenting with symptoms of vision loss and increased intracranial pressure. The early diagnosis with fundoscopic examination may increase visual acuity in these patients.

[Maculopathy in sickle cell disease]

Hintergrund

Die Sichelzellerkrankung (SZE) ist eine hereditäre Hämoglobinopathie, die durch rezidivierende vasookklusive Episoden zur Mikrozirkulationsstörung verschiedener Organsysteme mit teils letalem Ausgang führt. Bei der okulären Manifestation der SZE ist am bekanntesten die periphere Sichelzellretinopathie (SZR). Unabhängig davon kann es bereits früh im Krankheitsverlauf zur Sichelzellmakulopathie (SZM) kommen.

Methoden

Review der internationalen und deutschsprachigen Literatur zur okulären Beteiligung bei SZE mit Fokus auf die SZR und SZM sowie Überblick über aktuelle systemische Therapieansätze bei SZE anlässlich der Vorstellung zweier Patienten mit HbSS-SZE.

Ergebnis und Schlussfolgerung

Im Gegensatz zur SZR ist die SZM mit temporaler Verdünnung der inneren Netzhautschichten erst in den letzten 5 Jahren mit der Einführung von SD-OCT und OCTA vermehrt in die Literatur eingegangen. Unabhängig vom Vorliegen einer SZR kann es immerhin bei etwa der Hälfte der Patienten bereits früh im Krankheitsverlauf zu einer SZM kommen. Das Krankheitsbild wird auch in Deutschland durch den Fortschritt der systemischen Therapiemöglichkeiten und aufgrund von Migration präsenter werden. Durch Wissen um diese Komplikation der SZE kann eine frühzeitige Diagnosestellung erfolgen und unnötige Diagnostik vermieden werden.

Altered Brain Network Centrality in Patients with Diabetic Optic Neuropathy: A Resting-State FMRI Study

OBJECTIVE

Recent studies have suggested that diabetic optic neuropathy (DON) independently increases the incidence of brain diseases like cerebral infarction and hemorrhage. In this study, voxel-level degree centrality (DC) was used to study potential changes in functional network brain activity in DON patients.

METHODS

The study included 14 DON patients and 14 healthy controls (HCs) matched by age, sex, and weight. All subjects underwent resting functional magnetic resonance imaging. Receiver operating characteristic curves and Pearson correlation analysis were performed.

RESULTS

The DC values of the left frontal mid-orb and right middle frontal gyrus/right frontal sup were significantly lower in DON patients compared to HCs. The DC value of the left temporal lobe was also significantly higher than in HCs.

CONCLUSION

Three different brain regions show DC changes in DON patients, suggesting common optic neuropathy in the context of diabetes and providing new ideas for treating optic nerve disease in patients with long-term diabetes.

ABBREVIATIONS

AUC = area under the curve; BCVA = best corrected visual acuity; DC = degree centrality; DON = diabetic optic neuropathy; fMRI = functional magnetic resonance imaging; HC = healthy control; LFMO = left frontal mid orb; LTL = left temporal lobe; RFS = right frontal sup; RMFG = right middle frontal gyrus; ROC = receiver operating characteristic.

Swept-source optical coherence tomography angiography findings of diabetic papillopathy after intravitreal bevacizumab

Purpose

We report a case of diabetic papillopathy (DP) treated with intravitreal bevacizumab injections and evaluated for disc vessel changes using swept-source optical coherence tomography angiography (SS-OCTA).

