Retinopathy in juvenile diabetes: a 10-year (1990-2000) review

Comparison of digital color fundus imaging and fluorescein angiographic findings for the early detection of diabetic retinopathy in young type 1 diabetic patients

PURPOSE

To compare the findings from digital 7-field color fundus (CF) photography and fundus fluorescein angiography (FFA) in young patients with diabetes mellitus (DM) type 1 without known diabetic retinopathy.

METHODS

In this prospective, observational cohort study, 54 type 1 diabetic patients were recruited. Participants had been diagnosed with diabetes mellitus (DM) for at least 6 years, had Best Corrected Visual Acuity of 20/25 or better and did not have any known retinal pathology. One hundred and seven eyes were analyzed. All patients underwent a complete ophthalmic examination in the Retina Service of a University Eye Clinic including digital CF imaging and FFA.

RESULTS

The mean age of the patients was 18.6 years. Mean duration of DM was 11.3 years, and mean haemoglobin A1c (HbA1c) level was 8.6%. Of the 107 eyes, 8 eyes (7.5%) showed microvascular abnormalities on CF images, while FFA images revealed changes in 26 eyes (24.3%). Hence, 18 of the 26 eyes showing abnormalities on FFA did not show any abnormalities on CF images. Mean DM duration in the patient group with detectable microvascular changes was found to be significantly higher compared to patients without changes, while no difference in HbA1c levels, serum lipid levels or blood pressure was observed.

CONCLUSIONS

Comparison of digital CF and FFA findings for the detection of diabetic microvascular changes in type 1 diabetic patients showed that FFA reveals more information about retinal vascular pathology for early detection of diabetic retinopathy.

Vitrectomy for complications of proliferative diabetic retinopathy in young adults: clinical features and surgical outcomes

PURPOSE

To investigate the clinical manifestations and surgical results after vitrectomy for proliferative diabetic retinopathy (PDR) in young patients.

METHODS

Clinical features of patients between 18 to 40 years old who received vitrectomy for PDR between January 2009 and January 2015 were retrospectively reviewed. Those older than 40 years who received vitrectomy for PDR during the same period were retrospectively enrolled and compared as the control group.

RESULTS

There were 68 eyes (52 patients) in the study group and 77 eyes (61 patients) in the control group. The average age at operation was 33.15 ± 4.92 years and 56.67 ± 7.52 years, respectively (p < 0.001). At presentation, those in the study group had significantly higher proportions of active fibrovascular proliferation and traction retinal detachment, and with significantly higher-severity gradings than those in the control group. After operation, the recurrent detachment rates were 13.2% in the study group and 1.3% in the control group (p = 0.006), and the final anatomical success rates were 91.2% in the study group and 100% in the control group (p = 0.009). The most significant risk factor for poor visual outcome in the study group was neovascular glaucoma (NVG) (p = 0.001). Patients with Type 1 and Type 2 diabetes mellitus subgroups shared similar clinical features and visual outcome.

CONCLUSIONS

Younger patients who received vitrectomy for PDR presented with more severe anatomical features at the time of vitrectomy and had a higher rate of post-operative recurrent detachment. More than 90% achieved final anatomical success. NVG was associated with worse visual outcome.

Compliance with screening guidelines for diabetic retinopathy in a large academic children's hospital in the Bronx

OBJECTIVE

As the rate of type 2 diabetes mellitus (DM) in children is increasing, the number of children with complications of DM, such as retinopathy, will also increase. American Diabetes Association and American Academy of Pediatrics guidelines recommend annual eye exams for children with type 1 DM who are older than 10 years, starting 3-5 years after diagnosis. Adolescents with type 2 DM should have an exam when diagnosed. This study was designed to determine if these guidelines are followed and to determine factors that influence providers to follow them.

PATIENTS AND METHODS

We identified all 15- to 20-year-old patients seen in a pediatric diabetes clinic over 6 months. All patients with type 2 DM and those with type 1 DM diagnosed at least 5 years prior were included. Charts were reviewed for 18 months to determine whether patients were referred for an eye exam. Data extracted included demographics, DM type, DM duration, hemoglobin A(1C), and presence of microalbuminuria.

RESULTS

Of 80 patients, 28 (35%) were referred for an eye exam. Patients with a longer duration of DM (P=.006) and those with microalbuminuria (P=.02) were more likely to be referred for screening.

CONCLUSIONS

As only 35% of the patients in this study were referred for eye exams, patients at risk for retinopathy are missing opportunities for screening and early treatment. With the increasing number of children with type 2 DM, more patients will be at risk for retinopathy and its consequences. Pediatricians and endocrinologists should be educated about referring for annual eye exams.

Juvenile diabetes eye complications and treatment

BACKGROUND/AIM

Diabetes mellitus (DM) is a metabolic disorder characterized by hyperglycemia. The aim of this study was to explore the prognosis of patients with juvenile DM regarding diabetic eye complications, as well as the course of the diabetic eye disease related to the treatment undertaken.

METHODS

The study series involved 33 patients with juvenile DM during the period 1992-2007. The influence of the following factors on the course of the disease was estimated: age, the age of the disease onset, time when eye complications appeared, treatment modalities.

