Retinopathy in adolescents and young adults with onset of insulin-dependent diabetes in childhood

Iranian risk model as a predictive tool for retinopathy in patients with type 2 diabetes

OBJECTIVE

Diabetic retinopathy (DR) is the leading cause of blindness in patients with type 1 or type 2 diabetes. The gold standard for the detection of DR requires expensive equipment. This study was undertaken to develop a simple and practical scoring system to predict the probability of DR.

METHODS

A total of 1782 patients who had first-degree relatives with type II diabetes were selected. Eye examinations were performed by an expert ophthalmologist. Biochemical and anthropometric predictors of DR were measured. Logistic regression was used to develop a statistical model that can be used to predict DR. Goodness of fit was examined using the Hosmer-Lemeshow test and the area under the receiver operating characteristic (ROC) curve.

RESULTS

The risk model demonstrated good calibration and discrimination (ROC area=0.76) in the validation sample. Factors associated with DR in our model were duration of diabetes (odds ratio [OR]=2.14, confidence interval [CI] 95%=1.87 to 2.45); glycated hemoglobin (A1C) (OR=1.21, CI 95%=1.13 to 1.30); fasting plasma glucose (OR=1.83, CI 95%=1.28 to 2.62); systolic blood pressure (OR=1.01, CI 95%= 1.00 to 1.02); and proteinuria (OR=1.37, CI 95%=1.01 to 1.85). The only factor that had a protective effect against DR were body mass index and education level (OR=0.95, CI 95%=0.92 to 0.98).

CONCLUSIONS

The good performance of our risk model suggests that it may be a useful risk-prediction tool for DR. It consisted of the positive predictors like A1C, diabetes duration, sex (male), fasting plasma glucose, systolic blood pressure and proteinuria, as well as negative risk factors like body mass index and education level.

Multifocal ERG defects associated with insufficient long-term glycemic control in adolescents with type 1 diabetes

PURPOSE

To investigate the relationship between long-term glycemic control and localized neuroretinal function in adolescents with type 1 diabetes (T1D) without diabetic retinopathy (DR).

METHODS

Standard (103 hexagons) and slow-flash (61 hexagons) multifocal ERGs (standard mfERG and sf mfERG) were recorded in 48 patients and 45 control subjects. Hexagons with delayed responses were identified as abnormal. Negative binomial regression analysis was conducted with the number of abnormal hexagons as the outcome variable. Glycated hemoglobin (HbA(1c)) levels, time since diagnosis of T1D, age at diagnosis of T1D, age at testing, and sex were the covariates. Another model replacing HbA(1c) closest to the date of testing with a 1-year average was also generated.

RESULTS

There were more abnormal hexagons for mfOPs in patients than in control subjects (P = 0.005). There was no significant difference in the mean number of abnormal hexagons for standard mfERG responses between patients and control subjects (P = 0.11). Negative binomial regression analysis for the standard mfERG data demonstrated that a 1-unit increase in HbA(1c) was associated with an 80% increase in the number of abnormal hexagons (P = 0.002), when controlling for age at testing. Analysis using the 1-year HbA(1c) averages did not result in significant findings.

CONCLUSIONS

Poor long-term glycemic control is associated with an increase in areas of localized neuroretinal dysfunction in adolescents with T1D and no clinically visible DR. Stricter glucose control during the early stages of the disease may prevent neuroretinal dysfunction in this cohort.

Predicting diabetic retinopathy

The purpose of this study was to determine the occurrence and severity of diabetic retinopathy and to clarify its association with the duration of diabetes and several other factors in an outpatient diabetic population. The material consisted of 328 diabetics, mainly (77%) C-peptide negative, type 1 diabetics. The mean age of the patients was 45 years, and the mean duration of diabetes was 15 years. Retinal changes were assessed by ophthalmoscopy and widefield fundus photography. All retinopathy was confirmed in 59% and proliferative retinopathy (PR) in 20% of the patients. The frequency of diabetic retinopathy was 15% in patients with diabetes for less than five years but 100% in those with diabetes for 30 or more years. In type 1 diabetics PR was seen only after 10 or more years' duration but, after 20 years' duration it was seen in half of the patients with type 1 and in one-third of the patients with type 2 diabetes. The patients with diabetic nephropathy often had PR. In type 1 diabetics with onset of the disease less than 30 years peripheral sensory neuropathy, coronary disease, hypertension and leg-vessel disease were also often associated with PR. Because one reason for visual handicapping in diabetes is the delay of the diagnosing of vision-threatening lesions screening for treatable retinopathy should be intensive after 10 years' duration and in poorly-controlled diabetics even earlier.

