Type 1 diabetes

Sight threatening retinopathy upsurge in teens with poorly controlled diabetes

The emergence of sight-threatening retinopathy in teenagers with diabetes has led to calls for increased screening for those with poor glycaemic control and a young age of diagnosis.

Paediatric endocrinologists at the Children’s Hospital at Westmead, Sydney have expressed concern about a recent increase in adolescents presenting with sight-threatening retinopathy, which they say appears to be linked to factors such as poverty, obesity and a long period of exposure to poorly controlled diabetes.

A review of nine patients with sight-threatening retinopathy showed the disease progressed rapidly, with proliferative retinopathy and clinically significant macular oedema developing within two years of a previously normal examination on seven-field stereoscopic retinal photography.

The patients presenting to Westmead Hospital between 2017 and 2021 were 15–18 years old, non-Indigeous, had lived with diagnosed type 1 diabetes for over 10 years and historically had poor glycaemic control (HbA1c 86–130 mmol/mol, 10–15%), the authors wrote in Pediatric Diabetes.

Five patients developed retinopathy in the 2.5 years from normal imaging, three needed laser photocoagulation therapy and two were diagnosed with retinopathy following “improvement in diabetes control after being lost to medical follow-up” and improved their retinopathy with glycaemic control.

Led by Dr Lara Graves from the hospital’s Institute of Endocrinology and Diabetes, the authors said the series of nine cases of sight-threatening DR seen in adolescents recent years contrasted with just one case of moderate DR seen by the service in the previous two decades.

They said the increase in presentations might be related to the children with type 1 diabetes being from low socioeconomic areas and having little engagement with health services, poor treatment adherence, suboptimal glycaemic control and lack of regular retinal screening.

It was also notable that the adolescents were overweight or obese, which could increase insulin resistance. Another factor might be the rapid progression of retinopathy that leads to vision loss upon rapid glycaemic control restoration.

“Fortunately, none of our adolescents had visual loss despite their retinopathy being classified as ‘sight-threatening’,” the authors wrote.

Despite the ongoing difficulties in engaging adolescents with health services, the authors suggested that more pro-active steps be taken to encourage regular retinal screening in at-risk patients.

Much of the current screening advice for  adolescents in based on study subjects who had well controlled glycaemia, and may not be relevant to the microvascular complications in this high risk group, they said.

“Current guidelines recommend DR screening should occur every 2–5 years in patients with target glycaemic control, and some argue for screening only once during adolescence. A single retinal screen during adolescence would not be appropriate for the adolescents presented here,” they wrote.

There were also indications that the adolescents had other microvascular complications such as neuropathy and renal disease, the study authors said.

“As more children with very early onset diabetes enter mid-adolescence, we anticipate that there will be more cases of adolescent sight-threatening DR occurring here and at other sites around the world. Thus we support the recommendation that DR screening should be undertaken regularly in adolescents with suboptimal glycaemic control or diabetes duration more than 10 years as well as those from vulnerable populations,” they concluded.

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