Risks and management of diabetic retinopathy in paediatric patients

Ophthalmology Times EuropeOphthalmology Times Europe January / February 2021
Volume 17
Issue 1

Diabetes mellitus, which is a common chronic disease in children, can lead to significant eye morbidities with long-lasting effects, including diabetic retinopathy. Treatment should be tailored to the individual patient.

little girl getting eye exam

Diabetes mellitus (DM) is a metabolic disease of high glucose levels or poor glucose utilisation that leads to significant morbidity, particularly kidney, eye, heart and cerebrovascular disease, and premature mortality.1-3 Type 1 diabetes is one of the most common chronic diseases in children and represents a global public health challenge;4,5 the prevalence of type 2 diabetes ranges from 1 to 51 per 1,000.6,7

Although children and adolescents with type 1 diabetes are threatened daily with acute complications of hypoglycaemia and ketoacidosis, it is the long-term microvascular and macrovascular complications of the disease that place them at the greatest risk of serious morbidity and early mortality.8

Diabetic eye disease in the young

DM can affect any ocular tissue, although the retinal microvascular changes of diabetic retinopathy (DR) are thought to be the most important long-term complication.1,2 DR, which can occur in all types of DM, can have a debilitating effect on visual acuity and ultimately lead to blindness in some cases.1-3,9

The risk for and time to develop DR is variable, but it may already be present at the time of DM diagnosis. A Danish prospective cohort study that followed children and adolescents with type 1 DM for 8 years reported the prevalence of any level of DR as 17.7% in children aged 12–15 years and 45.4% in the 16–20 years age group, increasing to 67.6% after 20 years.10 Recent reports from the UK11 and Canada12 confirmed that DR was variable but uncommon before 12 years of age.

Specifically, mild DR occurred in 10% of UK children at 12–13 years; only 0.17% had sight-threatening DR.11 A multicentre study based in north-west England reported a DR prevalence of 11% in children with T1 DM.11,13 Of these, 44% had background DR whilst 56% had pre-proliferative DR, with early age at diagnosis and poor metabolic control as independent risk factors.13

Shibeshi et al. reported a DR prevalence in children in Ethiopia of 4.7% including two individuals who had maculopathy associated with vision loss.14 A recent study from the United States in young people reported an incidence of DR in 20.1% and 7.2% over a median period of 3.2 years in type 1 diabetes and 3.1 years in type 2 DM.15

DR risk depends on age at DM onset or diagnosis, duration of disease16,17 and glycaemic control.10,18,19 A population-based study from Australia reported that 24% of children and adolescents with type 1 diabetes developed DR after 6 years of DM;16 a similar study in Sweden reported a DR incidence of 27%20 after 13 years of DM. Prepubertal DM duration is strongly associated with the development of DR.10



The general management of DM in young patients has improved recently, supported by advancing technology. The development of insulin pumps, digital technology and outcome analyses have led to significant improvements in glycaemic control.21

Control of blood pressure and serum lipids is also necessary. Close working with diabetologists as well as renal paediatricians is important in achieving the best outcomes.


The current UK guidance is for annual screening from 12 years and above, based on the low prevalence of DR in younger children.22 A close check should be kept on patients younger than 12 by the diabetologist and appropriate referrals to the Eye Clinic effected as necessary.

The American Academy of Ophthalmology recommends that annual eye examinations in children should start 3–5 years after the diagnosis of type 1 DM.23 The International Diabetes Federation/International Society for Pediatric and Adolescent Diabetes guideline from 2017 recommends that eye examinations for children with type 1 DM commence at 11 years of age and after 2 years of DM duration; in children with type 2 DM, screening should commence from diagnosis.24

In populations where DR onset is earlier or more common in children, screening programmes should be appropriately directed at the vulnerable population. Evaluation for other eye changes may be initiated by paediatric diabetes teams as appropriate.

Colour fundus photographs have traditionally been used to document DR. Optical coherence tomography (OCT) and OCT angiography (OCTA) are non-invasive state-of-the-art imaging techniques that are very useful in evaluating the status of the macula and specifically in quantifying diabetic macular oedema (DMO).25,26 Recently, the advent of spectral domain OCT has allowed diabetic neurodegeneration to be identified, which is thought to precede clinical DR detection.25-27


Unfortunately, the literature on treatment of DR in the young is limited because clinical trials for DR treatments recruit participants aged 18 years or older. The standard treatment for focal DMO located more than 500 microns from the foveal avascular zone edge is focal laser photocoagulation, as per the ETDRS protocol. However, laser photocoagulation should be avoided in diffuse oedema.