Description of microangiopathy in children with type 1 diabetes mellitus: a 19-year retrospective study

BACKGROUND

The aim of the study was to estimate the outcome of patients with type 1 diabetes followed in a university hospital in the paediatric department and then in the adult diabetic department for at least 10 years.

METHODS

We made a retrospective analysis of 50 patients (28 women and 22 men) with type 1 diabetes with disease duration of 19 +/- 6 years and analysed whether retinopathy and nephropathy had progressed, had remained unchanged or had improved or normalised.

RESULTS

The mean age of diabetes onset was 8 +/- 4 years (1-16). Ketoacidosis revealed diabetes in 36% of the children. Mean HbA(1c) was 8.6 +/- 1.8%, and was over 8.5% in 34% of the patients. The mean age at onset of puberty (Tanner stage II) was 12 +/- 1 years in girls and 13 +/- 1 years in boys. Mean HbA(1c) was 7.9 +/- 1.2% during the year before onset of puberty and 8.7 +/- 1.1% in the following 3 years, corresponding to a 10% pubertal increase in HbA(1c). Retinopathy was seen in 50% of the patients at a mean age of 22 +/- 5 years, 15 +/- 6 years after onset of diabetes. Mean HbA(1c) was 9.7 +/- 1.6% in patients with proliferative retinopathy, 9.0 +/- 1.5% in patients with non proliferative retinopathy, and 8.1 +/- 1.3% in those without (p=0.02, proliferative versus no retinopathy, p > 0.05 non proliferative versus no retinopathy). Microalbuminuria was diagnosed in 26% of the patients. Mean HbA(1c) was 9.3 +/- 2.1% in patients with microalbuminuria versus 8.1 +/- 1.3% in those with normoalbuminuria (p=0.02).

CONCLUSIONS

Glycemic control was similar in patients with non proliferative retinopathy and those without. Proliferative retinopathy and nephropathy were both related to the level of glycemic control.

Development of proliferative retinopathy in Japanese patients with IDDM: Tokyo Women's Medical College Epidemiologic Study

We studied the development of proliferative diabetic retinopathy (PDR) in Japanese insulin-dependent diabetes mellitus (IDDM). Subjects were 373 patients who were diagnosed as IDDM between 1951 and 1984, before the age of 30 years, and had no PDR at the first visit to the Diabetes Center. Development of PDR was analyzed by Kaplan-Meier's life-table method in relation to the duration of IDDM. The cumulative incidence of PDR was 20% at 15 years of duration of IDDM, 40% at 19 years, and 70% at 29 years. Female patients (n = 233) developed PDR significantly faster than males (n = 140) (P < 0.002). In both sexes, patients with onset of IDDM at 0-8 years showed significantly slower development than patients with the onset at 9-17 (P < 0.0001) and 18-29 years (P < 0.001). Impact of femaleness on the development was the greatest in patients with age at onset of IDDM at 9-17 years (P < 0.005). Analysis according to the calendar year at onset of IDDM and diabetes duration at the first visit to the Diabetes Center did not show any significant influence on the development of PDR. In conclusion, sex and age at onset of IDDM may be associated with increased risk for the development of PDR in relation to the duration of diabetes in Japanese IDDM.

Ocular complications in young adults with insulin-dependent diabetes mellitus since childhood

A cross-sectional study in 80 insulin-dependent diabetic patients born 1963-1968 who experienced the onset of diabetes before 15 years of age showed that at a mean age of 21.6 (range 17-25) years and after a mean duration of diabetes of 13.3 (range 6-24) years, 80% of the patients had retinopathy: 70% had background and 10% proliferative changes. Retinopathy correlated with the duration of the diabetes and poor glucose control at 15 years of age but not with the actual level of glycated haemoglobin. The severity of retinopathy was worse in women than in men. One patient (1.2%) was blind. Two patients had had cataract operations and 66% had myopic refraction in one or both eyes. In 61 patients a further period of ophthalmological follow-up of 3-4 years was included. After 20 years of diabetes, all had retinopathy and 29% had proliferative changes: 33% had received laser treatment after 8-27 (mean 16.1) years of diabetes. Altogether, 2 patients (2.5% of the original series) were blind. For prevention of diabetic retinopathy and blindness, good glucose control from puberty and careful ophthalmological follow-up after transfer of the patient from paediatric to adult diabetes care play major roles.

