Screening for retinopathy in the pediatric patient with type 1 diabetes mellitus

Comparison of Clinical Profiles, Demographics, and Surgical Outcomes of 25-Gauge Vitrectomy for Proliferative Diabetic Retinopathy in Young Adults with Type 1 or Type 2 Diabetes

Purpose

Proliferative diabetic retinopathy (PDR) is a leading cause of poor vision in young adults. This study sought to evaluate the clinical characteristics and outcomes of primary vitrectomy for PDR in young adults.

Patients and Methods

Medical data were retrospectively collected at a large ophthalmology hospital in China. We analyzed data for 99 patients (140 eyes) aged <45 years with T1D or T2D who underwent primary vitrectomy for PDR-related complications.

Results

There were 18 patients with T1D and 81 patients with T2D. The proportion of males was significantly greater than that of females in both groups. The T1D group had a longer duration of diabetes (P = 0.008), younger age at primary vitrectomy (P = 0.049), and lower body mass index (P < 0.001) than the T2D group. The proportion of eyes with rhegmatogenous retinal detachment (RRD) was greater but the proportion of eyes with traction retinal detachment (TRD) was lower in the T1D group than in the T2D group. The final best-corrected visual acuity (BCVA) improved or remained stable in 100% and 85.3% of eyes and decreased in 0% and 14.7% of eyes in the T1D and T2D groups, respectively. After surgery, the incidence of postoperative complications was significant greater in the T2D group than in the T1D group (P = 0.045). Factors influencing the final visual acuity included preoperative BCVA in both groups, the duration of diabetes (P = 0.031) and preoperative FVP (P = 0.004) in the T1D group, and preoperative RRD (P < 0.001) and postoperative NVG (P < 0.001) in the T2D group.

Conclusion

In this retrospective study, young adults with T2D who underwent vitrectomy had worse final visual acuity and more complications than young adults with T1D.

Outcomes of 35-year duration of type 1 diabetes and proliferative diabetic retinopathy on functional vision and quality of life: Benefits of good glycemic control

AIMS

To evaluate clinical outcomes, functional vision and quality of life (QoL) after 35-year duration of type 1 diabetes (T1D) and proliferative diabetic retinopathy (PDR).

METHODS

A population-based cohort study of T1D. Data from laboratory tests, ophthalmic examinations, multifunctional vision-test, and 15D-QoL measurements were analysed.

RESULTS

35 % of the original cohort (n = 216) had PDR, and 48 % of them were re-evaluated. They were 41 ± 3 [34-46] years old and 62 % were males. The duration of T1D was 35 ± 4 [29-41] years. 76 % had transdermal glucose monitoring. HbA1c had decreased from 80.1 mmol/mol to 63.6 mmol/mol (p < 0.001). Visual acuity was 73-77 ETDRS-letters. Two patients had visual impairment. Visual field sensitivities were lower in PDR vs. healthy controls (23.2 ± 3.9 dB vs. 26.9 ± 1.0 dB, and 14.9 ± 5.6 dB vs. 21.0 ± 2.0 dB, respectively, p < 0.001). Contrast sensitivity was similar, but the reaction time was longer in the PDR group (490.5 ms vs. 462.8 ms, p = 0.004). QoL-parameters concerning sleeping, usual activities, discomfort and symptoms, and sexual activity had decreased, but improved for mobility and distress.

CONCLUSIONS

Long-term visual prognosis and QoL remained good despite the declined functional vision caused by PDR.

Ocular complications of diabetes mellitus in a pediatric population and proposals for screening and follow-up programs

Background

Diabetes mellitus (DM) is one of the world's greatest health emergencies of the 21st century. Ocular complications of DM are commonly chronic and progressive, but vision loss can be effectively prevented or delayed with early detection and timely treatment. Therefore, regular comprehensive ophthalmologic examinations are mandatory. Ophthalmic screening and dedicated follow-up for adults with DM are well established, whereas, there is no consensus on optimal recommendations for the pediatric population, reflecting the lack of clarity about the current burden of disease in this age group.

Objectives

To determine the epidemiology of ocular complications of diabetes and to assess optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA) macular features in a pediatric population with DM. To review ophthalmological screening and follow-up plans for the diabetic pediatric population.

Design

Observational study.

Methods

Retrospective consecutive cohort study of all 165 diabetic patients (330 eyes) aged 0-18 years, examined between January 2006 and September 2018 at the Pediatric Department of 'S. Maria della Misericordia' Udine Hospital who underwent at least one complete ophthalmologic examination at the Ophthalmology University Clinic at the Udine Hospital. OCT and OCTA data were available for 37 patients (72 eyes, 2 excluded). The associations between ocular complications and selected potential risk factors were evaluated by univariate analyses.

Results

No patient had signs of ocular diabetic complications or any macular morphological or micro-vascular impairment, regardless of any potential risk factor. The prevalence of strabismus and refractive errors in the study group, was found to be similar to non-diabetic pediatric populations.

Conclusion

Screening and follow-up of ocular diabetic complications in children and adolescents could be performed less frequently than in adults with diabetes. There is no need to screen potentially treatable visual disorders in diabetic children earlier or more frequently than in the healthy children thus reducing time spent in hospital and permitting a better tolerance to medical examinations in diabetic pediatric patients. We described the OCT and OCTA patterns in a pediatric population with DM.

Ocular Sequelae in a Population-Based Cohort of Youth Diagnosed With Diabetes During a 50-Year Period

Importance

Despite the increasing prevalence of type 2 diabetes (T2D) diagnosed in childhood, little is known about the natural history of ocular sequelae in youth-onset T2D compared with type 1 diabetes (T1D).

Objective

To assess the risk of developing diabetes-associated ocular complications among youth diagnosed with diabetes.

Design, Setting, and Participants

This retrospective, population-based medical record review included all residents of Olmsted County, Minnesota (95.7% White in 1990), diagnosed with diabetes at younger than 22 years (hereinafter referred to as children) from January 1, 1970, through December 31, 2019.

Main Outcomes and Measures

Risk of developing ocular complications over time.

Results

Among 1362 individuals with a diagnostic code of diabetes, medical record reviews confirmed a diagnosis of T1D or T2D in 606 children, of whom 525 (86.6%) underwent at least 1 eye examination (mean [SD] age at diabetes diagnosis, 12.1 [5.4] years; 264 [50.3%] male). Diabetes-associated ocular complications occurred in 147 of the 461 children (31.2%) with T1D and in 17 of the 64 children (26.6%) with T2D. The hazard ratio illustrating the risk between T2D and T1D rates was 1.88 (95% CI, 1.13-3.12; P = .02) for developing any diabetic retinopathy (nonproliferative or greater), 2.33 (95% CI, 0.99-5.50; P = .048) for proliferative diabetic retinopathy, 1.49 (95% CI, 0.46-4.89; P = .50) for diabetic macular edema, 2.43 (95% CI, 0.54-11.07; P = .24) for a visually significant cataract, and 4.06 (95% CI, 1.34-12.33; P = .007) for requiring pars plana vitrectomy by 15 years after the diagnosis of diabetes.

