Diabetic Retinopathy Screening in Children Should Start Later

Nicola M. Parry, DVM

September 04, 2015

Vision-threatening diabetic retinopathy (DR) is rare in children, regardless of the duration of diabetes and blood glucose control, so DR screening could begin later than previously recommended, according to a new study.

Megan M. Geloneck, MD, pediatric ophthalmology and adult strabismus fellow at the Children's Hospital of Philadelphia in Pennsylvania, and colleagues published the results of their retrospective, consecutive cohort study online August 31 in Ophthalmology.

"Many of our young patients with diabetes diligently come in every year for screenings that consistently show no sign of the disease," explained study coauthor Gil Binenbaum, MD, from the Children's Hospital of Philadelphia, in a news release. "Of course, that's good news for them, and it is very important to have annual eye exams once the risk of vision loss develops. But, is it worth the burden on the family and the healthcare system if evidence shows that [DR] doesn't reach a treatable stage until years later?"

Diabetes is the leading cause of blindness among American adults aged 20 to 74 years, and it is well recognized that early detection and treatment of diabetic macular edema and proliferative DR in patients with diabetes reduces the risk for vision loss. The American Academy of Ophthalmology current guidelines therefore encourage annual DR screening examinations for all patients with type 1 diabetes to begin 5 years after diagnosis of diabetes, and the American Academy of Pediatrics guidelines suggest starting annual examinations 3 to 5 years after the diagnosis of diabetes in children or after the age of 9 years, whichever occurs later. However, in children, the prevalence of severe DR and the value of DR screening have not been clearly established.

Therefore, Dr Geloneck and colleagues aimed to investigate the prevalence and onset of ocular disease, and its risk factors, in children with diabetes, and consequently recommend a delayed screening regimen for asymptomatic children.

The researchers performed a retrospective study of 370 children younger than 18 years (mean age, 11.2 years) with type 1 and type 2 diabetes. All children had received at least one complete dilated eye examination, including dilated fundoscopy and cycloplegic refraction, between 2009 and 2013.

Children had a mean duration of diabetes of 5.2 years and a mean hemoglobin A1c level of 8.6. No children (0%; 95% confidence interval [CI], 0.0 - 1.0) had DR. Eighteen eyes of 12 children (3.3%; 95% CI, 1.5% - 5.1%) had cataract, and although nine eyes of five children required cataract extraction, the diagnosis of cataract was made after they presented with symptoms of decreased vision, not during DR screening. Nineteen children had strabismus (5.2%; 95% CI, 2.9% - 7.4%), only one of which had microvascular paralytic strabismus.

Of 41 children with high refractive error, nine members of the total study population (2.8%; 95% CI, 1.0% - 5.0%) had high myopia, nine (2.8%; 95% CI, 1.0% - 5.0%) had high hyperopia, and 23 (7.2%; 95% CI, 4.3% - 10.0%) had astigmatism in at least one eye. These conditions were not associated with diabetes duration or control.

The researchers also conducted a literature review, and among these studies, the prevalence of DR among children was reported to be between 9% and 28%. This discrepancy could be a result of differences in either baseline characteristics of the study samples or screening modalities, as well as advances in diabetes diagnosis and management over time, the authors note. Most children with DR in these studies had mild, nonproliferative DR. The youngest age at diagnosis of DR was 5.5 years, in a child with a single microaneurysm in one eye. In contrast, only five possible cases of sight-threatening DR were reported in children younger than 18 years. The earliest documented age at diagnosis of severe DR was 15 years, and the shortest duration of diabetes before developing severe DR was 5 to 6 years.

"On the basis of our study results and review of the literature, screening for ocular complications of diabetes could begin later than suggested by these [American Academy of Ophthalmology and American Academy of Pediatrics] guidelines," the authors write. "We believe that screening examinations for DR could begin at age 15 years or after 5 years of diabetes mellitus duration, whichever occurs later, with an exception made for high-risk children and type 2 diabetic children," the authors conclude.

This study was supported by the National Institutes of Health. The authors have disclosed no relevant financial relationships.

Ophthalmology. Published online August 31, 2015. Abstract

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