Prevalence and risk factors of retinopathy in children with diabetes. A population-based study on Finnish children

The prevalence of retinopathy in children with insulin-dependent diabetes mellitus (IDDM) was studied in a population-based survey on 194 of the 216 subjects (89.8%) with IDDM aged 4.6 to 16.6 years living in the county of Oulu, Finland. The diagnosis of retinopathy was based on fundus photography. The median age of the children was 12.2 years and the median duration of diabetes 4.5 years (range 0.14.2 years). Retinopathy was found in 21 (10.8%) of cases. All of the changes seen were mild and did not require treatment. All the children with retinopathy were pubertal or postpubertal, and an association was found between the presence of retinopathy and the long-term diabetes control, duration of diabetes, age and albuminuria. Logistic regression analysis showed increasing duration of diabetes, puberty and elevated blood glycated haemoglobin to be the main risk factors explaining the occurrence of retinopathy. In patients aged 13-16 years retinopathy was also related to female sex and diastolic blood pressure, but in logistic regression analysis duration of diabetes and glycated haemoglobin were the best predictors.

Glycemic control and development of retinopathy in youth-onset insulin-dependent diabetes mellitus. Results of a 12-year longitudinal study

BACKGROUND

In 1979, the authors began a prospective study of the natural history of retinopathy in youth-onset insulin-dependent diabetes mellitus (IDDM). Their major goal was to determine if there was an association between glycemic control and the development and progression of retinopathy.

METHODS

The study consisted of 420 individuals with IDDM (onset younger than 20 years of age) and no retinopathy at baseline. Study subjects were enrolled between 1979 and 1988. Stereo color fundus photographs were obtained annually. Two eye endpoints were recorded: duration when retinopathy was first detected, and when proliferative retinopathy was detected. Glycemic control was assessed by quarterly determinations of glycohemoglobin (GHb). Life-table analyses were performed relating duration of diabetes, sex, GHb, and age of diabetes onset to development of retinopathy.

RESULTS

Retinopathy did not develop before 2 years' duration or before puberty. The prevalence of retinopathy was 50% by 9 years' duration and 100% by 20 years' duration. Retinopathy developed in females approximately 2 years sooner than in males, but plotting duration as postpubertal years resulted in nearly identical rates. Retinopathy developed significantly earlier in subjects with prepubertal onset of diabetes than in subjects with postpubertal onset if duration was plotted as postpubertal years. When separated into three groups based on GHb levels (< 7.5%, 7.5%-9%, > 9%), retinopathy developed approximately 2 years later in subjects in the less than 7.5% GHb group than those in the higher GHb groups. Proliferative retinopathy developed in 11 subjects. Their mean GHb level was higher than the mean GHb for those without proliferative retinopathy (10.9 versus 8.6%; P < 0.01). The higher the level of GHb, the sooner proliferative changes were detected.

CONCLUSION

Long-term glycemic control is significantly related to both development and progression of retinopathy. Prepubertal duration of diabetes is a significant risk factor for the development of retinopathy.

Diabetic retinopathy: methodologies in practice

In France, 20% of patients with diabetes are monitored by diabetologists, and of these 88% are screened for retinopathy by fundal examination with dilation of pupils and 78% by fluorescein angiography. Colour retinal photography is performed in 24% of cases. Eye examination is performed every year in 85% of patients. Diabetic retinopathy is generally considered to be a vascular disease causing loss of vision by macular oedema, vitreous haemorrhage or retinal detachment. However, it may also be a neurosensory disorder, with functional changes occurring before anatomical vascular abnormalities. These include changes in colour vision, contrast sensitivity, dark adaptation, visual-evoked potentials, electroretinography, nyctometry, and fluorometry. The majority of these methods have a predictive value for the late onset of retinopathy in diabetic patients.

Can retinopathy be prevented?