Conclusions and Relevance

Diabetic retinopathy, proliferative diabetic retinopathy, and the need for pars plana vitrectomy occurred within a shorter diabetes duration for children with T2D compared with T1D in this population-based cohort. Children with T2D had almost twice the risk of developing retinopathy compared with those with T1D. These findings suggest that to prevent serious ocular complications, children with T2D may require ophthalmoscopic evaluations at least as frequently as or more frequently than children with T1D.

Racial/Ethnic Disparities and Barriers to Diabetic Retinopathy Screening in Youths

Importance

Diabetic retinopathy is a major complication of diabetes for which regular screening improves visual health outcomes, yet adherence to screening is suboptimal.

Objective

To assess disparities in diabetic eye examination completion rates and evaluate barriers in those not previously screened.

Design, Setting, and Participants

In this cohort study at a single academic center (Johns Hopkins Hospital pediatric diabetes center in Baltimore, Maryland) from December 2018 to November 2019, youths with type 1 or type 2 diabetes who met criteria for diabetic retinopathy screening and were enrolled in a prospective observational trial implementing point-of-care diabetic retinopathy screening were asked about prior diabetic retinopathy screening.

Main Outcomes and Measures

Demographic and clinical characteristics were compared between those who did and did not have a previous diabetic eye examination and stratified according to race/ethnicity, using t tests and χ2 tests. Multivariate logistic regression was used to analyze the association between race/ethnicity, screening, and other social determinants of health. A questionnaire assessing barriers to screening adherence was administered.

Results

Of 149 participants (76 male patients [51.0%]; mean [SD] age, 14.5 [2.3] years), 51 (34.2%) had not had a prior diabetic eye examination. These individuals were more likely than those who had prior diabetic eye examinations to be non-White youths (38 [75%] vs 31 [32%]; P < .001) and have type 2 diabetes (38 [75%] vs 10 [10%]; P < .001), Medicaid or public insurance (43 [84%] vs 31 [32%]; P < .001), lower household income (annual income ≤$25 000, 21 [41%] vs 9 [9%]; P < .001), and parents with education levels of high school or less (29 [67%] vs 22 [35%]; P < .001). The main barriers reported included not recalling being recommended to obtain a diabetic eye examination (19 [56%]), difficulty finding time for an additional appointment (10 [29%]), and transportation issues (7 [20%]). Minority youths were less likely to have a previous diabetic eye examination (non-White, 34 [46%] vs White, 64 [85%]; P < .001) and more likely to have diabetic retinopathy (11 [15%] v 2 [3%]; P = .008). Minority youths were less likely to get diabetic eye examinations even after adjusting for insurance, household income, and parental education level (odds ratio, 0.29 [95% CI, 0.10-0.79]; P = .02).

Conclusions and Relevance

In this cohort study, non-White youths were less likely to undergo diabetic eye examinations yet more likely to have diabetic retinopathy compared with White youths. Addressing barriers to diabetic retinopathy screening may improve access to diabetic eye examination and facilitate early detection.

Barriers to retinopathy screening in youth and young adults with type 1 diabetes

Early detection of diabetic retinopathy (DR) is imperative; however, adherence to screening guidelines is poor. We hypothesized that youth and young adults with type 1 diabetes (T1D) who met American Diabetes Association criteria for recommended DR screening at the time of the study (10 years old or greater with diabetes duration of 5 years or more) would report multiple barriers to screening and that targeted barriers and subpopulations could be identified to improve access to care. 271 youth aged 10 to 26 years with T1D of at least 5 years duration were recruited from clinic, diabetes camp, and a diabetes conference and completed a patient-reported questionnaire. 113 (41.7%) reported at least one barrier to DR screening, with missed school and work being the most common (20.7%). Older participants (P = 0.007) and those with a longer diabetes duration (P = 0.018) were more likely to report barriers to screening. Recruitment location, sex, race and ethnicity, HbA1c, insulin regimen, and clinic visit frequency were not associated with reporting at least one barrier. Slightly less than two-thirds (62.1%) of participants who responded (n = 235 out of 271) adhered to recommended screening guidelines of the time and reported having an eye exam within the past year, 24.7% 12-23 months ago, 9.8% 2 years ago or more, and 3.4% had never had a DR exam. As older patients and those with longer duration of diabetes are more likely to have DR, targeted interventions to address barriers to care, such as, missed school and work should be implemented in these groups.

Real-World Screening for Retinopathy in Youth With Type 1 Diabetes Using a Nonmydriatic Fundus Camera

OBJECTIVE

To assess the use of a portable retinal camera in diabetic retinopathy (DR) screening in multiple settings and the presence of associated risk factors among children, adolescents, and young adults with type 1 diabetes.

DESIGN AND METHODS

Five hundred youth with type 1 diabetes of at least 1 year's duration were recruited from clinics, diabetes camp, and a diabetes conference and underwent retinal imaging using a nonmydriatic fundus camera. Retinal characterization was performed remotely by a licensed ophthalmologist. Risk factors for DR development were evaluated by a patient-reported questionnaire and medical chart review.

RESULTS

Of the 500 recruited subjects aged 9-26 years (mean 14.9, SD 3.8), 10 cases of DR were identified (nine mild and one moderate nonproliferative DR) with 100% of images of gradable quality. The prevalence of DR was 2.04% (95% CI 0.78-3.29), at an average age of 20.2 years, with the youngest affected subject being 17.1 years of age. The rate of DR was higher, at 6.5%, with diabetes duration >10 years (95% CI 0.86-12.12, P = 0.0002). In subjects with DR, the average duration of diabetes was 12.1 years (SD 4.6, range 6.2-20.0), and in a subgroup of clinic-only subjects (n = 114), elevated blood pressure in the year before screening was associated with DR (P = 0.0068).

CONCLUSION

This study in a large cohort of subjects with type 1 diabetes demonstrates that older adolescents and young adults (>17 years) with longer disease duration (>6 years) are at risk for DR development, and screening using a portable retinal camera is feasible in clinics and other locations. Recent elevated blood pressure was a risk factor in an analyzed subgroup.

Evidence-Based Clinical Practice Guideline: Comprehensive Pediatric Eye and Vision Examination

Republished with written permission granted from the American Optometric Association, October 2, 2020.

Association of state vision screening requirements with parent-reported vision testing in young children

PURPOSE

To examine the relationship between state school vision screening requirements and the likelihood that children 3-5 years of age receive vision testing.

METHODS

We obtained nationally representative data from the 2016 National Survey of Children's Health on children ages 3-5 (n = 7,567) and used available sources to compile state policies that mandate childhood vision testing. We calculated the rates of parent-reported vision testing for each state and fit logistic regression models using survey-based estimation methods with nationally representative weights. Our models controlled for factors such as age, sex, race/ethnicity, and insurance coverage. Additional analyses added comorbidities that may lead to an eye care provider referral.

