Prevalence of diabetic retinopathy in children and adolescents with IDDM. A population-based multicentre study.

Vision-threatening diabetic retinopathy can be prevented if it is diagnosed before becoming too advanced. Since diabetic retinopathy has been reported to occur only rarely before the end of pubertal development, children and adolescents are seldom included in screening programmes. We invited 780 children and adolescents with insulin-dependent diabetes mellitus diagnosed before the age of 15.0 years (disease duration of < 12 years) and who were older than 9.0 years at the time of examination from eight regions of Sweden. Retinal examination was performed with stereoscopic fundus photograph. The photograph were rated according to a modified Airlie House classification. The dropouts (223/780, 28.6%) were significantly older and with a longer duration of diabetes than the examined children (p < 0.001 and 0.001, respectively). Photographs from 557 patients aged (median [interquartile range]:14.6 [12.4-17.0]) years and with a diabetes duration of 8.0 (5.5-9.9) years were evaluated. Retinopathy was demonstrated in 81 patients (14.5%):66 with background retinopathy, 2 with microaneurysms and hard exudates, 12 with preproliferative retinopathy, 1 with proliferative retinopathy. Preproliferative retinopathy was diagnosed in a 12.8-year-old girl in pubertal stage 3 and an 11.8-year-old boy in pubertal stage 2, and proliferative retinopathy was found in a 21.5-year-old girl. Retinopathy was demonstrated in 6% and 18% of patients in pubertal stages 1 and 5, respectively. The overall prevalence of retinopathy in this population may even be higher since the dropouts were older and had a longer duration of diabetes. Since background and preproliferative retinopathy were found in children before puberty, we recommend including children and adolescents in screening programmes for diabetic retinopathy from the age of 10 years.

Fluorescein angiographic evaluation of the effect of latanoprost treatment on blood-retinal barrier integrity: a review of studies conducted on pseudophakic glaucoma patients and on phakic and aphakic monkeys.

Endogenous prostaglandins (PGs) have been claimed to play a role in the development of cystoid macular edema (CME). Two fluorescein angiographic studies evaluating the effect of latanoprost, a new ocular hypotensive PG analogue, on blood-retinal barrier integrity are, therefore, reviewed here. In the first study, six of eight unilaterally aphakic cynomolgus monkeys were treated bilaterally once daily for six months with 0.035% latanoprost (seven times the clinically used oculohypotensive concentration). Two of the animals served as controls. Fluorescein angiography of the fundus after one, three and six months of treatment revealed no leakage of fluorescein in any of the 16 eyes. In another study, pseudophakic eyes of 16 glaucoma patients who received twice-daily treatment with 0.006% latanoprost for four weeks were compared to eight patients treated with placebo. Biomicroscopic examination did not reveal any signs of CME and only one placebo-treated eye revealed a slight perifoveal leakage of fluorescein. These studies suggest that topically-applied latanoprost does not have a fluorescein angiographically detectable direct effect on the integrity of the blood-retinal barrier system in phakic or aphakic monkey eyes or in pseudophakic human eyes. This does not rule out the occurrence of CME in eyes more susceptible to CME, due to vitreous loss, posterior capsulotomy, or other postoperative situations. Especially in those eyes a study with latanoprost is proposed. Since, fluorescein angiography is a rather crude method of detecting abnormalities of the blood-retinal barriers, vitreous fluorometry in addition is suggested.

Results of pneumatic retinopexy with air.

Although scleral buckling yields good results in retinal reattachment surgery, we search for less laborious methods which could give the same high cure rate. Fifty-one consecutive patients with phakic, rhegmatogenous retinal detachment and breaks within 60 degrees of the upper retinal quadrants were treated by retino-cryopexy, drainage of subretinal fluid (under an operating microscope), and intravitreal injection of air (0.8 to 2.0 ml). Follow-up examinations (after 6 to 12 months) disclosed retinal reattachment in 44 of 51 eyes (86%). Cases with macular detachment showed good visual recovery, and 15 of 23 eyes (65%) achieved 0.5 (20/40) or more in visual acuity. Postoperatively, new retinal breaks occurred in 6%, proliferative vitreoretinopathy in 2%, and macular pucker also in 2%. Pneumatic retinopexy with air is an easy procedure, it is associated with few complications, and enables rapid postoperative recovery.