Clinical retinopathy eventually develops in the majority of insulin dependent diabetics during several decades of metabolic abnormality. Early structural lesions short of clinical significance may occasionally be detected in children much more frequently, however, after puberty. Major factors modulating the development of retinopathy are duration of diabetes, glycemic control and blood pressure.

Long-term glycaemic control and diabetic retinopathy

216 patients with insulin-dependent diabetes mellitus were studied by retinal photography, and the absence or presence of retinopathy was related to the mean of serial glycosylated haemoglobin measurements (mean HbA1) carried out every 3 months during the previous 6 years. 122 patients had no diabetic retinopathy, 86 had background retinopathy, and 8 proliferative retinopathy. Mean HbA1 levels showed a strong correlation with increasingly severe grades of retinopathy, even when differences in duration of diabetes were taken into account. Proliferative retinopathy was seen only in patients with mean HbA1 above 10%. These results support the view that the development of diabetic retinopathy is related to long-term glycaemic control and emphasise the desirability, and possible benefit, of achieving control as close to normal as is possible for each individual patient.

Relationship of islet cell and islet cell surface antibodies to the presentation and early course of IDDM in childhood

Islet cell (ICA) and islet cell surface (ICSA) antibodies were measured in 30 children (aged 6-17.7 years) with newly diagnosed insulin-dependent diabetes mellitus (IDDM) to determine the relationship of antibody positivity/negativity to a variety of factors both at presentation (e.g., age, severity of onset, residual insulin secretion, insulin autoantibodies) and during the first year thereafter (HbA1c, insulin antibody binding, residual insulin secretion). At diagnosis, 10 of 30 were ICA (+) and 13 ICSA (+): no differences were found between ICA (+) and (-) subjects at onset; however ICSA (+) children had a lower bicarbonate concentration than those (-) for ICSA (P less than 0.01). During the first year after diagnosis the only significant finding was that in ICA (+) patients insulin dose (units/kg) was lower at both 6 and 12 months (mean +/- SD 0.55 +/- 0.14 and 0.67 +/- 0.12 U/kg, respectively) than ICA (-)'s (0.70 +/- 0.22 and 0.96 +/- 0.38, respectively, both P less than 0.05). Those children positive for both ICA and ICSA did not differ in any way at onset or during the subsequent 12 months from those negative for both antibodies. These results suggest that, except for minor differences, the presentation and course during the first year after diagnosis of IDDM do not differ in those children positive or negative for either or both ICA and ICSA.

Prevalence and development of retinopathy in children and adolescents with type 1 (insulin-dependent) diabetes mellitus. A longitudinal study

In 231 subjects with Type 1 diabetes mellitus aged 17.6 +/- 4.0 years, with a diabetes duration of 8.5 +/- 4.9 years at the end of the study, the prevalence and the development of retinopathy during a period of 5 years were studied. All patients were examined between one and six times both by ophthalmoscopy and fluorescein angiography. A total of 626 fluorescein angiographies were evaluated. By the end of the study, 109 out of 231 patients (47%) had developed retinal changes, half of which were classified as minimal (less than 5 microaneurysms). Thirty-eight patients (35% of those affected) had background (n = 28) or proliferative (n = 10) retinopathy. In subjects less than 15 years of age and diabetic for less than 5 years, retinal lesions were rare. With increasing age and duration of diabetes, both the prevalence and severity of retinal changes increased markedly. Life-table analysis was used to calculate the median individual risk for the development of early retinal changes, which was 9.1 years of diabetes duration. This risk differed in sub-groups with different ages at onset of diabetes, i.e. 12.1, 8.9 and 6.6 years (p less than 0.0001), with diabetes starting below 4, between 5 and 9, and after 10 years of age respectively. After 18 years of diabetes, every patient demonstrated at least incipient structural changes. Fluorescein angiography allowed the detection of retinopathy, on average, four years earlier than with ophthalmoscopy. The median interval between the 'onset' of retinopathy, as indicated by a few microaneurysms, and background retinopathy was 5 years.