RESULTS

Parent-reported vision testing rates by state ranged from 41% to 84%. A significant association was found between the presence of state-level vision screening requirements and parent-reported vision testing, which remained after controlling for comorbidities (aOR = 1.374; P = 0.016). Of these comorbidities, arthritis, blindness, and very low birth weight were associated with a higher rate of vision screening (all P < 0.05).

CONCLUSIONS

The presence of a state-level school vision screening requirement is associated with increased parent-reported vision testing in children 3-5 years of age. This suggests that state policy may ensure timely screening for amblyopia and other sight-threatening complications.

Evaluation of microvascular changes in retinal zones and optic disc in pediatric patients with type 1 diabetes mellitus

PURPOSE

The objective of this study was to evaluate the vascular parameters of the retinal zones and the optic disc (OD) with the use of optical coherence tomography angiography (OCTA) in pediatric patients with type 1 diabetes mellitus (T1DM).

METHODS

This study enrolled 60 patients with T1DM without clinically detectable diabetic retinopathy (DR), along with 59 age-, gender-, and pubertal stage-matched controls. The ages of the participants in both groups were < 18 years. Retinal and OD measurements were carried out with OCTA. Foveal avascular zone (FAZ) area, non-flow area (NFA), FAZ perimeter (PERIM), acircularity index of FAZ (AI, the rate of the perimeter of FAZ and the perimeter of a circle with equal area), foveal density (FD), superficial (SCP), and the deep capillary plexus (DCP) were analyzed in the macular region. SCP and DCP were also scanned centered on the OD. Correlations between the OCTA parameters with duration of DM, glycated hemoglobin (HbA1c) levels, and microalbuminuria were evaluated among patients with T1DM.

RESULTS

The mean values for NFA were significantly higher and mean FD were significantly lower in the diabetic group compared with the controls (p = 0.02 and p = 0.01, respectively). The mean values for SCP and DCP were significantly lower in diabetic group (p < 0.05). The mean values for capillary density in the OD were also significantly lower in diabetic group (p < 0.05). There were correlations between the duration of T1DM, HbA1c levels and microalbuminuria, and the investigated parameters of OCTA.

CONCLUSIONS

The presence of microvascular changes in both retinal zones and the OD in children with T1DM without retinopathy is an important data. OCTA can be used for the early detection of DR in children.

Epidemiology of visual impairment, sight-threatening or treatment-requiring diabetic eye disease in children and young people in the UK: findings from DECS

BACKGROUND

We investigated the incidence and causes of sight-threatening diabetes-related eye disease in children living with diabetes in the UK, to inform the national eye screening programme and enable monitoring of trends.

METHODS

We undertook a prospective active national surveillance via the British Ophthalmic Surveillance Unit. Eligible cases were children aged 18 years or younger, with type 1 or 2 diabetes, newly diagnosed between January 2015 and February 2017 with sight-threatening diabetic eye disease.

RESULTS

Eight children were reported. The annual incidence of all sight-threatening diabetes-related eye disease requiring referral to an ophthalmologist among children living with diabetes (n=8) in the UK was 1.21 per 10 000 person-years (95% CI 0.52 to 2.39) and was largely attributable to cataract (n=5) 0.76 per 10 000 person-years (95% CI 0.25 to 1.77). The incidence of sight-threatening diabetic retinopathy (n=3) among those eligible for screening (12 to 18 year-olds living with diabetes) was 1.18 per 10 000 person-years (95% CI 0.24 to 3.46). No subjects eligible for certification as visually impaired or blind were reported.

CONCLUSIONS

Secondary prevention of visual disability due to retinopathy is currently the sole purpose of national eye screening programmes globally. However, the rarity of treatment-requiring retinopathy in children/young people living with diabetes, alongside growing concerns about suboptimal screening uptake, merit new consideration of the utility of screening for primary prevention of diabetes-related morbidity by using the screening event and findings as a catalyst for better diabetes self-management.

Change in peripapillary and macular choroidal thickness change in children with type 1 diabetes mellitus without visual impairment or diabetic retinopathy

PURPOSE

To study the characteristics of choroid thickness (CT) of the optic disc and macula in children with type 1 diabetes mellitus (T1DM) without visual impairment and diabetic retinopathy (DR) and analyse associated factors.

METHODS

A square area of 6 × 6 mm around the centre of the optic disc and macula was scanned. The indices analysed mainly included CT at the macular centre (1 mm), and temporal, superior, nasal or inferior aspect of the inner ring (1-3 mm) and outer ring of (3-6 mm) optic disc and macula. Independent risk factors were analysed using multifactor linear regression.

RESULTS

A total of 44 children with T1DM and 48 healthy subjects were enrolled. The diabetic group showed significant increase in the inferior inner ring of parapapillary CT (100.99 ± 30.42 μm versus 89.41 ± 34.00 μm, p = 0.04) and nasal outer ring of parapapillary CT (157.02 ± 47.35 μm versus 131.15 ± 35.17 μm, p = 0.01) as compared to those values in the healthy controls. Spherical equivalent refraction and family history of hypertension are independent factors of both peripappillary choroid thickness (PPCT) and macular choroid thickness (PMCT). Spherical equivalent refraction (p = 0.01) and serum cholesterol (p = 0.03) were independent factors of the inferior inner ring of parapapillary CT, whereas family history of hypertension was an independent factor of the nasal outer ring of parapapillary CT (p = 0.001).

CONCLUSION

In children with diabetes without DR or visual impairment, the CT increase in nasal outer ring of parapapillary (PPNO) and the inferior inner ring of parapapillary (PPII) may be the characteristic pre-DR alteration at the early stage of DM. For children with higher serum cholesterol and family history of hypertension, the change of the nasal outer ring of parapapillary CT and the inferior inner ring of parapapillary CT may be more advanced.

Pediatric diabetic retinopathy telescreening

PURPOSE

To describe the role of telemedicine screening for pediatric diabetic retinopathy (DR) and to identify risk factors for pediatric DR.

METHODS

The medical records of a telemedicine program at a tertiary, academic medical center over 17 months were reviewed retrospectively. Patients visiting an academic pediatric endocrinology clinic who met guidelines underwent telescreening. Presence of pediatric DR and risk factors for retinopathy were evaluated.

RESULTS

The fundus photographs of 852 patients 10-23 years of age were reviewed. Diabetic retinopathy was noted in 51 (6%). Patients with an abnormal screening photograph were compared to patients with diabetes who had normal screening photographs (n = 64). Older age, longer diabetes duration, type 1 diabetes, and higher average glycated hemoglobin (HbA1c) from the year prior to the photograph were associated with increased risk of retinopathy. Of these, longer duration (P = 0.003) and higher average A1c (P = 0.02) were significant after adjusting for sex, race, and age.

CONCLUSIONS

Our telemedicine program found a higher percentage of diabetic retinopathy screening non-mydriatic photographs than prior studies found through standard ophthalmic examinations. In this relatively small sample size, longer duration of disease and higher average A1c were associated with increased risk of having diabetic retinopathy in our study.

