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CME / ABIM MOC / CE

Does Type 2 Diabetes Increase Retinopathy Risk for Children?

  • Authors: News Author: Caleb Rans, PharmD; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 1/21/2022
  • THIS ACTIVITY HAS EXPIRED FOR CREDIT
  • Valid for credit through: 1/21/2023, 11:59 PM EST
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Target Audience and Goal Statement

This activity is intended for diabetologists/endocrinologists, ophthalmologists, family medicine/primary care clinicians, pediatricians, nurses, and other members of the health care team for children with type 2 diabetes who may be at risk for retinopathy or other ocular complications.

The goal of this activity is to describe the risk of developing diabetes-associated ocular complications among youth diagnosed with diabetes, based on a retrospective, population-based medical record review including all residents of Olmsted County, Minnesota, diagnosed with either type 1 diabetes or type 2 diabetes during a 50-year period.

Upon completion of this activity, participants will:

  • Assess the risk of developing diabetes-associated ocular complications among youth with type 1 diabetes compared with those with type 2 diabetes, based on a retrospective, population-based medical record review
  • Evaluate the clinical and public health complications of risk of developing diabetes-associated ocular complications among youth with type 1 diabetes compared with those with type 2 diabetes, based on a retrospective, population-based medical record review
  • Outline implications for the healthcare team


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News Author

  • Caleb Rans, PharmD

    Freelance writer, Medscape

    Disclosures

    Disclosure: Caleb Rans, PharmD, has disclosed no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.

Editor/Nurse Planner

  • Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP, has disclosed no relevant financial relationships.

CME Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Amanda Jett, PharmD, BCACP, has disclosed no relevant financial relationships.


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CME / ABIM MOC / CE

Does Type 2 Diabetes Increase Retinopathy Risk for Children?

Authors: News Author: Caleb Rans, PharmD; CME Author: Laurie Barclay, MDFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED FOR CREDIT

CME / ABIM MOC / CE Released: 1/21/2022

Valid for credit through: 1/21/2023, 11:59 PM EST

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Clinical Context

Diabetes is a prevalent, chronic childhood disease associated with chronic hyperglycemia and end-organ damage often causing the microvascular triad of nephropathy, neuropathy, and retinopathy. Subsequent retinal neurodegeneration and blood-retinal barrier breakdown lead to diabetic retinopathy, the leading cause of blindness in working-age and young adults.

Study Synopsis and Perspective

Children diagnosed with type 2 diabetes (T2D) appear significantly more likely to develop retinopathy and other ocular complications over time than children who are diagnosed with type 1 diabetes (T1D), researchers report.

Among a population-based cohort of children (defined as younger than 22 years), the risk for diabetic retinopathy was 88% greater in those with T2D than those with T1D within the first 15 years of disease diagnosis.

"The purpose of this study was to assess the risk of developing diabetes-associated ocular complications...among a population-based cohort of children diagnosed with either T1D or T2D during a 50-year period," lead author Patricia Bai, from the Mayo Clinic, Phoenix, Arizona, and colleagues reported in JAMA Ophthalmology.[1]

The researchers retrospectively reviewed medical records from all residents of Olmsted County, Minnesota, from 1970 to 2019. The study cohort included 606 children with a confirmed a diagnosis of T1D or T2D, 525 (86.6%) of whom had at least 1 ocular examination.

The mean age at diabetes diagnosis was 12.1 years (standard deviation, 5.4 years); most participants were White (95.7% in 1990), and half (50.3%) were male. Diabetes-associated ocular complications occurred in 31.9% and 26.6% of children with T1D and T2D, respectively.

The hazard ratios illustrating the risk between T2D and T1D rates were 1.88 (95% confidence interval [CI], 1.13-3.12; P=.02) for any diabetic retinopathy, 2.33 (95% CI, 0.99-5.50; P=.048) for proliferative diabetic retinopathy (PDR), 1.49 (95% CI, 0.46-4.89; P=.50) for diabetic macular edema, 2.43 (95% CI, 0.54-11.07; P=.24) for a visually significant cataract, and 4.06 (95% CI, 1.34-12.33; P=.007) for requiring pars plana vitrectomy (PPV) within the first 15 years of diagnosis.

These results suggest that earlier surveillance and intervention may help prevent vision-threatening complications, the researchers explained.

"After adjusting for race using self-identified categories of White or not White, the adjusted HR of developing any retinopathy was 1.63 (95% CI, 0.96-2.79; P = .07), and the adjusted [hazard ratio] of developing PDR was 2.02 (95% CI, 0.79-5.16; P = .14)" in patients with T2D versus T1D, the researchers wrote.

"We would expect the reported rate of type 2 diabetes to be potentially underestimated in our study cohort," Bai commented in an interview. "Race has been suggested to be a surrogate for other social determinants of health, such as lower rates of optimal follow-up care received by racial and ethnic minorities, which could influence subsequent retinopathy rates."

Understanding Retinopathy Outcomes in Youth

In an accompanying editorial, Jennifer K. Sun, MD, MPH, from Harvard Medical School, Boston, wrote that the present study indicates that the natural history of retinopathy may differ between patients with T1D and T2D.[2]

Although the pathophysiology of diabetic retinopathy in T1D and T2D appears similar, other patient-related factors such as lipid profiles, the presence of hypertension, and body mass index may differ between the 2 disease states.

