The American Academy of Pediatrics (AAP), in conjunction with the American Association for Pediatric Ophthalmology and Strabismus, released a clinical report reviewing the risk factors and screening guidelines for diabetic retinopathy in children. “Screening for Retinopathy in the Pediatric Patient with Type 1 Diabetes Mellitus” can be found in the July 2005 issue of Pediatrics and is available online at http://www.pediatrics.org.

Diabetic retinopathy is the number one cause of blindness in young adults in the United States. According to the report, the strategy for minimizing the risk for diabetic retinopathy should have three parts: (1) treating the underlying metabolic disorder and related comorbidities, (2) developing treatment options for patients with ocular disease, and (3) identifying the risk factors for ocular disease and implementing screening programs.

In one study, patients who received intensive treatment (i.e., insulin pump or at least three insulin injections per day, frequent phone calls and office visits, self-management education materials) had a substantially decreased risk of onset and progression of retinopathy compared with patients treated with conventional therapy.

Studies of diabetic macular edema and proliferative diabetic retinopathy showed that laser therapy improved outcomes in patients at high risk for ocular disease. The risk of moderate vision loss caused by diabetic macular edema was reduced by 50 percent. Risk of severe vision loss caused by proliferative diabetic retinopathy was reduced to less than 2 percent.

Early nonproliferative diabetic retinopathy is characterized by microvascular changes that may lead to ischemia, small retinal hemorrhages, and leakage of exudative fluid in the retina. More severe nonproliferative diabetic retinopathy is characterized by microvascular abnormalities in the retina, more extensive hemorrhages or microaneurysms, and changes in venous caliber and tortuosity caused by capillary closure and ischemia. Proliferative diabetic retinopathy can cause vision loss because of vitreous hemorrhage or retinal detachment. The report suggests that laser surgery is indicated when a patient’s eye approaches or reaches high-risk proliferative diabetic retinopathy, which is characterized by one or more of the following lesions:

• New vessels on the optic disc that are at least one fourth of the disc area in size

• New vessels on the optic disc that are less than one fourth of the disc area in size when fresh hemorrhage is present

• New vessels on other parts of the retina that are at least one half of the disc area in size when fresh hemorrhage is present

Risk factors for the development of diabetic retinopathy include:

• Duration of disease (98 percent of patients who have had diabetes for 15 or more years have diabetic retinopathy)

• Age (children younger than 10 years with type 1 diabetes mellitus have a very small risk of diabetic retinopathy)

• Puberty (hormonal changes during puberty increase the risk of diabetic retinopathy regardless of age)

• Pregnancy

The American Academy of Ophthalmology recommends yearly screening beginning five years after the diagnosis of diabetes. The American Diabetes Association recommends yearly screening three to five years after diagnosis of diabetes after the patient reaches 10 years of age. The AAP recommends yearly screening three to five years after the diagnosis of diabetes in patients older than nine years.