Resolution of diabetic papillopathy with a single intravitreal injection of bevacizumab combined with triamcinolone acetonide

Abstract

Dear Editor, As we know, diabetic papillopathy (DP) is an uncommon condition in diabetic patients, and traditionally considered to be a self-limiting disease [1]. In recent case reports, treatment with a single injection of intravitreal triamcinolone acetate or intravitreal inhibitor of vascular endothelial growth factor was effective in reducing disc swelling and shortening the course [2–6]. However, self-healing cases and treated cases are rare in optic atrophy, which results in best-corrected visual acuity (BCVA) not reaching 1.0 (leading BCVA only reached 0.8). We reported a case of diabetic papillopathy that demonstrated a rapid and complete visual recovery when intravitreal bevacizumab was administered with an intravitreal triamcinolone injection. A 37-year-old Chinese male with a 9-year history of poorly controlled Type 2 diabetes mellitus presented with a 1-month history of decreased vision without pain in his right eye. Six months earlier, the patient had undergone grid pattern retinal photocoagulation, and received oral prednisone in doses decreasing from 30 mg per day for 3 weeks for clinically significant optic swelling in his left eye. His BCVA was 0.2 in the right eye (OD) and 0.4 in the left eye (OS). The intraocular pressure (IOP) was 17 mmHg in both eyes (OU). There was no afferent pupillary defect. An anterior segment examination was unremarkable. A posterior segment examination showed mild non-proliferative diabetic retinopathy without macular edema and a pale optic disc OS. An OD fundus examination was significant for a swollen optic disc (Fig. 1a). Optical coherent tomography (OCT) revealed a significant increase in retinal nerve fiber layer (RNFL) thickness without macular edema (Fig. 1b). Glycosylated hemoglobin was 11.2 %. Arterial blood pressure was 118/70 mmHg. An MRI scan of the brain was normal. A diagnosis of DP was made in the right eye. After receiving consent from the patient for a trial of triamcinolone and off-label use of bevacizumab, the patient received an intravitreal injection of bevacizumab (1.25 mg/0.05 ml) and triamcinolone (4 mg/0.1 ml). One week post-injection, the patient’s visual acuity OD had improved to 0.8, and the disc swelling disappeared. Six weeks post-injection, his visual acuity had improved to 1.0, and a fundus examination revealed no disc swelling (Fig. 1c and d). One year after the injection, the right eye visual acuity remained at 1.0 with normal IOP. In the case of the 37-year-old Chinese male, we used a combination of anti-VEGF and anti-inflammatory therapies to treat the DP. Compared with reports of single anti-VEGF [4–6] or anti-inflammatory [2, 3] treatment cases, this patient experienced a more rapid visual improvement 1 week after the intravitreal injection, and his BCVA improved from 0.2 J. Feng : J.<F. Qu :Y.<R. Jiang (*) Department of Ophthalmology, People’s Hospital, Peking University, 11 Xizhimen South Street, Xicheng District, 100044 Beijing, China e-mail: drjyr@vip.sina.com