She wrote that "there is a particular need to document retinopathy outcomes and risk factors for advanced disease in youth with T2D, for whom there is a paucity of information."

Bai and colleagues acknowledged that a key limitation of the study was the retrospective design. As a result, irregular follow-up and incomplete data may limit the applicability of the findings.

"Some children with milder forms of diabetes may have eluded detection, a limitation that is more likely to affect T2D, which may exist undetected for years before a diagnosis," Bai explained.

Dr Sun recommended that further epidemiologic studies are needed to help optimize guidelines for screening and follow-up for young people diagnosed with diabetes. "Such efforts may potentially lead to increased understanding of the mechanistic differences between pathology in T1D versus T2D," she concluded.

This study used the resources of the Rochester Epidemiology Project (REP) medical records linkage system, which is supported by grant funding from the National Institute on Aging, the Mayo Clinic Research Committee, and by fees paid annually by REP users. The study authors have disclosed no relevant financial relationships.

JAMA Ophthalmol. Published online December 2, 2021.

Study Highlights

  • This retrospective, population-based medical record review included all Olmsted County, Minnesota, residents (95.7% White in 1990) diagnosed with diabetes when they were younger than 22 years (referred to as children) from January 1, 1970, to December 31, 2019.
  • Of 1362 children with a diagnostic code of diabetes, medical record reviews confirmed T1D or T2D diagnosis in 606 children, of whom 525 (86.6%) had at least 1 eye examination.
  • Mean age at diabetes diagnosis was 12.1±5.4 years; 50.3% were male.
  • Diabetes-associated ocular complications developed in 147 (31.2%) of 461 children with T1D and in 17 (26.6%) of 64 children with T2D.
  • HbA1c values did not differ significantly between the 2 groups, but a higher percentage of patients with T2D than with T1D met hypertensive criteria at initial diagnosis of diabetic retinopathy.
  • HR for risk comparing T2D vs T1D rates was 1.88 (95% CI, 1.13-3.12; P=.02) for any diabetic retinopathy (nonproliferative or greater, within the first 15 years of disease), 2.33 (95% CI, 0.99-5.50; P=.048) for PDR, 1.49 (95% CI, 0.46-4.89; P=.50) for diabetic macular edema, 2.43 (95% CI, 0.54-11.07; P=.24) for visually significant cataract, and 4.06 (95% CI, 1.34-12.33; P=.007) for requiring PPV by 15 years after diabetes diagnosis.
  • Adjusting for sex, the differences between Kaplan-Meier curves for developing any diabetic retinopathy remained statistically significant (P=.02), but PDR became nonsignificant (P=.052).
  • After adjustment for race (White or not White), adjusted hazard ratio for developing any retinopathy was 1.63 (95% CI, 0.96-2.79; P=.07), and for developing PDR was 2.02 (95% CI, 0.79-5.16; P=.14) in patients with T2D vs T1D.
  • The investigators concluded that diabetic retinopathy, PDR, and the need for PPV occurred within a shorter diabetes duration for children with T2D vs T1D and that children with T2D vs those with T1D had nearly twice the risk of developing retinopathy.
  • The findings are consistent with previous studies suggesting that retinopathy occurs sooner and visual acuity is worse in youth with T2D than in those with T1D.
  • The results suggest that to prevent serious ocular complications, children with T2D may need earlier surveillance and intervention, including ophthalmoscopic examinations at least as often or more often than children with T1D.
  • The natural history of developing retinopathy may differ in youth diagnosed with T2D vs T1D, in that they may be more susceptible to developing retinopathy despite controlling for diabetes duration.
  • Similar HbA1c values in T2D and T1D suggest that hyperglycemia insufficiently explains increased development of vision-threatening retinopathy in T2D, although hypertension may be implicated, as a higher percentage of patients with T2D than with T1D met hypertensive criteria at initial diagnosis of diabetic retinopathy.
  • Sex differences may also modulate some of the differences seen in development of vision-threatening retinopathy between T2D and T1D.
  • Race may be a surrogate for other social determinants of health, such as lower rates of optimal follow-up care for racial and ethnic minorities, which could affect subsequent retinopathy rates.
  • Study limitations include retrospective nature, incomplete data, irregular follow-up, relatively small number of children diagnosed with T2D, predominately White population precluding generalizability to more racially diverse populations, and failure to detect children with milder diabetes, particularly T2D, which may be undetected for years before diagnosis.
  • An accompanying editorial recommended further epidemiologic studies to help optimize guidelines for screening and follow-up among youth diagnosed with diabetes, which could also clarify the mechanistic differences in pathology in T1D vs T2D.

Clinical Implications

  • Diabetic retinopathy, PDR, and the need for PPV occurred within a shorter diabetes duration for children with T2D vs T1D, and children with T2D had nearly twice the risk of developing retinopathy.
  • The natural history of developing retinopathy may differ in youth diagnosed with T2D vs those with T1D, in that they may be more susceptible to developing retinopathy despite controlling for diabetes duration.
  • Implications for the Health Care Team: To prevent serious ocular complications, children with T2D may need earlier surveillance and intervention, including ophthalmoscopic examinations at least as often or more often than children with T1D.

 

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