Emerging Complications: Diabetic Retinopathy

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Emerging ComplicationsDiabetic Retinopathy

• Irl B. Hirsch, M.D.
• University of Washington

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Natural History
Pittsburgh Epidemiology of Diabetes
Complications Study

• 657 type 1 patients diagnosed between 1950 and
  1980 with mean duration of 20 years
• NPDR universal after 20 years duration
• PDR present in 70 after 30 years duration
• With shorter durations, PDR more prevalent in
  females

Orchard TJ et al Diabetes 1990391116-24
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Natural History
Pittsburgh Epidemiology of Diabetes
Complications Study

• The prevalence of retinopathy and overt
  nephropathy in 552 White T1 subjects mean DM
  duration 20.8 yr was significantly greater in
  subjects diagnosed during puberty compared with
  those diagnosed before puberty.

Kolstraba JN et al Diabetes Care. 198912686-9
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Natural History
Pittsburgh Epidemiology of Diabetes
Complications Study

• Results concerning the risk of diabetes-related
  mortality in a cohort of 1582 subjects (mean
  duration 12.9 yr) indicated that postpubertal
  duration of T1DM may be a more accurate
  determinant of the development of microvascular
  complications and diabetes-related mortality than
  total duration, and it is suggested that the
  contribution of the prepubertal years of diabetes
  to long-term prognosis may be minimal.

Kolstraba JN et al Diabetes Care. 198912686-9
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Major Question RE PDR and T1DM
When does the clock start ticking?
Does pre-pubertal status protect against DR? How
does puberty impact duration of diabetes for
teens and young adults?
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German Registry Study
University of Ulm

• N441, median age 15.5 years, median duration
  DM 6.3 years
• 19 BID NPH/REG 42 TID injections, 40 QID
  injections
• Shortest duration prior to Dx of NPDR was 2.2
  years
• Youngest child with NPDR 5.5 years old

Holl RW, et al J Pediatr 199813279--794
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German Registry Study

• Life table analysis revealed a median duration of
  16.6 years until the occurrence of early DR

Holl RW, et al J Pediatr 199813279--794
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German Registry Study
Pubertal Duration

• Comparing children with onset before to
  during/after puberty, those with pre-pubertal Dx
  developed DR a median of 10.9 years after puberty
  compared to 15.1 years with pubertal onset of DM

Holl RW, et al J Pediatr 199813279--794
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German Registry Study

• Good glycemic control (A1C lt 7.5) delayed the
  onset of DR by about 3 years

NOTE DR was generally not prevented by good
control
Holl RW, et al J Pediatr 199813279--794
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German Registry Study

• Pre-pubertal glycemic exposure does not protect
  against DR
• Metabolic control should be attempted
  irrespective of age

Holl RW, et al J Pediatr 199813279--794
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Ophthalmology 19931001125-31
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Missouri DR Data

• N420 with onset lt 20 years of age enrolled
  between 1979 and 1988
• Annual stereo fundus photographs
• Results
• No DR before 2 years in anyone
• 50 by 9 years DM duration
• 100 by 20 years duration
• DR developed 2 years sooner in females, but no
  difference when considering pubertal status

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Missouri PDR Data

• PDR developed in 11 patients
• Higher A1C with PDR (10.9 vs. 8.6)
• The higher the A1C, the sooner PDR detected

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Missouri DR Data Conclusions

• Long-term glycemic control impacts both the
  appearance and the progression of DR
• Prepubertal duration of diabetes is a significant
  risk factor for the development of DR

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What About Screening of DR in Youth

• 667 children and adolescents at the Childrens
  Hospital at Westmead, Sydney Australia
• DR in lt 11 years old
• 16 baseline 1-2 years later, regressed in 80,
  progressed in none
• DR in gt 11 year olds
• 22 baseline 1-2 years later, regressed in 36,
  progressed in 13

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Screening of DR in Diabetic Youth
Risk of DR progression in children lt 11 years of
age
Maguire A et al. Diabetes Care 200528 509-13
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Screening of DR in Diabetic Youth
Risk of DR progression in children gt 11 years of
age
Maguire A et al. Diabetes Care 200528 509-13
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Screening of DR in Diabetic Youth

• In the highest risk group (gt 10 years duration DM
  with A1C at any screening gt 10) DR progressed
  significantly after 2 years but not until after 3
  years in the group whose A1C was always lt 10
• Although patients with diabetes gt 10 years were lt
  likely to have an improvement of their DR after 1
  year, there was no increase in DR at 1 year
  follow-up

Maguire A et al. Diabetes Care 200528 509-13
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Screening of DR in Diabetic Youth

• These studies suggest that adolescents in
  reasonable metabolic control could safely be
  screened every 2 years instead of the current
  yearly recommendation
• In younger children the next screening could be gt
  2 years later
• Those with poor control (A1C gt 10), duration gt
  10 years, or significant DR should be screened
  more frequently

Maguire A et al. Diabetes Care 200528 509-13
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Current ADA Recommendations

• 1. Adults and children aged 10 years or older
  with type 1 diabetes should have an initial
  dilated and comprehensive eye examination by an
  ophthalmologist or optometrist within 5 years
  after the onset of diabetes. (B)
• 2. Subsequent examinations for type 1 and type 2
  diabetic patients should be repeated annually by
  an ophthalmologist or optometrist. Less frequent
  exams (every 23 years) may be considered
  following one or more normal eye exams.
  Examinations will be required more frequently if
  retinopathy is progressing. (B)

Diabetes Care 33 (Suppl 1) S11-61, 2010