Retinopathy screening guidelines may be inadequate for kids with diabetes

Paul Basilio, MDLinx | February 23, 2017

Current screening guidelines may be inadequate to catch blindness and other problems in children and teenagers with diabetes, according to a new study published in Ophthalmology.

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Current guidelines may offer a missed opportunity to detect diabetic retinopathy early and preserve sight.

Guidelines suggest that ophthalmic screening should begin 3 to 5 years after an initial diabetes diagnosis, but the study results indicated that more than 18% of those with type 1 diabetes had already received a diagnosis of diabetic retinopathy by then.

The large, national study led by the University of Michigan Kellogg Eye Center showed that more than 1 in 5 youths with type 1 diabetes and 7% with type 2 diabetes have a diagnosis of diabetic retinopathy. Children as young as 6 years of age had been diagnosed with proliferative diabetic retinopathy, the more advanced form of the disease.

“There is a perception that diabetic retinopathy is very uncommon in youth, but there’s reason to believe they are at considerable risk,” according to Sophia Y. Wang, MD, a resident physician at Kellogg Eye Center and the study’s lead author.

In the past, the majority of children who kept track of their blood glucose did so because of a diagnosis of type 1 diabetes. However, type 2 diabetes now accounts for nearly half of all new diabetes cases among adolescents—an increase concurrent with the rise of obesity and inactivity among kids.

The researchers wanted to know more about the risk factors for diabetic retinopathy in this age group, and whether screening guidelines would adequately catch signs of diabetic retinopathy in time to preserve a child’s sight.

Results showed that those with uncontrolled blood glucose on HbA1c testing were at risk of jeopardizing their vision. For every 1-point increase in HbA1c, the risk for diabetic retinopathy increased 20% for those with type 1 diabetes, and 30% in those with the type 2 form.

The results are troubling, according to the study’s authors. They represent a missed opportunity to detect diabetic retinopathy in its early stages and to prevent irreversible retinal damage and preserve sight.

Timing is everything

Wang and her co-authors, including Joshua Stein, MD, MS, an associate professor of ophthalmology at the University of Michigan Medical School, suggest that more research is needed to better understand the ideal timing of screening.

“We hope our study will help inform pediatricians and other health care providers who care for youth with diabetes about the importance of referrals to an ophthalmologist or optometrist to check for retinopathy,” said Dr. Stein, who is also the director of the Center for Eye Policy and Innovation.

The checks should happen at least as often as the current guidelines suggest, but high-risk groups may benefit from earlier screening.

Dr. Stein noted that as more adolescents are diagnosed with diabetes, new ways to monitor them for diabetic eye problems should be developed that are convenient for patients and their parents. He suggested that telemedicine appointments, in which eye specialists can examine patients remotely or evaluate digital images that were taken during a primary care appointment, may be indicated.

The Michigan Medicine research team also included statistician Chris A. Andrews, PhD, William H. Herman, MD, MPH, professor of endocrinology, and Thomas W. Gardner, MD, MS, professor of ophthalmology. Stein and Herman also hold joint appointments in the U-M School of Public Health.

Funding for the research was provided by Research to Prevent Blindness, W.K. Kellogg Foundation, Juvenile Diabetes Research Foundation, the Taubman Institute, Michigan Diabetes Research Center, and the Janssen Research Foundation.

The data from the study was from the Clinformatics Data Mart created for Optum Inc. and includes information from people enrolled in a nationwide managed care organization from 2001 to 2014.

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