RESULTS

Of the total of 33 diabetics 15 patients were followed for 10 or more years and 18 from 5 to 9 years. At the time of their first visit the mean age was 23.12 +/- 6.39 and the mean duration of DM was 17.42 +/- 7.42 years. On their first visit, 7 eyes were without any complication. Most of the patients already developed clinical signs of proliferative diabetic retinopathy (41.39%), the signs of nonproliferative diabetic retinopathy (13.13%) and macula involvement (10.10%). Diabetic cataract was found in 8.8% as well as tractional retinal detachment. Eleven out of 66 eyes were with vitreous hemorrhage. Two patients (5.5%) suffered neovascular glaucoma. There was 1 (2.2%) patient with developed rubeosis iridis and simplex glaucoma. Panretinal photocoagulation was performed in 65% of patients, focal photocoagulation in 15%, 12% patients underwent pars plana vitrectomy and 4% had cataract surgery with intraocular lens implantation and peripheral retinal kryopexy.

CONCLUSION

Total vision loss due to eye complications of juvenile DM may be prevented if timely diagnosed with regular check ups and early treatment.

Retinopathy in subjects with impaired fasting glucose: the NANSY-Eye baseline report

AIMS

Network for Pharmacoepidemiology (NEPI) Antidiabetes Study-Eye is a randomized placebo-controlled Swedish trial investigating if treatment with sulphonylurea, in addition to dietary regulation and increased exercise, delays the development of retinopathy in subjects with impaired fasting glucose (IFG).

METHODS

Subjects were surveyed in primary care with repeated fasting blood glucose measurements. Those with a mean of two consecutive values >or=5.6 and <6.1 mmol/l were invited to participate. Baseline physical examination included blood pressure and body mass index (BMI). Fundus photos were taken in two fields using 35-mm diafilm. The alternative classification of the Wisconsin Epidemiologic Study of Diabetic Retinopathy was used to classify the retinopathy level.

RESULTS

At baseline, 90 men and 64 women with IFG were photographed. Of these, 16 subjects (10%) had mild or very mild retinopathy. There was no difference in occurrence of retinopathy between subjects with known diagnosis of hypertension or not. However, subjects with retinopathy had significantly higher systolic (154 vs. 141 mmHg, p = 0.013) and diastolic (86 vs. 81 mmHg, p = 0.008) blood pressure levels independent of differences in age, sex and known hypertension. There was a corresponding difference in BMI, being greater in subjects with than in those without retinopathy (32.4 vs. 29.2 kg/m(2), p = 0.013). There were no associations between levels of fasting blood glucose or haemoglobin A1c, on the one hand, and retinopathy, on the other.

CONCLUSION

Retinopathy may be present even before type 2 diabetes is manifest. It is associated with higher blood pressure levels and higher BMI values, that is, with predominant features of the metabolic syndrome.

Are phospholipid-binding antibodies implicated in the pathogenesis of diabetic microangiopathy?

Diabetic retinopathy (DR) is a major cause of blindness in the working population of the Western world and there is no doubt that its prevalence is strongly related to the duration of diabetes and the glycemic control. However, although intensive diabetes management, with the goal of achieving near-normal glycemia, has been shown to prevent and/or delay the onset of DR, there is now ample of evidence that the development of this microangiopathy is a multifactorial process in which genetic, metabolic, haemostatic and growth factors play an important role. Moreover, given the suggestions that immunological mechanisms might have a role in the pathogenesis of diabetic microangiopathy via immune complex deposition, it has been hypothesized that antiphospholipid antibodies (A-Ab) directed against endothelial antigens could be responsible for initiating vascular injury. In particular, not only A-Ab production was found to be increased in patients with overt nephropathy or macroangiopathy but also Lupus Anticoagulant positivity, representing an intersection point between immune and haemostatic alterations, has been highlighted as a potential and additional risk factor in the pathogenesis of microangiopathy in type 1 diabetics. Moreover, given the high levels of activated protein C, endothelin-1 and thrombo-modulin that have been observed in normo-albuminuric and uncomplicated patients, it has been concluded that the vascular endothelium shifts pathologically from an antithrombotic to a prothrombotic state even in the early phases of the disease. This condition was found to be more pronounced in subjects with anticardiolipin positivity and/or high circulating immune complexes concentrations, since they possess the ability not only to induce platelet activation and aggregation but also to activate the complement system via the classical pathway. Therefore, a potential synergism between generation of autoantibodies, haemostatic alterations and endothelial stress has been suggested, a stimulating hypothesis that needs further studies to be clarified in its complexity.

Is medical treatment for diabetic retinopathy still an unreal dream?

Diabetic retinopathy is a highly specific vascular complication of both type 1 and type 2 diabetes, estimated to be the most frequent cause of new cases of blindness in the working population of the Western world. The prevalence of retinopathy is strongly related to the duration of diabetes and glycemic control, even though a multifactorial pathogenesis should be probably considered in genetically susceptible subjects. Intensive diabetes management, with the goal of achieving near-normal glycemia, has been shown to prevent and/or delay the onset of diabetic retinopathy and laser photocoagulation has an established clinical efficacy in preventing visual loss. However, as laser scars always destroy the retinal anatomy permanently, a medical approach to nonproliferative retinopathy should be preferred if its clinical efficacy could be demonstrated. In this paper, recently published reports supporting this hypothesis are reviewed and their conclusions critically discussed.