Observations

A 52-year-old man was referred with a 1-week history of acute painless decreased vision in both eyes (OU). His best-corrected visual acuity (BCVA) was 20/40 in the right eye (OD) and 20/100 in the left eye (OS). Fundus examination showed swollen optic discs with superficial radially oriented telangiectatic vessels, peripapillary splinter hemorrhages, and hard exudates OU. On SS-OCTA, B-scan images displayed blood flow signals in the thickened retinal nerve fiber layer (RNFL) of the optic disc and superficial RNFL slab images displayed radially oriented telangiectatic vessels OU. Laboratory tests revealed previously unknown diabetes, and we diagnosed the patient with DP OU. Two weeks after an intravitreal injection of bevacizumab OS, the disc swelling, radially oriented telangiectatic vessels, and peripapillary splinter hemorrhages had decreased OS. The superficial RNFL slab OS also depicted decreased radially oriented telangiectatic vessels. However, OD showed no interval changes. Two weeks after an intravitreal bevacizumab injection OD, improved BCVA, decreased disc swelling, radially oriented telangiectatic vessels, and peripapillary splinter hemorrhages were observed OU. The superficial RNFL slab also showed decreased radially oriented telangiectatic vessels OU.

Conclusions and importance

This case showed that bevacizumab is a useful treatment option for DP as they resolve underlying optic nerve capillary vasculopathy. SS-OCTA demonstrated resolved superficial telangiectatic vessels of the optic disc which has not been previously described.

Diabetic Optic Neuropathy and Its Risk Factors in Chinese Patients With Diabetic Retinopathy

Purpose

To investigate diabetic optic neuropathy (DON) prevalence and risk factors in Chinese diabetic retinopathy (DR) patients.

Methods

This retrospective study included 1067 eyes (550 patients) that underwent ocular imaging. The diabetes duration, systolic blood pressure (SBP), hemoglobin A1c (HbA1c), and high-density lipoprotein (HDL) were also recorded simultaneously.

Results

A total of 410 eyes with DON and 657 eyes without DON were included (38.4% DON prevalence). DON eyes were classified as having diabetic papillopathy (DP), optic disc neovascularization (NVD), anterior ischemic optic neuropathy (AION), or optic atrophy (OA). Proliferative DR eyes had a higher DON prevalence than nonproliferative DR eyes (P < 0.001). Diabetes duration, SBP, and HbA1c were higher in DON patients than in non-DON patients (all P < 0.001). Additionally, HDL was lower in patients with DON (0.74 ± 0.13 mM) than in those without DON (1.00 ± 0.24 mM, P < 0.001). HbA1c levels were greater in AION patients (10.00 ± 1.53% [85.76 ± 16.71 mmol/mol]) than in DP patients (8.78 ± 1.97% [72.45 ± 21.55 mmol/mol], P = 0.017); central foveal thickness (CFT) significantly varied among groups (P < 0.001). Increased age, diabetes duration, SBP, CFT, and DR severity were risk factors for DON; and increased HbA1c was a risk factor for NVD, AION, and OA (all P < 0.05).

Conclusions

Our study results strengthen the argument that increased age, diabetes duration, SBP, CFT, DR severity, and HbA1c are all risk factors for DON in patients with DR.

Peripapillary retinal nerve fiber layer changes in preclinical diabetic retinopathy: a meta-analysis

Background

Diabetic retinopathy is a microvascular neurodegenerative disorder in diabetic patients. Peripapillary retinal nerve fiber layer changes have been described in patients with preclinical diabetic retinopathy, but study results have been inconsistent.

Objective

To assess changes in peripapillary retinal nerve fiber layer thickness in diabetic patients with preclinical diabetic retinopathy.

Methods

A literature search was conducted through PubMed, EMBASE, Web of Science and Cochrane Library. Case-control studies on RNFL thickness in preclinical diabetic retinopathy patients and healthy controls were retrieved. A meta-analysis of weighted mean difference and a sensitivity analysis were performed using RevMan 5.2 software.

