Occurrence of diabetic retinopathy in children with type 1 diabetes mellitus

INTRODUCTION

Diabetes is a chronic, complex condition necessitating regular medical management with multifaceted strategies for risk reduction beyond glycaemic control. According to the World Health Organization, global diabetes prevalence has escalated from 108 million to 422 million in 1980–2014.^[1]

Type 1 diabetes mellitus (T1DM) accounts for approximately 5–10% of all diabetes cases, resulting from the autoimmune destruction of pancreatic beta cells, with around three-quarters of diagnoses occurring in individuals under the age of 18.^[2]

It is estimated that nearly 5 lakh children under 15 years old worldwide have type 1 diabetes, with significant regional variations in incidence.^[3]

Diabetic retinopathy (DR), a microvascular complication associated with diabetes mellitus (DM), results from damage to the retinal capillaries and venules, making it the most prevalent microvascular condition amongst children with type 1 diabetes.^[4]

Nearly all individuals with type 1 diabetes will eventually develop DR, with approximately 25% affected within 5 years of diagnosis, 60% within 10 years, and 80% within 15 years. After 15 years, around 18% of patients may progress to proliferative DR.^[5]

The global incidence of diabetes has steadily risen over recent decades across all age groups, including youth, and this trend is projected to continue.^[6]

This study aims to highlight the significance of DR occurrence in individuals with T1DM, which will, in turn, support the development of effective screening and management strategies for these conditions.

MATERIAL AND METHODS

RESULTS

The study investigated 54 children with T1DM to evaluate several aspects, including age, gender, duration of diabetes, glycaemic control and the prevalence of DR [Table 1].

A majority of the participants (51.9%) were within the 11–15-year age range, while 25.9% were aged 16–18 years. The average age of the sample was 12.72 years, with no statistically significant difference observed between females and males (P = 0.532). The cohort comprised an equal distribution of females and males, each representing 50.0% of the total sample.

The most common age of onset for diabetes was between 6–10 years and 11–15 years, with each age group representing 38.9% of the cases. The mean age of diagnosis of T1DM was 8.87 years. A significant percentage of the children (79.6%) had been living with diabetes for 1–5 years, with an average duration of 3.85 years [Chart 1].

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Chart 1:

Multiple bar diagram represents age and sex-wise distribution of children.

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A significant majority (83.3%) of the children exhibited HbA1c levels ≥8.5%, reflecting inadequate glycaemic control. The mean HbA1c level across the group was 10.6% [Chart 2].

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Chart 2:

Pie diagram represents level of glycated haemoglobin (HbA1c)-wise distribution.

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No signs or symptoms of retinopathy were reported amongst the entire cohort. However, 3.7% of the participants were diagnosed with DR. The majority (96.3%) displayed normal findings upon fundoscopy [Table 2].

A statistically significant relationship was identified between elevated HbA1c levels and the presence of DR (P = 0.011), with children exhibiting retinopathy showing a notably higher mean HbA1c of 13.60%. Furthermore, a significant correlation was established between the duration of diabetes and the occurrence of retinopathy (P = 0.023). Children with retinopathy had a longer average duration of diabetes (7.33 years) compared to those without retinopathy [Table 3].

In conclusion, the study indicates that while the prevalence of DR in children with T1DM is relatively low, poor glycaemic control and longer diabetes duration are significantly associated with the development of DR.

DISCUSSION

In this cross-sectional study of 54 patients with T1DM, we examined the impact of glycaemic control and diabetes duration on the prevalence of DR over 18 months. The study found a 3.7% prevalence of DR, with significant associations between higher HbA1c levels and longer diabetes duration. Our cohort was evenly split by gender, with 27 males and 27 females, contrasting with other studies such as those by Ferm et al.,^[4] Shibeshi et al.^[2] and Porter et al.,^[6], where as Rajguru et al.^[7] had male prevalence, which reported a higher female prevalence [Table 4].

The mean age diagnosis of diabetes in our study was 8.87 years, aligning closely with Ferm et al.^[4] findings but lower than the mean ages reported by Zabeen et al.^[8] and Shibeshi et al.^[2] The mean duration of diabetes was 3.85 years, which is shorter compared to Ferm et al.^[4] and Shibeshi et al.^[2] findings [Table 5].

This study observed a mean HbA1c of 10.6%, reflecting poorer glycaemic control relative to other studies like those by Ferm et al.,^[4] Zabeen et al.,^[8] Porter et al.^[6] and Strul et al.^[9] [Table 6].

In patients with DR, the mean HbA1c was significantly higher at 13.6%, a result consistent with Ferm et al.^[4] and Porter et al.^[6] studies. The mean duration of DM amongst these patients was 7.3 years, which aligns with Zabeen et al.^[8] and indicates that both extended diabetes duration and elevated HbA1c levels are significant risk factors for DR. These findings emphasise the critical role of maintaining stringent glycaemic control to mitigate the risk of retinopathy in paediatric T1DM patients.

CONCLUSION

The current study demonstrates a relatively low incidence of DR amongst children with diabetes. It underscores the significance of diabetes duration and HbA1c levels as contributing factors in Indian paediatric patients. Optimal glycaemic control is highlighted as crucial in mitigating the onset and progression of DR in young diabetics. Given the chronic nature of diabetes and the heightened risk of DR with prolonged disease duration, ensuring stringent glycaemic control is imperative as the primary and most effective measure to prevent or delay retinal complications. In addition to counselling for improved diabetes management, both young patients and their caregivers should be educated about the risks associated with DR and its potential vision-threatening consequences. Healthcare institutions and governmental bodies are encouraged to initiate extensive educational campaigns and screening initiatives, particularly amongst minority groups and rural populations.