Vascular complications

Diabetic eye disease

Retinopathy

• Diabetic retinopathy remains the most common cause of acquired blindness in young and older adults
• Early retinopathy is asymptomatic but may be detected by sensitive methods (e.g. fundus photography or fluorescein angiography) in a large proportion of young people with diabetes duration of more than 10 years

Types of retinopathy

Early or background retinopathy

• Microaneurysms
• Hemorrhages
• Hard and soft exudates
• Intra-retinal microvascular abnormalities (IRMA)

Vision-threatening retinopathy

• Macular edema (rare in children)
• Pre-proliferative retinopathy (vascular obstruction, progressive IRMA, infarctions of the retinal nerve fiber layer causing cotton wool spots)
• Proliferative retinopathy (new vessel formation of retina and/or vitreous posterior surface). New vessel formation is responsible for further retinal and vitreous hemorrhage, fibrous reactions and subsequent retinal detachment

Recommended screening procedures

• Clinical examination of the eyes and ophthalmoscopy should be performed soon after diagnosis to exclude cataract formation or other disorders. At this early stage, ophthalmoscopy provides the added educational opportunity of linking good control with prevention of eye problems. Expert ophthalmological advice should be sought if the examination is not entirely normal
• Visual acuity will usually be determined at times of expert eye examination to rule out refractive and other errors not necessarily associated with diabetes itself

• Screening for retinopathy by ophthalmoscopy is not a sensitive method of screening for retinopathy and there are few data to support its effectiveness. It is best performed through pharmacologically dilated pupils by a trained observer (diabetologist, specialist nurse, optometrist or ophthalmologist)
• Fundus photography (preferably stereoscopic several field views through dilated pupils) has been shown to be a safe, non-invasive and sensitive screening procedure. Photography has the advantage over simple ophthalmoscopy of providing a hard copy capable of being compared with subsequent photographs and transferable to other clinics

Age of retinopathy screening Prepubertal onset of diabetes: 5 years after onset or at age 11 years, or at puberty (whichever is earlier), and annually thereafter Pubertal onset of diabetes: 2 years after onset, and annually thereafter

Further retinopathy monitoring

• Progression of retinopathy to more than 10 microaneurysms
  Recommend
  evaluation by experts in interpreting retinal photographs and ophthalmological management
  
• Advanced background retinopathy, macular edema or proliferative changes
  Recommend
  immediate referral for expert ophthalmological management

Prevention and intervention

• Improve BG control
• Strongly discourage smoking
• Encourage healthy exercise
• Monitor microalbuminuria and blood pressure as these complications are associated with retinopathy in adolescents
• Ophthalmological management: laser photocoagulation is effective in preventing visual loss in proliferative retinopathy; focal laser photocoagulation is beneficial in eyes with macular edema

• There is evidence that angiotensin-converting enzyme (ACE) inhibitor treatment should be considered in progressive retinopathy
• Tight metabolic control after prolonged unsatisfactory control may worsen retinopathy initially, followed by later benefits in reducing the risks of further progression of retinopathy

Other eye complications

• Cataracts have been described very soon after the onset of diabetes. They are rare but may occur more often in adolescents with a long history of polyuria before diagnosis. Cataracts later in diabetes are a consequence of prolonged poor metabolic control
• Refractive errors and blurring of vision occur during major changes in glycemia (e.g. following prolonged hyperglycemia before diagnosis and during stabilization). They are usually transient
• Glaucoma and other eye diseases are rare in the pediatric age group