Results

Thirteen case-control studies containing 668 diabetic patients and 556 healthy controls were selected. Peripapillary RNFL thickness was significantly reduced in patients with preclinical diabetic retinopathy compared to healthy controls in studies applying Optical Coherence Tomography (-2.88μm, 95%CI: -4.44 to -1.32, P = 0.0003) and in studies applying Scanning Laser Polarimeter (-4.21μm, 95%CI: -6.45 to -1.97, P = 0.0002). Reduction of RNFL thickness was significant in the superior quadrant (-3.79μm, 95%CI: -7.08 to -0.50, P = 0.02), the inferior quadrant (-2.99μm, 95%CI: -5.44 to -0.54, P = 0.02) and the nasal quadrant (-2.88μm, 95%CI: -4.93 to -0.82, P = 0.006), but was not significant in the temporal quadrant (-1.22μm, 95%CI: -3.21 to 0.76, P = 0.23), in diabetic patients.

Conclusion

Peripapillary RNFL thickness was significantly decreased in preclinical diabetic retinopathy patients compared to healthy control. Neurodegenerative changes due to preclinical diabetic retinopathy need more attention.

Ocular complications of diabetes mellitus

Diabetes mellitus (DM) is a important health problem that induces ernestful complications and it causes significant morbidity owing to specific microvascular complications such as, retinopathy, nephropathy and neuropathy, and macrovascular complications such as, ischaemic heart disease, and peripheral vasculopathy. It can affect children, young people and adults and is becoming more common. Ocular complications associated with DM are progressive and rapidly becoming the world’s most significant cause of morbidity and are preventable with early detection and timely treatment. This review provides an overview of five main ocular complications associated with DM, diabetic retinopathy and papillopathy, cataract, glaucoma, and ocular surface diseases.

The association between diabetes mellitus and nonarteritic anterior ischemic optic neuropathy: a systematic review and meta-analysis

Background

The association of diabetes mellitus (DM) with nonarteritic anterior ischemic optic neuropathy (NAION) has been inconclusive.

Purpose

To determine whether DM is associated with an increased risk of NAION.

Methods

A comprehensive literature search was performed for published studies reporting both DM and NAION based on PubMed and EMBASE. After reviewing characteristics of all the included studies systematically, meta-analytical method was employed to calculate the pooled odds ratio (OR) and associated 95% confidence interval (CI) from random-effects models. Heterogeneity was assessed by Q-statistic test. Funnel Plot, Begg's and Egger's linear regression test were applied to evaluate publication bias. A sensitivity analysis and meta-regression analysis were also performed to assess the robustness of results.

Results

2,096 participants from 12 case-control studies were pooled for a meta-analysis. The result of meta-analysis of these studies indicated that DM is associated with increased risk of NAION (pooled OR = 1.64, 95% CI = 1.17–2.30; P = 0.004). Sensitivity analysis indicated our findings are robust, and meta-regression analysis revealed no significant effect in terms of geographical area, gender, age of patients with NAION, the year of the publication, source of the controls, and sample size (all p>0.05). Evidence of publication bias was not observed in our study.

Conclusion

Meta-analysis suggests that DM might be associated with increased risk of NAION.

Blood pressure treatment in acute ischemic stroke: a review of studies and recommendations

PURPOSE OF REVIEW

Elevated blood pressure (BP) is frequent in patients with acute ischemic stroke. Pathophysiological data support its usefulness to maintain adequate perfusion of the ischemic penumba. This review article aims to summarize the available evidence from clinical studies that examined the prognostic role of BP during the acute phase of ischemic stroke and intervention studies that assessed the efficacy of active BP alteration.

RECENT FINDINGS

We found 34 observational studies (33,470 patients), with results being inconsistent among the studies; most studies reported a negative association between increased levels of BP and clinical outcome, whereas a few studies showed clinical improvement with higher BP levels, clinical deterioration with decreased BP, or no association at all. Similarly, the conclusions drawn by the 18 intervention studies included in this review (1637 patients) were also heterogeneous. Very recent clinical data suggest a possible beneficial effect of early treatment with some antihypertensives on late clinical outcome.

SUMMARY

Observational and interventional studies of management of acute poststroke hypertension yield conflicting results. We discuss different explanations that may account for this and discuss the current guidelines and pathophysiological considerations for the management of acute poststroke hypertension.