Case 147: Acute Diabetic Papillopathy (?) Reversed in Association with Boot Therapy Twice Eight Years Apart

At age 43 this nutritionist came to the office for recent onset diabetes in March of 1986. Standing 63 3/4 inches in height and having lost weight down to 117 pounds, she was advised that insulin therapy was necessary. She insisted on attempts of diet therapy only. Over the next few months, she came to accept the necessity of insulin but never became a tightly regulated patient. Personal problems were major diversions from her diabetes. An office visit on April 19th, 1991 was spent on discussing her feelings of isolation and her comfort in eating. She had no health complaints. On April 26th, 1991 she returned complaining of poor vision in her right eye. The ophthalmoscope revealed what appeared to be a venous clot on her optic disc. She was sent to see a diabetic retina specialist who performed fluorescein angiograms a few days later.

A diffuse area of hyperfluorescence of the right optic disc was found.

The diagnosis was thought to be most consistent with the diagnosis of diabetic papillopathy. See Kodachromes below.

With the ophthalmoscope, a "clot" had been seen where the small "mass" is located to the right of the disc.

The retinal specialist offered no therapy. He recommended observation and noted that given her age, persisting vision and lack of other pathology, a significant recovery of vision was possible. She remained anxious about the possibility of going blind in her right eye. We advised her of our anecdotal success in improving vision in occasional patients and of the report of Yu S, Da H and Zhen Z (1990)(See our pneumatic boot library). We offered her a few weeks of free boot treatments. Subsequently, she received 12 treatments to both legs. She found her vision to slowly improve and by May 24th appeared to be cured. She remains active playing both squash and tennis as of January 8th, 1998, almost seven years later..

Comments: The retina specialist did not consider her recovery miraculous. She might have gotten better anyhow. Her case might be compared with those reported by Barr et al (Barr CC, Glaser JS and Blankenship G: Acute disc swelling in juvenile diabetes. Arch Ophthalmol 98:2185-2192, 1980). Among their 12 cases, 12 had background retinopathy of note and 2 had retinal proliferations. At follow-up, visual acuity improved in about half in a few months while after several months to a few years significant visual loss was the general rule. Thus, in their report, concomitant eye disease was commonly present and, although early improvements were seen in about half, the long term prognosis was not good. If our patient had the same process, she has done extremely well. It may be the pathological process was different. Clot was seen by the disc when she was first seen and noted to disappear with her boot treatments. Her third photograph above shows a small mass just to the right of the disc. Our ophthalmologist did not comment on it being more impressed with the hyperfluorescence of her disc. Perhaps other ophthalmologists reviewing this webpage may want to comment? This patient by herself proves nothing. Boot therapy elevates systemic blood levels of fibrinolysins, nitric oxide and prostacyclin while at the same time increasing cardiac output. These effects provide a mechanism whereby ischemic eye lesions might benefit from boot therapy. We are hoping some physicians with access to large numbers of patients with diabetic retinopathy might be interested in a formal study.

Follow-up: She returned to the office January 14th, 1999. Her right eye had remained normal but she had noted some decrease in her vision in her left eye. She found a new ophthalmologist at Jefferson Hospital who advised her that she had diabetic papillopathy of her left eye and that it would likely get better spontaneously. She told him about her previous boot therapy which he advised would at least likely do no harm. Our office has contacted this ophthalmologist who advises us that he will get retinal photographs and that Regillo has written a more recent study on diabetic papillopathy

Comments: The ophthalmologist referred us to the article titled "Diabetic Papillopathy" by Regillo CD, Brown GC, Savino PJ, Byrnes GA, Benson WE, Tasman WS and Sergott RC in Arch Ophthalmol 113: 889-895, 1995. These authors did a record review of diabetic patients who had been evaluated in the Neuro-ophthalmology or Retina-Vascular Service of the Wills Eye Hospital in Philadelphia. Included on their study were all patients with transient unilateral or bilateral disc swelling of less than 12 months duration. Patients were excluded for many causes: data suggesting a specific cause of disc edema (vasculitic, infectious, inflammatory, unexplained Westergren erythrocyte sedimentation elevation), arterial hypertension, angiographic evidence for neovascularization, abnormal neuroimaging or lumbar puncture results, or findings suggesting typical anterior ischemic optic neuropathy (patients with pallid swelling or late optic nerve pallor, patients with major visual field abnormalities or significant dyschromatopsia short term on follow-up, those with or developing afferent pupillary defect, and those with a lack of improvement of any decreased visual field acuity without contributing macular disease). Between 1986 and 1992, they found 19 patients who met these criteria, six with type 1 diabetes and 13 with type 2 diabetes. They had an average age of 50 and a average duration of diabetes of 12 years. As 8 patients had bilateral disease, there were 27 affected eyes. The average duration of follow-up was 14 months. The authors do not tell us how many patients with papillopathy were actually excluded in their various categories. They were seeking and they found a group of patients with papillopathy that got better. The disc swelling was consistently hyperemic in their patients and resolved on the average in three months. Apparently, if they did not get better and if new pathology developed, they were excluded from the study. One is not sure how this report relates to our patient. She is older than most with the syndrome in the literature. With booting, her eye got better in about a month and has remained normal for almost 8 years of follow-up. As her diabetes has not been well-controlled, she is a candidate for progressive retinal disease. Her episodes of papillopathy are 8 years apart. She is different. We will post her photographs if we get them.

Our Bryn Mawr ophthalmologist was kind enough to recover her Kodachromes pictures from April 29th, 1991. Here the left retina was thought to be normal.

The Kodachrome of the right eye showed swelling of the disc and flame-shaped hemorrhages. In reviewing the fluorescein studies above, he attributed the findings to leakage around the disc.

Our Bryn Mawr ophthalmologist also obtained the Kodachromes taken January 12th, 1999 at the Will's Eye Hospital. He pointed out that the left retina showed elevation of the optic disc with edema and flame-shaped hemorrhages compatible with a diagnosis of ischemic optic neuropathy.

Here the right disc appeared to be normal.

Follow-up films March 29th, 1999. The patient received Long-Boot therapy to both legs five days a week for 40 minutes giving her legs new life and possibly contributing to her restoration of vision. Here her left eye shows resolution of the disc edema. The ophthalmologist pointed out a lack of vessels on the superior aspect of the disc.

The right disc remained normal. With her return of close to normal vision, she again returned to playing tennis.

The follow-up fluorescein films showed hypofluorescence of the superior aspect of the disc compatible with decreased perfusion.

He pointed out no pathology of the right disc.