Vulnerabilities in diabetic eye screening for children and young people in England

BACKGROUND

Children and young people (CYP) living with diabetes require integrated child-centered care. We hypothesized that suboptimal uptake to diabetic retinopathy screening in CYP may be partly related to the degree of services integration. We investigated the structure of the current pediatric diabetic eye care pathway and associations between service-level characteristics and screening uptake.

METHODS

A quality improvement project between January and May 2017 comprising a survey of practice of all 158 pediatric diabetes services (pediatric diabetes units, PDUs) across England and secondary data analysis of routinely collected service data. Generalized linear models for proportional responses were fitted to investigate associations between reported PDU characteristics and screening uptake.

RESULTS

124 PDUs (78%) responded. In 67% (n = 83), patients could be referred directly to screening programs; the remainder relied on primary care for onward referral. 97% (n = 120) considered eye screening results useful for counseling patients but only 65% (n = 81) reported it was "easy" to obtain them. Factors independently associated with higher screening uptake were a higher proportion of patients referred from primary care (OR = 1.005; 95%CI = 1.004-1.007 per 1% of increase), absence of "out-of-catchment area" patients (OR = 1.13; 95%CI = 1.04-1.22), and easy access to eye screening results (OR = 1.45; 95%CI = 1.34-1.56).

CONCLUSIONS

There is limited direct communication between the services involved in diabetic eye care for CYP in England. This risks reducing the effectiveness of diabetic retinopathy screening. Similar vulnerabilities are likely to exist in other countries where retinopathy screening for CYP has been "bolted on" to provision for adults.

Changes in Retinal Microcirculation Precede the Clinical Onset of Diabetic Retinopathy in Children With Type 1 Diabetes Mellitus

PURPOSE

To investigate whether abnormal glucose metabolism in diabetes mellitus (DM) affects the retinal microcirculation of children with well-controlled type 1 DM and to compare these results with those obtained from healthy children.

DESIGN

Cross-sectional prospective study.

METHODS

This study enrolled 60 patients with DM without clinically detectable diabetic retinopathy (DR) and 57 age-matched control subjects. Optical coherence tomography angiography (OCT-A) was performed using AngioVue (Avanti, Optivue). Foveal avascular zone (FAZ) area, nonflow area, superficial and deep vessel densities, FAZ perimeter, acircularity index of FAZ (AI; the ratio of the perimeter of FAZ and the perimeter of a circle with equal area), and foveal density (FD-300; vessel density in 300 μm around FAZ) were analyzed. Correlations between the investigated OCT-A parameters with DM duration and glycated hemoglobin (HbA1c) levels were evaluated among patients with type 1 DM.

RESULTS

Differences in the mean values for FAZ perimeter, AI, and FD-300 were statistically significant between DM group and control group (P < .001, P = .001, and P = .009, respectively). There were also statistically significant differences between the groups for vessel densities of deep superior hemi-parafovea, deep temporal parafovea, and deep superior parafoveal zones (P = .008, P = .015, and P = .005, respectively). There were no significant correlations between DM duration and HbA1c levels with the investigated OCT-A parameters.

CONCLUSION

Diabetic eyes without clinically detectable DR exhibited alterations in FD-300, AI, perimeter, and vessel density of parafoveal capillaries in deep capillary plexus preceding the enlargement of FAZ; therefore, these new parameters might be sensitive imaging biomarkers to define early DR.

Retinal Microvascular Abnormalities in Children with Type 1 Diabetes Mellitus Without Visual Impairment or Diabetic Retinopathy

Purpose

To study the characteristics and associated factors of retinal microvascular abnormalities in children with type 1 diabetes mellitus (T1DM) without visual impairment and diabetic retinopathy (DR).

Methods

Case-control hospital-based study including children with or without DM. Optical coherence tomography angiography (OCTA; CIRRUS HD-OCT model 5000) was used to scan 6 × 6 mm square area of posterior retina and optic disc. The indexes analyzed mainly included vascular length density (VD), perfusion density (PD), and foveal avascular zone area, perimeter, and morphology. Independent risk factors were analyzed by multifactor linear regression.

Results

A total of 47 children with T1DM and 44 healthy subjects were enrolled. Statistical analysis showed that VD within 1 to 3 mm (inner ring) of the macula in the case group was smaller than that in the control group (18.561 ± 1.151/mm: 19.161 ± 0.464/mm; P< 0.001), and mother's excessive weight gain during pregnancy was an independent factor (P = 0.004); VD within 3 to 6 mm (outer ring) of the macula in the case group was smaller than that in the control group (19.044 ± 0.847/mm; 19.404 ± 0.496/mm, P = 0.029), while serum creatinine level was revealed to be an independent factor (P = 0.009); PD within 3 to 6 mm of the macula in the case group was higher than that in the control group (0.456 ± 0.015: 0.442 ± 0.030) (P = 0.003), with no independent factor observed in regression analysis.

Conclusion

Retinal microvasculopathy had already occurred in the parafoveal area of diabetic children without visual impairment and DR; early screening and close follow-up were recommended for children with high-risk factors.

Analysis of Retinal Perfusion in Children, Adolescents, and Young Adults with Type 1 Diabetes Using Optical Coherence Tomography Angiography

We performed a cross-sectional study to analyze the retinal vasculature in children, adolescent, and young adults with type 1 diabetes using optical coherence tomography angiography (OCTA). Patients underwent funduscopic examination for diabetic retinopathy (DR) screening during an annual visit for the screening of diabetes-related complications which included the evaluation of glycated hemoglobin (HbA1c), microalbuminuria, lipid profile, arterial pressure, and neurological assessment. In addition, OCTA of the retinal vasculature was performed. Quantitative analysis of the OCTA images evaluated the vessel density at the superficial (SCP) and deep (DCP) capillary plexus of the retina. Structural vascular alterations were evaluated qualitatively. Results were compared to those obtained in a group of healthy age-, sex-, and pubertal stage-matched controls. The effect of age, disease duration, age at the disease onset, mean HbA1c since the onset, and lipid profile on vascular density was tested. Fifty-three patients (median age 15.5, IQR 12.4-19.4 years; 57% females) with type 1 diabetes and 48 controls were enrolled. The median (IQR) HbA1c was 7.6% (60 mmol/mol) (6.9-8.1%, 52-65 mmol/mol), and the median (IQR) duration of disease was 6.0 (3.3-10.3) years. Mean vessel density measured with OCTA was lower in patients compared to controls with the temporal sector showing the highest difference both in the SCP (0.55 vs. 0.57, p < 0.001) and the DCP (0.63 vs. 0.65, p < 0.001). None of the predictors was associated with the superficial and deep vascular densities. Only 2 patients had clinically detectable DR. Microvascular structural changes were found on OCTA in both of these patients and in one without funduscopic alterations. In conclusion, patients with type 1 diabetes without clinically detectable DR had decreased capillary density compared to controls on OCTA images. These findings may provide useful information for the screening and the management of patients with type 1 diabetes. Further studies are needed to confirm our results and their clinical relevance.

Evidence-based Danish guidelines for screening of diabetic retinopathy

PURPOSE

Diabetic retinopathy (DR) is among the leading causes of visual loss in the working-age population. It is generally accepted that screening of DR is cost-effective and can detect DR before it becomes sight-threatening to allow timely treatment.