Risk factors for the development of retinopathy in children and adolescents with type 1 (insulin-dependent) diabetes mellitus

In our preceding paper, the prevalence and development of retinopathy in 231 Type 1 diabetic children and adolescents were reported to be associated with the duration of diabetes and its age at onset. This paper analyses the relationships between the development of retinopathy and the following factors: age, sex, puberty, blood pressure, insulin dosage, HLA antigens, long-term glycaemic control, and serum cholesterol and triglycerides. All these variables were longitudinally evaluated in a cohort of 322 insulin-dependent patients aged 16.2 +/- 4.9 years with diabetes for 7.4 +/- 5.2 years, including those 231 subjects whose eyes were examined once or repeatedly by ophthalmoscopy and fluorescein angiography. Long-term glycaemic control from the onset of diabetes to the retinal examination was assessed by both an arbitrary score comprising different parameters and by mean values of glycosylated haemoglobin, and was categorised as good, fair, and poor. With life-table analysis, the overall median individual risk for developing early retinal changes (9.1 years) was found to be significantly influenced by glycaemic control. Minimal lesions developed earlier (8.0 years) with poor control, but later with fair (10.5 years) and good glycaemic control (12.5 years) (p less than 0.01). Mean HbA1 values below 10% delayed the onset of both incipient (10.8 years) and background retinopathy (16.6 years), while values above 10% advanced it (8.0 and 11.8 years respectively) (p less than 0.05 and less than 0.008). By multivariate regression and stepwise discrimination analyses, only 4 out of 14 variables were found to exert significant independent influences on the development of retinopathy: diabetes duration, long-term glycaemic control, serum triglycerides and age.(ABSTRACT TRUNCATED AT 250 WORDS)

Failure and efficacy of insulin therapy in insulin dependent (type I) diabetic patients

In order to determine the degree of metabolic control (HbA1c [normal less than 5.8%], mean blood glucose [MBG], glucosuria and lipids) and the prevalence of late diabetic complications in insulin-dependent diabetic patients treated by conventional insulin therapy both patients of a diabetes center (DC: n = 130; age 37.1 +/- 1.4 years) and a rural area (RA: n = 73; age 38.4 +/- 2.4 years) were examined within their local setting. Eighty such insulin-dependent diabetic patients were also taught a technique of near normal glycemic insulin substitution (NIS), which separates basal from prandial insulin replacement and instructs the patients to immediately correct self-controlled (3.8 +/- 0.1/day) aberrant blood glucose values. None of the groups on conventional insulin therapy was able to achieve satisfactory metabolic control or to avoid late diabetic complications, but rural patients were even worse off (BG 240 +/- 10 mg/dl; HbA1c 8.7 +/- 0.2% [normal: 3/73 = 4%]) than those of the DC (MBG 191 +/- 5 mg/dl; HbA1c 7.1 +/- 0.2% [normal: 27/130 = 21%]), while the prevalence of late diabetic complications was almost identical (RA/DC: neuropathy 22%/25%; retinopathy 41%/38%; macroangiopathy 15%/13%; but proteinuria 14%/5.4%). Metabolic control was improved by NIS with twice daily injections of basal (long acting) and separately of prandial (regular) insulin (total: 4.8 +/- 0.1 injections/day; MBG 130 +/- 2 mg/dl; HbA1c 5.8 +/- 0.1% [normal: 41/80 = 51%]. We conclude (1) that conventional insulin therapy just prevents metabolic catastrophe but in more than 79% of insulin-dependent diabetic patients lacks the ability to provide good metabolic control, while (2) NIS, a more physiological form of insulin therapy, improves this deplorable situation 5- to 12.4-fold.

Diabetic retinopathy under age 20. A review of 71 cases

A review of the fluorescein angiograms on 4547 diabetic patients with clinically suspected retinopathy was performed. Although only 26 (1%) of the 2013 males and 45 (2%) of the 2534 females were less than 20 years old (71 patients total), proliferative diabetic retinopathy (PDR) was diagnosed in 14 females (31%) and 4 males (15%). The youngest patient, a 13-year-old boy with diabetes for eight years, presented with severe proliferative diabetic retinopathy in both eyes as documented angiographically. He showed no evidence of other systemic complications of diabetes. A review of the literature revealed one other case of proliferative diabetic retinopathy in a patient this young; a 13-year-old girl who was nephrotic and hypertensive upon presentation. This study emphasizes the importance of having prepubescent and teenage diabetics examined for the presence of retinopathy.