Where the DMO is diffuse, or patient cooperation unlikely, pharmacotherapy is more appropriate. Vascular endothelial growth factor (VEGF) blockage through intravitreal injections of anti-VEGF agents is now well established as a treatment for DMO in adults,28 although its safety and efficacy has not been established in children and adolescents. Some limited data on the use of ranibizumab (Lucentis, Genentech/Roche) for the treatment of choroidal neovascularisation in patients between the ages of 12 and 17 years showed that it was well tolerated.29

Similarly, no data exist for use of intravitreal steroids in DMO in the young, although non-randomised study data exist for dexamethasone in non-infectious uveitis in a similar age group.30-32 As intravitreal steroids are cataractogenic, their use in young diabetic patients is best avoided. However, it may be reasonable in older children if the DMO is unresponsive to other therapies, or if a young diabetic patient has to undergo cataract surgery.

It has been suggested that blockage of the renin–angiotensin system withangiotensin-converting enzyme (ACE) inhibitors even in the absence of hypertension may slow progression of DR,33 although this was not supported in a study of adolescent diabetics.34 In summary, as there are limited trial data to guide treatment decisions in young patients, treatments for DR in this patient group should be individually tailored.


Prof. Winfried Amoaku, FRCS, FRCOphth, PhD, AFHEA
E: winfried.amoaku@nottingham.ac.uk
Prof. Amoaku is an associate professor/reader in Ophthalmology and honorary consultant ophthalmologist, based in Academic Ophthalmology and Visual Sciences, Division of Clinical Neurosciences, in the Faculty of Medicine and Health Sciences at the University of Nottingham, UK. He has no financial disclosures related to the content of this article to report.