METHODS

A group of retinal specialists was formed by the Danish Ophthalmological Society with the aim to formulate contemporary evidence-based guidelines for screening of DR in order to implement these in the Danish screening system.

RESULTS

We hereby present evidence for DR-screening regarding (1) classification of DR, (2) examination techniques, (3) screening intervals and (4) automated screening. It is our recommendation that the International Clinical Retinopathy Disease Severity Scale should be used to classify DR. As a minimum, mydriatic two-field disc- and macular-centred images are required. In the case of suspected clinically significant diabetic macular oedema, supplementary optical coherence tomography can increase the diagnostic accuracy. There is solid evidence to support a flexible, individualized screening regimen. In particular, it is possible to prolong screening intervals to 24-48 months for patients with no or mild nonproliferative diabetic retinopathy (NPDR), but it is also possible to use extended intervals of 12-24 months for patients with moderate NPDR given that these are well-regulated regarding glycaemic control (HbA1c ≤ 53 mmol/mol) and blood pressure (≤130/80 mmHg). Automated screening of DR is encouraging but is not ready for implementation at present.

CONCLUSION

Danish evidenced-based guidelines for screening of DR support high-quality imaging and allow flexible, individualized screening intervals with a potential for extension to patients with low risk of DR progression.

Prevalence of diabetic retinopathy in children and young people living with diabetes: protocol for a systematic review

INTRODUCTION

The frequency of diabetes mellitus in childhood is increasing. Thus, more children and young people are at risk of developing diabetic retinopathy and diabetes related visual impairment. However, there is no consensus on optimal screening strategies for the paediatric population reflecting the lack of clarity about the current burden of disease in this group. We aim to estimate the prevalence of diabetic retinopathy in children and young people living with types 1 or 2 diabetes, and to investigate potential sources of heterogeneity in this figure so as to inform screening strategies for this population.

METHODS AND ANALYSIS

PubMed and EMBASE will be searched from 1995 to 2016 using the OvidSP platform with no language restriction. Additionally, manual review of the references lists of included articles will be conducted. Two investigators will independently screen titles and abstracts for potential eligibility. Studies which report prevalence of diabetic retinopathy among general populations of children and young people with types 1 or 2 diabetes will be included. Pooled prevalence estimates of diabetic retinopathy reported in studies with sample size greater than 200 participants will be calculated by the random effect model. Forest plots will be used to summarise individual and pooled estimates of the prevalence. Heterogeneity between studies will be assessed using the I² statistic and explored through meta-regressions and subgroup analyses if the necessary data are available.

ETHICS AND DISSEMINATION

Ethics approval is not required as this is a review of anonymised published data. We will report the findings of this systematic review in a peer-reviewed journal, and share it with the relevant professionals including health authorities through our Diabetic Eye disease in Childhood Study collaborative network.

CLINICAL TRAIL REGISTRATION

PROSPERO (CRD42017067178).

Optical coherence tomography angiography vessel density in children with type 1 diabetes

PURPOSE

To assess the optical coherence tomography angiography (OCTA) retinal vessel density and foveal avascular zone (FAZ) in children with type 1 diabetes (T1D) and compare potential pathologic early changes in this population to healthy age-matched controls.

METHODS

This study included 130 pubescent children: 94 with T1D (188 eyes) and 36 of their age-matched control group (60 eyes). OCTA was performed using AngioVue (Avanti, Optivue). FAZ area (mm2) in superficial plexus, whole superficial capillary vessel density (wsVD), fovea superficial vessel density (fsVD), parafovea superficial vessel density (psVD), whole deep vessel density (wdVD), fovea deep vessel density (fdVD), parafovea deep vessel density (pdVD), foveal thickness (FT) (μm) and parafoveal thickness (PFT) (μm) were taken into analysis. Among the studied patients with T1D there were assessed codependences regarding the investigated foveal and parafoveal parameters and selected potential predictors, i.e. patient's age (years), diabetes duration time (years), age of onset of the disease (years), mean level of glycated hemoglobin (HbA1C) (%), and concentration of serum creatinine (mg/dL).

RESULTS

None of the abovementioned OCT and OCTA parameters was statistically significantly different between the groups. The patient's age statistically significantly did not influent any of the OCT and OCTA parameters. Yet an elevated level of HbA1C tended to reduce the parafovea superficial vessel density (p = 0.039), and parafoveal thickness (p = 0.003) and an increased serum creatinine level correlated with the decreased whole deep vessel density (p < 0.001). The parafovea deep vessel density in the diabetic patients decreased when the serum creatinine level (p = 0.008), age of onset of the disease (p = 0.028), and diabetes duration time (p = 0.014) rose.

CONCLUSIONS

Vessel density, both in superficial and deep plexuses, and FAZ area are normal in pubescent children with T1D comparing to healthy subjects. An elevated level of HbA1C correlated with reduced psVD and PFT. Longitudinal observation of these young patients is needed to determine if any of these OCTA measurements are predictive of future DR severity.

Optical coherence tomography angiography analysis of retinal vascular plexuses and choriocapillaris in patients with type 1 diabetes without diabetic retinopathy

AIMS

To analyze retinal vascular plexuses and choriocapillaris by optical coherence tomography angiography (OCT-A) and retinal nerve fiber layer and ganglion cell layer (GCL) by structural optical coherence tomography (OCT) in patients with type 1 diabetes mellitus (T1DM) without diabetic retinopathy (DR).

METHODS

A total of 25 eyes of 25 consecutive T1DM patients without signs of DR were prospectively recruited and compared to 25 healthy subjects (control eyes). All patients underwent OCT-A (CIRRUS HD-OCT model 5000, Carl Zeiss Meditec, Dublin, CA) and structural OCT. Qualitative and quantitative analyses with vessel density were performed on OCT-A images in the superficial capillary plexus (SCP), deep capillary plexus (DCP) and choriocapillaris for all patients.

RESULTS

By means of OCT-A, a rarefaction of the perifoveal capillary network in SCP was detected in 7 out of 25 eyes. No significant difference was found in FAZ area of both SCP and DCP comparing diabetic and control groups. By analyzing the DCP, diabetic eyes revealed a significant decreased vessel density compared to control eyes [0.464 ± 0.016 and 0.477 ± 0.014, respectively (p = 0.005)]. Instead, no significant difference was found in the vessel density of all-retina plexus, SCP and choriocapillaris. By RFNL and GCL thickness analysis, no significant differences were disclosed between diabetics and healthy subjects.

CONCLUSIONS

We demonstrated the ability of OCT-A to disclose early vascular alterations in patients with T1DM diagnosed as without any signs of DR on the basis of fundus biomicroscopy. Our results also suggest that microvascular changes could precede detectable damage of diabetic neuroretinopathy.