The association between long-term diabetic control and early retinopathy

A study was performed to determine the relationship between level of long-term antecedent diabetic control and early diabetic retinopathy changes. Fifty-eight insulin dependent diabetics aged 14 to 17 1/2 years, with duration of diabetes of at least 8 years, were studied. Glycosylated hemoglobins were assessed a mean of 8.5 times per patient, over a mean period of 3.1 years, representing 28% of the mean duration of diabetes in this patient population. Fluorescein angiography, obtained according to a standardized technique, was assessed in masked fashion for number of microaneurysms, presence of abnormal areas of capillary nonperfusion, and presence of intraretinal dye leakage. Sixty-four percent of the study population showed some evidence of retinopathy. There was a high correlation found between degree of metabolic control as measured by glycosylated hemoglobin level, and presence of early retinopathy changes as defined by angiography.

Diabetic retinopathy and insulin therapy in a rural diabetic population

The prevalence of diabetic retinopathy was lower in a rural diabetic population when compared to the prevalence of diabetic retinopathy in medical center clinic populations. Adult-onset (Type II) diabetics were at greater risk for developing diabetic retinopathy shortly after diagnosis than newly diagnosed cases of juvenile diabetes (Type I). The use of insulin positively correlated with the prevalence of diabetic retinopathy in this rural population.

Growth and maturation of children with insulin-dependent diabetes mellitus

By plotting and evaluating height and weight measurements of children with diabetes on the Iowa Growth Chart, the authors have found that children with diabetes under their care who maintained relatively high degrees of metabolic control had normal growth patterns and that only children in lower degrees of control failed to grow at normal rate and had delayed maturation.

Narrowing of the palpebral fissure in diabetes

In 204 adult, white diabetics the palpebral fissure was measured and related to the state of metabolic control of the diabetes. A control group was formed of 204 persons matched by age and sex. The average palpebral fissure in the control group was 9.9 mm: there was a slight, but not significant, difference between the age groups and the sexes. In diabetics who were not insulin dependent the average width of the palpebral fissure was found to be 9.4 mm; in severe chronic deregulation of the diabetes, however, an average palpebral fissure of 8.0 mm was found, a significant narrowing. In insulin-dependent diabetics the average width of the palpebral fissure was 8.3 mm. This significant narrowing also increased if there was severe chronic deregulation of the diabetes. The average palpebral fissure associated with proliferative retinopathy in insulin-dependent type 1 diabetics was 6.0 mm (nearly 4 X standard deviation). This ptosis in diabetes is very probably due to chronic tissue hypoxia, to which the levator palpebrae muscle is probably extra sensitive, and in which thickening of the basal membrane of the capillaries may be one of the most important factors.

Lack of correlation between ocular hypertensive response to topical corticosteroids and progression of retinopathy in insulin-dependent diabetes mellitus

We studied the relationship of intraocular pressure responsiveness to topical corticosteroids and the development of retinopathy in 86 patients with insulin-dependent juvenile-onset diabetes available for long-term follow-up and examination during 1982. Eleven patients had background retinopathy at the initial examinations. High (GG) and intermediate (NG) corticosteroid responsiveness was more common in these 86 patients (13 high responders and 39 intermediate responders) than in previously reported volunteer series. Background diabetic retinopathy was present at the end of the study in 75 of the 86 patients and proliferative retinopathy was present in 29. The proportions of patients developing either type of retinopathy were similar among the low (NN), intermediate, and high response groups. The rate of diabetic retinopathy development was related to the duration of the disease and not to the intraocular pressure response to topical corticosteroids.

Severe diabetic retinopathy in adolescents

This paper reports on 9 patients aged 13-18 years (mean 15.4) with severe diabetic retinopathy. Two patients were prepubertal and 4 were going through puberty. Hypertension was present in 2 patients, while 4 had proteinuria. Severe preproliferative disease was present in 3 patients initially and proliferative retinopathy in the remainder. In 5 this retinopathy was considered to be florid. Two patients seen prior to 1975 had pituitary ablation, while those seen after 1975 were treated by extensive argon and xenon arc photocoagulation. Proliferative lesions regressed in both groups. At the latest follow-up 7 of the 9 patients achieved a final visual acuity of 6/9 or better in at least one eye. One patient became blind. Proliferative retinopathy advances rapidly in adolescents, but photocoagulation, as used now, can maintain vision in most.