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Diabetic retinopathy screenings unnecessary for young children
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The low prevalence of diabetic retinopathy among children with type 1 diabetes aged 12 or 13 years indicates that screenings for younger children are not necessary, according to an analysis of retinopathy screening programs in the United Kingdom.
“The low prevalence and incidence rates in this large cohort of children suggest that earlier screening for sight-threatening diabetic retinopathy is not necessary in this age group,” Peter H. Scanlon, MD, of the Gloucestershire Retinal Research Group, and colleagues wrote. “There may be value in detecting diabetic retinopathy at a mild stage, but only if it could be shown that closer follow-up in this at-risk group could reduce the progression rate and the development of complications in these children.”
Scanlon and colleagues analyzed data from 2,125 children aged 12 or 13 years with type 2 diabetes participating in one of seven diabetic retinopathy screening programs in the United Kingdom. Researchers assessed grading results at first screen and age at diabetes diagnosis. Screening data from both eyes were combined to categorize children as having no diabetic retinopathy; mild nonproliferative diabetic retinopathy in one eye; mild nonproliferative diabetic retinopathy in both eyes; or referable diabetic retinopathy. Researchers used Cox proportional hazard models to estimate HRs for diabetic retinopathy in children by duration of diabetes at first screening.
Among children diagnosed with type 1 diabetes at age 2 years or younger, 20.1% had any signs of retinopathy; 11% had mild nonproliferative diabetic retinopathy in both eyes. Among children diagnosed with type 1 diabetes at age 10 years, 6.3% of children had any signs of retinopathy; 0.7% had mild nonproliferative diabetic retinopathy in both eyes.
Within the cohort, three children were reported as having referable retinopathy at first screening, aged 8, 10 and 11 years at diagnosis of diabetes. Two of the three children had nonreferable diabetic retinopathy at all subsequent screenings, according to researchers.
Of 1,703 children with subsequent images, 25 were graded as having sight-threatening or referable diabetic retinopathy during a mean follow-up of 3.1 years, three of whom were graded as having proliferative diabetic retinopathy. In Cox proportional hazard model analysis, researchers found that children with a longer diabetes duration at baseline screening at age 12 or 13 years were at a higher risk for progression to referable diabetic retinopathy (HR = 1.36; 95% CI, 1.2-1.53).
The researchers noted that the findings support current U.K. recommendations, which call for yearly screenings for children aged at least 12 years with type 1 diabetes.
“Although 10% of children have some retinopathy at baseline screening at the age of 12 to 13 years, only three children (0.17%) were graded as having sight-threatening diabetic retinopathy,” the researchers wrote. “Of the three we identified, it seems likely that none required treatment, because only one case was consistently diagnosed as sight-threatening and this was pre-proliferative diabetic retinopathy, which does not normally require laser treatment.” – by Regina Schaffer
Disclosure: The NHS Diabetic Eye Screening Program and Scottish Diabetes Retinal Screening Program funded this study. The researchers report no relevant financial disclosures.
Perspective
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Zachary T. Bloomgarden
Literature supports in both with type 1 and type 2 diabetes that diabetic retinopathy risk is particularly an issue in people with longer-standing disease, and many pediatricians have suggested that annual screenings for children may not be necessary. A reasonable alternative approach, is to use the 5-year cut-off period to do a retinal exam and then, with negative exam, follow up after 2 or 3 years. Much more data in adults with than in children show that those individuals who have no retinopathy at baseline have about 1% annual likelihood of developing retinopathy, while those with baseline nonproliferative retinopathy (not threatening in itself) have five to six times greater rates of developing retinal abnormality requiring treatment. A reasonable approach for children then may be to examine at 5 years and then at 2 or 3 year intervals unless evidence of retinal vascular abnormality is found. Additionally, individuals with poor glycemic control and/or evidence of other diabetes complications, particularly renal (for which urine microalbumin and serum creatinine screening are useful) have higher risk for developing diabetic retinopathy and might benefit from annual eye examination.
Disclosure: Bloomgarden reports consulting for Astra Zeneca, Intarcia, Johnson & Johnson, Merck and Novartis; speaking for Astra Zeneca, Johnson & Johnson and Merck; and holding stock in Allergan, Novartis, Pfizer and Zimmer Biomet.
Blake Cooper
Current guidelines uniformly recommend that people with type 1 diabetes have annual screenings for diabetic retinopathy beginning 5 years after the onset of their disease. For type 2 diabetes, the recommendation is for yearly screenings, immediately following diagnosis. Yet in this new study, the researchers conclude that due low prevalence of diabetic retinopathy among children with type 1 diabetes aged 12 or 13 years, screenings for younger children are not necessary.
While the researchers conclude that screening exams prior to the onset of puberty my not be necessary due to the lack of visually significant retinopathy, I would caution providers of the need for annual exams after puberty. Currently, only about 60% of people with diabetes (type 1 and 2) have yearly screenings for diabetic retinopathy. Early detection of retinopathy depends on educating patients and health care providers about the importance of regular eye examinations even though the patient may be asymptomatic. Patients must be informed that they may have good vision and no ocular symptoms, but that they may still have significant disease that needs treatment. They should be educated that early treatment works best, and that is why they need to return for an annual eye examination, even when their vision is good. Remember that proper medical care is habit forming, and screening exams will save many patients from serious treatable eye conditions.
Disclosure: Cooper reports no relevant financial disclosures.
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