Ophthalmic Screening Patterns Among Youths With Diabetes Enrolled in a Large US Managed Care Network

Importance

Ophthalmic screening to check for diabetic retinopathy (DR) is important to prevent vision loss in persons with diabetes. The American Academy of Ophthalmology recommends that ophthalmic screening for DR occur beginning at 5 years after initial diabetes diagnosis for youths with type 1 diabetes; the American Diabetes Association recommends screening of youths with type 2 diabetes at the time of initial diagnosis. To our knowledge, it is unknown to what extent youths with diabetes obtain eye examinations in accordance with these guidelines.

Objective

To assess the rate of obtaining ophthalmic examinations and factors associated with receipt of eye examinations for youths with diabetes.

Design, Setting, and Participants

This retrospective, longitudinal cohort study examined youths 21 years or younger with newly diagnosed diabetes enrolled in a US managed care network from January 1, 2001, through December 31, 2014.

Main Outcomes and Measures

Kaplan-Meier survival curves estimated the time from initial diabetes diagnosis to first eye examination by an ophthalmologist or optometrist. Multivariable Cox proportional hazards regression models identified factors associated with receiving an ophthalmic examination after initial diabetes diagnosis.

Results

Among 5453 youths with type 1 diabetes (median age at initial diagnosis, 11 years; interquartile range, 8-15 years; 2972 male [54.5%]; 4505 white [82.6%]) and 7233 youths with type 2 diabetes (median age at initial diagnosis, 19 years; interquartile range, 16-22 years; 1196 male [16.5%]; 5052 white [69.9%]), 64.9% of patients with type 1 diabetes and 42.2% of patients with type 2 diabetes had undergone an eye examination by 6 years after initial diabetes diagnosis. Black youths (1367 [10.8%] of the sample) had an 11% and Latino youths (1450 [11.4%] of the sample) had an 18% decreased hazard of undergoing an eye examination by 6 years compared with white youths (black youths: adjusted hazard ratio [HR], 0.89; 95% CI, 0.79-0.99; Latino youths: HR, 0.82; 95% CI, 0.73-0.92). As household net worth increased, youths were increasingly more likely to undergo an eye examination by 6 years after initial diabetes diagnosis (net worth of ≥$500 000 vs <$25 000: HR, 1.50; 95% CI, 1.34-1.68).

Conclusions and Relevance

Despite possessing health insurance, many youths with diabetes are not receiving eye examinations by 6 years after initial diagnosis to monitor for DR. These data suggest that adherence to clinical practice guidelines is particularly challenging for racial minorities and youths from less affluent families.

Incidence and Risk Factors for Developing Diabetic Retinopathy among Youths with Type 1 or Type 2 Diabetes throughout the United States

PURPOSE

Despite the increasing prevalence of type 2 diabetes mellitus (T2DM) among children and adolescents, little is known about their risk of developing diabetic retinopathy (DR). We sought to identify risk factors for DR in youths with diabetes mellitus, to compare DR rates for youths with type 1 diabetes mellitus (T1DM) and those with T2DM, and to assess whether adherence to DR screening guidelines promoted by the American Academy of Ophthalmology, American Academy of Pediatrics, and American Diabetes Association adequately capture youths with DR.

DESIGN

Retrospective observational longitudinal cohort study.

PARTICIPANTS

Youths aged ≤21 years with newly diagnosed T1DM or T2DM who were enrolled in a large US managed-care network.

METHODS

In this study of youths aged ≤21 years with newly diagnosed T1DM or T2DM who were under ophthalmic surveillance, we identified the incidence and timing of DR onset. Kaplan-Meier survival curves assessed the timing of initial diagnosis of DR for participants. Multivariable Cox proportional hazard regression modeling identified factors associated with the hazard of developing DR. Model predictors were age and calendar year at initial diabetes mellitus diagnosis, sex, race/ethnicity, net worth, and glycated hemoglobin A1c fraction (HbA1c).

MAIN OUTCOME MEASURES

Hazard ratios (HRs) with 95% confidence intervals (CIs) for developing DR.

RESULTS

Among the 2240 youths with T1DM and 1768 youths with T2DM, 20.1% and 7.2% developed DR over a median follow-up time of 3.2 and 3.1 years, respectively. Survival curves demonstrated that youths with T1DM developed DR faster than youths with T2DM (P < 0.0001). For every 1-point increase in HbA1c, the hazard for DR increased by 20% (HR = 1.20; 95% CI 1.06-1.35) and 30% (HR = 1.30; 95% CI 1.08-1.56) among youths with T1DM and T2DM, respectively. Current guidelines suggest that ophthalmic screening begin 3 to 5 years after initial diabetes mellitus diagnosis, at which point in our study, >18% of youths with T1DM had already received ≥1 DR diagnosis.

CONCLUSIONS

Youths with T1DM or T2DM exhibit a considerable risk for DR and should undergo regular screenings by eye-care professionals to ensure timely DR diagnosis and limit progression to vision-threatening disease.

Fundus Photography as a Screening Method for Diabetic Retinopathy in Children With Type 1 Diabetes: Outcome of the Initial Photography

PURPOSE

To determine the success rate of the initial fundus photography session in producing gradable images for screening diabetic retinopathy in children <18 years of age with type 1 diabetes (T1D), and to analyze outcome-associated factors.

DESIGN

Retrospective observational cohort study.

METHODS

Mydriatic red-free monochromatic 60-degree digital fundus images centered on the macula and optic disc of 213 patients were graded. Photography success was classified as "complete" if both images of both eyes were gradable, "partial" if both images of 1 eye were gradable, "macula-centered image(s) only" if only the macula-centered image of one or both eyes was gradable, and "unsuccessful" if neither macula-centered image was gradable.

RESULTS

Complete success was reached in 97 (46%; 95% confidence interval [CI], 39-52) patients, at least partial success in 153 (72%; 95% CI, 65-78) patients, success of macula-centered image(s) only in 47 (22%; 95% CI, 17-28) patients, and in 13 (6%; 95%CI, 3-10) patients fundus photography was unsuccessful. Macula-centered images were more often gradable in both eyes than optic disc-centered images (P < .001). Success of photography did not differ between right and left eye. Sex, age at diagnosis of T1D, and the duration of diabetes, age, and glycemic control at the time of initial photography were unassociated with complete success. Partial success tended to decrease with increasing age category (P = .093), and the frequency of gradable macula-centered image(s) only increased with increasing age (P = .043).

CONCLUSIONS

Less than half of the children achieved complete success, but in only 6% initial fundus photography was unsuccessful, indicating its value in assessing retinopathy in the pediatric setting.

Diagnosis of retinopathy in children younger than 12 years of age: implications for the diabetic eye screening guidelines in the UK

AimTo assess whether the current starting age of 12 is suitable for diabetic retinopathy (DR) screening and whether diabetes duration should be taken into account when deciding at what age to start screening patients.Materials and methodsA retrospective analysis of 143 patients aged 12 years or younger who attended diabetic eye screening for the first time in the Birmingham, Solihull and Black Country Diabetic Eye Screening Programme was performed.ResultsThe mean age of the patients was 10.7 (7-12) years with 73 out of 143 aged below 12 years and 70 were 12 years of age. 98% had type 1 diabetes and mean diabetes duration was 5 (1 month-11 years) years. For those younger than 12 years, 7/73 (9.6%) had background DR (BDR), of these mean diabetes duration was 7 years (6-8). The youngest patient to present with DR was aged 8 years. In those aged 12 years, 5/70 (7.1%) had BDR; of these mean diabetes duration was 8 years (6-11). No patient developed DR before 6 years duration in either group.ConclusionsThe results show that no patient younger than the age of 12 had sight-threatening DR (STDR), but BDR was identified. Based on the current mission statement of the Diabetic Eye Screening Programme to identify STDR, 12 years of age is confirmed as the right age to start screening, but if it is important to diabetic management to identify first development of DR, then screening should begin after 6 years of diabetes diagnosis.