  1. Ciulla TA, Amador AG, Zinman B. Diabetic retinopathy and diabetic macular edema: pathophysiology, screening, and novel strategies. Diabetes Care. 2003;26:2653-2664.
  2. Gardner TW, Gabbay RA. Diabetes and obesity – a challenge for every ophthalmologist.Arch Ophthalmol. 2009;127:328-329.
  3. Mayer-Davis EJ, Kahkoska AR, Jefferies C, et al. ISPAD Clinical Practice Consensus Guidelines 2018: Definition, epidemiology, and classification of diabetes in children and adolescents. Pediatr Diabetes. 2018;19(suppl 27):7-19.
  4. Dabelea D, Mayer-Davis EJ, Saydah S, et al. Prevalence of type 1 and type 2 diabetes among children and adolescents from 2001 to 2009. JAMA. 2014;311:1778-1786.
  5. Mayer-Davis EJ, Lawrence JM, Dabelea D, et al. Incidence trends of type 1 and type 2 diabetes among youths, 2002–2012. N Engl J Med. 2017;376:1419-1429.
  6. Fagot-Campagna A, Pettitt DJ, Engelgau MM, et al. Type 2 diabetes among North American children and adolescents: an epidemiologic review and a public health perspective. J Pediatr. 2000;136:664-672.
  7. Pulgaron ER, Delamater AM. Obesity and type 2 diabetes in children: epidemiology and treatment. Curr Diab Rep. 2014;14:508.
  8. Sochett E, Daneman D. Early diabetes-related complications in children and adolescents with type 1 diabetes. Implications for screening and intervention. Endocrinol Metab Clin North Am. 1999;28:865-882.
  9. Sayin N, Kara N, Pekel G. Ocular complications of diabetes mellitus. World J Diabetes. 2015;6:92-108.
  10. Olsen BS, Sjølie AK, Hougaard P, et al. The significance of the pre-pubertal diabetes duration for the development of retinopathy and nephropathy in patients with type 1 diabetes. J Diabetes Complications. 2004;18:160-164.
  11. Scanlon PH, Stratton IM, Bachmann MO, et al. Risk of diabetic retinopathy at first screen in children at 12 and 13 years of age.Diabet Med. 2016;33:1655-1658.
  12. Abdella K, McReelis KD, Strungaru MH. Diabetic retinopathy screening in a Canadian community pediatric diabetes clinic. Can J Ophthalmol. 2019;54:27-32.
  13. Ng SM, Ayoola OO, McGuigan MP, Chandrasekaran S. A multicentre study evaluating the risk and prevalence of diabetic retinopathy in children and young people with type 1 diabetes mellitus. Diabetes Metab Syndr. 2019;13:744-746.
  14. Shibeshi MS, Fantahun B, Kebede T, Tilahun B. Pediatric diabetic retinopathy: experience of a tertiary hospital in Ethiopia. BMC Res Notes. 2016;9:116.
  15. Wang SY, Andrews CA, Herman WH, et al. Incidence and risk factors for developing diabetic retinopathy among youths with type 1 or type 2 diabetes throughout the United States. Ophthalmology. 2017;124:424-430.
  16. Donaghue KC, Craig ME, Chan AK, et al. Prevalence of diabetes complications 6 years after diagnosis in an incident cohort of childhood diabetes. Diabet Med. 2005;22:711-718.
  17. Pinhas-Hamiel O, Zeitler P. Clinical presentation and treatment of type 2 diabetes in children. Pediatr Diabetes 2007;8(suppl. 9):16-27.
  18. Holl RW, Lang GE, Grabert M, et al. Diabetic retinopathy in pediatric patients with type-1 diabetes: effect of diabetes duration, prepubertal and pubertal onset of diabetes, and metabolic control. J Pediatr. 1998;132:790-794.
  19. Massin P, Erginay A, Mercat-Caudal I, et al. Prevalence of diabetic retinopathy in children and adolescents with type-1 diabetes attending summer camps in France.Diabetes Metab. 2007;33:284-289.
  20. Nordwall M, Hyllienmark L, Ludvigsson J. Early diabetic complications in a population of young patients with type 1 diabetes mellitus despite intensive treatment. J Pediatr Endocrinol Metab. 2006;19:45-54.
  21. Prahalad P, Tanenbaum M, Hood K, Maahs DM. Diabetes technology: improving care, improving patient-reported outcomes and preventing complications in young people with Type 1 diabetes. Diabet Med. 2018;35:419-429.
  22. National Institute for Health and Care Excellence (NICE). Diabetes in children and young people: diagnosis and management of type 1 and type 2 diabetes in children and young people. 2015. Available at https://www.nice.org.uk/Guidance/InDevelopment/gid-cgwaver118. Last accessed 1 October 2020.
  23. American Academy of Ophthalmology Retina Panel. Preferred Practice Pattern Guidelines. Diabetic Retinopathy. San Francisco: American Academy of Ophthalmology, 2012.
  24. International Diabetes Federation/International Society for Pediatric and Adolescent Diabetes (IDF/ISPAD). Global IDF/ ISPAD guideline for diabetes in childhood and adolescence. Available at http://www.idf.org/sites/default/files/Diabetes-in-Childhood-and-Adolescence-Guidelines.pdf Last accessed 30 October 2020.
  25. Tekin K, Inanc M, Kurnaz E, et al. Quantitative evaluation of early retinal changes in children with type 1 diabetes mellitus without retinopathy. Clin Exp Optom. 2018;101:680-685.
  26. Mameli C, Invernizzi A, Bolchini A, et al. Analysis of retinal perfusion in children, adolescents, and young adults with type 1 diabetes using optical coherence tomography angiography. J Diabetes Res. 2019;2019:5410672.
  27. El-Fayoumi D, Badr Eldine NM, Esmael AF, Ghalwash D, Soliman HM. Retinal nerve fiber layer and ganglion cell complex thicknesses are reduced in children with type 1 diabetes with no evidence of vascular retinopathy. Invest Ophthalmol Vis Sci. 2016;57:5355-5360.
  28. Amoaku WM, Ghanchi F, Bailey C, et al. Diabetic retinopathy and diabetic macular oedema pathways and management: UK Consensus Working Group. Eye (Lond). 2020;34(suppl 1):1-51.
  29. Lucentis® 10 mg/ml solution for injection SmPC. https://www.medicines.org.uk/emc/product/307/smpc.
  30. Lei S, Lam WC. Efficacy and safety of dexamethasone intravitreal implant for refractory macular edema in children. Can J Ophthalmol. 2015;50:236-241.
  31. Sella R, Oray M, Friling R, et al. Dexamethasone intravitreal implant (Ozurdex®) for pediatric uveitis. Graefes Arch Clin Exp Ophthalmol. 2015;253:1777-1782.
  32. Ratra D, Barh A, Banerjee M, et al. Safety and efficacy of intravitreal dexamethasone implant for refractory uveitic macular edema in adults and children. Ocul Immunol Inflamm. 2018;26:1034-1040.
  33. Chiang JL, Maahs DM, Garvey KC, et al. Type 1 diabetes in children and adolescents: a position statement by the American Diabetes Association. Diabetes Care. 2018; 41(9):2026-2044.
  34. Marcovecchio ML, Chiesa ST, Bond S, et al. ACE inhibitors and statins in adolescents with type 1 diabetes.N Engl J Med. 2017;377:1733-1745.
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