The potentialities proteomic analysis of ocular fluids and tissues in different ophthamic disordeers

The article presents a review of current researches in using the proteomic analysis for different eye diseases diagnosis. Special attention is paid to tear fluid and aqueous humor mass-spectrometry results in primary open-angle glaucoma, and to the possibility of using this method for diagnosis at disease early stages.

Pediatric diabetic retinopathy: experience of a tertiary hospital in Ethiopia

BACKGROUND

Diabetic retinopathy is one of the micro vascular complications of diabetes mellitus. To date there are no studies that show the magnitude of diabetic retinopathy in the pediatric population of Ethiopia with only very few in Africa. The purpose of this study was to determine the prevalence of diabetic retinopathy in children and adolescents at a tertiary center in Ethiopia.

METHODS

This cross-sectional hospital based descriptive study included children aged between 9 and 17 years attending the endocrine follow-up clinic of Tikur Anbesa Specialized Hospital. A structured questionnaire was used for evaluating sociodemographic data and information pertinent to diabetes. The prevalence of diabetic retinopathy was determined by fundus photography of each eye.

RESULTS

A total of 86 patients were examined with a mean age of 13.7 (SD = 1.8) years. At onset of diabetes, 95.6% of children presented with diabetic ketoacidosis(DKA); 22 children (25.6%) had at least two episodes of DKA, and 45 children (52.3%) had poor glycemic control. Background retinopathy was present in four children (4.7%) with a mean age of 14.25 (SD = 1.89) years and two of them also had maculopathy.

CONCLUSION

Although there are some methodological limitations, this study highlights the difficulties of achieving good glycemic control and the early occurrence of diabetic retinopathy in Ethiopian diabetic children.

Ocular Complications in Children with Diabetes Mellitus

PURPOSE

The effectiveness of annual eye examinations in diabetic children is unclear. We sought to determine the prevalence and onset of ocular pathology in children with diabetes mellitus (DM), identify risk factors for ocular disease, and recommend a screening regimen for asymptomatic children.

DESIGN

Retrospective, consecutive cohort study.

PARTICIPANTS

Children aged less than 18 years with type 1 or 2 DM examined over a 4-year period.

METHODS

All children underwent a complete eye examination, including dilated fundoscopy and cycloplegic refraction. A literature review was performed, identifying the youngest reported age and shortest reported duration of DM before the diagnosis of diabetic retinopathy (DR).

MAIN OUTCOME MEASURES

Prevalence of DR, cataract, high refractive error, and strabismus.

RESULTS

A total of 370 children (mean age, 11.2 years; range, 1-17.5 years) had 693 examinations, with a mean DM duration of 5.2 years (range, 0.1-16.2 years) and a mean hemoglobin A1c (HbA1c) of 8.6 (range, 5-≥14). No children had DR. A total of 12 children had cataract; 5 required extraction but were identified by decreased vision, not diabetic screening. A total of 19 children had strabismus; only 1 was microvascular paralytic strabismus. A total of 41 children had high refractive error. There were no associations between these conditions and duration or control of DM. In the literature, the youngest age at diagnosis of severe DR was 15 years, and the shortest duration of disease was 5 years.

CONCLUSIONS

Diabetic retinopathy is rare in children regardless of duration and control of DM. On the basis of our study and literature review, screening examinations for type 1 diabetes could begin at age 15 years or at 5 years after the diagnosis of DM, whichever occurs later, unless the child is judged by the endocrinologist as being at unusually high risk. Other ocular complications are identifiable through existing amblyopia screening methods.

Insulin Delivery Into the Peripheral Circulation: A Key Contributor to Hypoglycemia in Type 1 Diabetes

Hypoglycemia limits optimal glycemic control in type 1 diabetes mellitus (T1DM), making novel strategies to mitigate it desirable. We hypothesized that portal (Po) vein insulin delivery would lessen hypoglycemia. In the conscious dog, insulin was infused into the hepatic Po vein or a peripheral (Pe) vein at a rate four times of basal. In protocol 1, a full counterregulatory response was allowed, whereas in protocol 2, glucagon was fixed at basal, mimicking the diminished α-cell response to hypoglycemia seen in T1DM. In protocol 1, glucose fell faster with Pe insulin than with Po insulin, reaching 56 ± 3 vs. 70 ± 6 mg/dL (P = 0.04) at 60 min. The change in area under the curve (ΔAUC) for glucagon was similar between Pe and Po, but the peak occurred earlier in Pe. The ΔAUC for epinephrine was greater with Pe than with Po (67 ± 17 vs. 36 ± 14 ng/mL/180 min). In protocol 2, glucose also fell more rapidly than in protocol 1 and fell faster in Pe than in Po, reaching 41 ± 3 vs. 67 ± 2 mg/dL (P < 0.01) by 60 min. Without a rise in glucagon, the epinephrine responses were much larger (ΔAUC of 204 ± 22 for Pe vs. 96 ± 29 ng/mL/180 min for Po). In summary, Pe insulin delivery exacerbates hypoglycemia, particularly in the presence of a diminished glucagon response. Po vein insulin delivery, or strategies that mimic it (i.e., liver-preferential insulin analogs), should therefore lessen hypoglycemia.

Structural Changes by Spectral Domain Optical Coherence Tomography in Patients With Type 1 Diabetes Mellitus

BACKGROUND

With a possible increase in the prevalence of type 1 diabetes mellitus (DM1), the pediatric patient population is expected to be at risk for other health care complications. Current imaging modalities, such as the spectral domain optical coherence tomography (SD-OCT), that allow micron resolution imaging of the retina have become a standard of care for showing morphological changes seen in the retina in adults with diabetes. Such pathologies can be associated with known risk factors such as poor glycemic control (HbA1C) and body mass index (BMI).

METHODS

A comprehensive screening was performed in subjects with DM1 including nonmydriatic fundus imaging (Canon, CR2 Plus-AF with EOS-60D, Tokyo, Japan) and SD-OCT imaging (Optovue, iVue, Fremont, CA). SD-OCT scans were acquired showing macular thickness (MT) and thickness of the parafoveal regions and the perifoveal regions. Associations of macular, paramacular, and perimacular thickness were analyzed as a function of HbA1C and BMI by simple linear regressions.

RESULTS

SD-OCT changes were analyzed in eyes of subjects with DM1 and normal fundus appearance by color imaging. Linear regression analysis of thickness of macula right eye (RT), paramacula RT, paramacula left eye (LT), perimacula LT with BMI were statistically significant (P < .05). HbA1C >7.5% was also found statistically significant in the macula RT, paramacula RT, paramacula LT, perimacula RT, and perimacula LT. A general trend of thickening of the macula, paramacula, and perimacula was observed with increasing HbA1C (>7.5%) and increasing BMI; however, no statistical significance was found.

CONCLUSIONS

SD-OCT with retinal imaging was feasible in young individuals with DM1 and revealed ultrastructural macular and perimacular changes prior to manifest clinical disease.

Feasibility and efficacy of diabetic retinopathy screening among youth with diabetes in a pediatric endocrinology clinic: a cross-sectional study

BACKGROUND

We examined the feasibility and efficacy of using a non-mydriatic camera to screen for diabetic retinopathy (DR) among youth with type 1 or type 2 diabetes seen in a pediatric endocrinology clinic serving Alabama, the state that has the highest diabetes rate in the United States.

METHODS

236 youths with type 1 or type 2 diabetes were screened for DR using a non-mydriatic camera. Visual acuity was also assessed. A questionnaire asked parents about diabetes and eye care history.

RESULTS

Mean duration since diabetes diagnosis was 5.5 years. 66 % reported receiving an eye examination within the previous year. 97.5 % had images that were gradable. DR was detected in 3.8 % of participants. 9.1 % were visually impaired.

CONCLUSIONS

Use of a non-mydriatic fundus camera is feasible and efficacious for DR screening in youth with diabetes. DR screening at routine endocrinology visits may be beneficial in managing youth with diabetes and preventing irreversible vision loss, particularly for those in regions where diabetes rates are high.

Feasibility of retinal screening in a pediatric population with type 1 diabetes mellitus

PURPOSE

To study the feasibility of using a nonmydriatic camera to screen children with type 1 diabetes mellitus (DM1) as young as 2 years for diabetic retinopathy.

METHODS

Prospective pilot imaging study involving children with DM1 aged 2 to 17 years. The screening consisted of: (1) intake form; (2) measurement of blood pressure, pulse, and oximetry; (3) assessment of visual acuity (SIMAV, Padova, Italy); and (4) nonmydriatic color imaging (Canon CX-1 45° 15.1 megapixel camera; Canon Corp., Tokyo, Japan). Images were assessed for signs of diabetic retinopathy and graded for quality on a scale of 1 to 5 by two clinicians. Kappa coefficient was calculated to determine inter-observer agreement.

RESULTS

One hundred four of 106 (98%) children underwent imaging (mean age: 11.1 years, 51% male, 88% white). One (1%) child had nonproliferative diabetic retinopathy and 2 (1.9%) had incidental findings. Only 62% of children had an eye examination within the past year, with children with DM1 for more than 5 years significantly more likely to have done so (P = .03). Children who had an eye examination within the past year were significantly older than their counterparts (P = .01). Images of high quality (grades 4 and 5) were acquired in 178 (86%) eyes, and images of some clinical value (grades ≥ 2) were obtained in 207 (99.5%) eyes. Inter-observer agreement for image quality was 0.896.

CONCLUSIONS

The feasibility of using a nonmydriatic camera to screen children as young as 2 years for changes related to diabetic eye disease was demonstrated. Nonmydriatic imaging may supplement standard dilated clinical ophthalmology examinations for select patient populations.

Prevalence of diabetic retinopathy within a national diabetic retinopathy screening service

AIMS

Determine the prevalence and severity of diabetic retinopathy (DR) and risk factors in a large community based screening programme, in order to accurately estimate the future burden of this specific and debilitating complication of diabetes.

METHODS

A cross-sectional analysis of 91,393 persons with diabetes, 5003 type 1 diabetes and 86,390 type 2 diabetes, at their first screening by the community based National Diabetic Retinopathy Screening Service for Wales from 2005 to 2009. Image capture used 2×45° digital images per eye following mydriasis, classified by qualified retinal graders with final grading based on the worst eye.

RESULTS

The prevalence of any DR and sight-threatening DR in those with type 1 diabetes was 56.0% and 11.2%, respectively, and in type 2 diabetes was 30.3% and 2.9%, respectively. The presence of DR, non-sight-threatening and sight-threatening, was strongly associated with increasing duration of diabetes for either type 1 or type 2 diabetes and also associated with insulin therapy in those with type 2 diabetes.

CONCLUSIONS

Prevalence of DR within the largest reported community-based, quality assured, DR screening programme, was higher in persons with type 1 diabetes; however, the major burden is represented by type 2 diabetes which is 94% of the screened population.

Racial disparities in screening for diabetic retinopathy in youth with type 1 diabetes

Of 1112 children with type 1 diabetes, dilated eye exams were performed in 717 (64%). Children were less likely to be screened for diabetic retinopathy (DR) if they were black (OR=1.6; p=0.005) or had poorer diabetes control (p=0.002). Those at greatest risk for DR were least likely to be screened.

Mitigating micro-and macro-vascular complications of diabetes beginning in adolescence

Diabetes is a chronic disorder, which manifests when insulin levels or resistance to insulin action becomes insufficient to control systemic glucose levels. Although the number of available agents to manage diabetes continues to expand rapidly, the maintenance of euglycemia by individuals with diabetes remains a substantial challenge. Unfortunately, many patients with type 1 and type 2 diabetes will ultimately experience diabetes complications. These complications result from the toxic effects of chronic hyperglycemia combined with other metabolic derangements that afflict persons with diabetes. This review will present a comprehensive look at the complications of diabetes, the risk factors for their progression, the mechanistic basis for their development, and the clinical approach to screening for, preventing, and treating these sequelae. In addition, since diabetes is commonly diagnosed in childhood, we will provide a special focus on the care of the adolescent patient.

Doppler ultrasonography imaging of hemodynamic alteration of retrobulbar circulation in type 1 diabetic children and adolescents without retinopathy

AIM

We aimed to investigate the retrobulbar blood circulation using Colour Doppler Imaging (CDI) in type 1 diabetic children and adolescents who had no diabetic retinopathy and to compare the results with their healthy peers.

METHODS

Forty-nine patients with type 1 diabetes mellitus with no retinopathy on fundoscopic examination were included in the study. Forty-nine healthy children were defined as the control group. Central retinal artery (CRA), ophthalmic artery (OA) and posterior ciliary artery (PCA) were examined with Doppler US bilaterally. Peak systolic velocity (PSV), end diastolic velocity (EDV) and resistive indices (RI) for each artery were recorded.

RESULTS

Blood flow velocity of the OA was significantly different in diabetic patients (p<0.05). EDV of the OA was significantly higher (p=0.011) and RI was significantly lower (p=0.027) in patients with diabetes duration of longer than 5 years. RI of the CRA was significantly higher in patients who had higher microalbuminuria levels (p=0.016).

CONCLUSION

EDV of the OA increases and RI of the OA decreases in diabetes duration longer 5 years. Raised AER increases RI of the CRA. These findings may be the initial changes in the arterial circulation before vascular rigidity develops.