Efficacy of cryotherapy for retinopathy of prematurity.

This is a retrospective study of the benefit of transconjunctival cryotherapy for retinopathy of prematurity (ROP) in 43 eyes of 22 infants (birth weight 716-1675 g) from July 1985 to January 1988. Nine eyes were treated at ROP stage 4A (early), 14 eyes at stage 3 plus disease, and 20 eyes at stage 3. Cryotherapy was applied to the retinal avascular zone. In 13 eyes the ridge of extraretinal fibrovascular proliferation was also treated. Two eyes with peripheral exudative retinal detachment in two quadrants had additional treatment of the area of elevated retina. Reexamination was performed at the age of 26 to 52 months (average 38 months). Regression of the ROP was found in all eyes. Seven eyes showed a lateral traction of the temporal vascular arcades, six of these eyes had a slight macular ectopia. None of the eyes progressed to stage 4B or 5. Visual acuity was 6/60 or better. Twelve children (60%) achieved 6/18 or better and 5 (25%) 6/9 or more. Our data indicate that cryotherapy for ROP grade 3 and early stage 4A prevents the progression to advanced stages. The results also imply a functional benefit of cryotreatment in infants with progressive severe ROP.

Residual C-peptide excretion is associated with a better long-term glycemic control and slower progress of retinopathy in type I (insulin-dependent) diabetes mellitus.

We evaluated the progression of microangiopathic lesions in 22 type I diabetic patients with residual C-peptide excretion and in 22 type I diabetic patients matched for age at onset and disease duration without residual C-peptide excretion. We also wished to elucidate whether certain HLA-DR phenotypes were associated with preserved insulin secretory activity and/or microvascular lesions. The two groups of patients were investigated in 1984 and 1985. In the previous report, we observed less frequent signs of early microangiopathic lesions in association with a lower HbA1c in the group with a detectable urinary C-peptide excretion. The HbA1c level has been measured regularly (7-12 times) since the initial investigation; the mean value was lower in the patient group with residual C-peptide excretion than in the non-C-peptide group (p = 0.01). Nine of the patients in the group without urinary C-peptide excretion had increased severity of retinopathy, but only two in the group with urinary C-peptide excretion (p = 0.04) had progression of retinopathy. Incipient and/or manifest albuminuria was observed in six of the nonexcretor group and one of the C-peptide excretors. Four of the patients were receiving antihypertensive treatment and three others had a diastolic blood pressure greater than or equal to 90 mmHg in the non-C-peptide excretor group as compared with one with a pressure greater than or equal to 90 mmHg in the C-peptide excretor group.(ABSTRACT TRUNCATED AT 250 WORDS)

Circulating insulin-like growth factor I in type 1 (insulin-dependent) diabetic patients with retinopathy.

The relationship between insulin-like growth factor I (IGF I) and diabetic retinopathy was investigated. This somatomedin circulates bound to at least two large carrier proteins with molecular weights of approximately 150,000 and 35,000. Total and protein binding profiles of insulin-like growth factor I were determined in the serum of 18 patients who had had Type 1 (insulin-dependent) diabetes for 15-20 years, but had no signs of nephropathy and a similar degree of mild subclinical neuropathy. Nine had preproliferative or proliferative retinopathy and 9 had little or no background retinopathy but there was no difference in diabetes duration, insulin doses or glycaemic control between the two groups. In the latter group, the amounts of the somatomedin I and the serum profiles were similar to those in 9 healthy control subjects. In patients with advanced retinopathy, however, binding of insulin-like growth factor I to the carrier proteins was significantly altered. Binding to the low molecular weight protein increased to 140% whereas binding to the large molecular weight protein decreased to 70% of the normal level. In the latter Type 1 diabetic patients total serum insulin-like growth factor I was decreased to 60% of the normal level (p less than 0.02). When the alteration in serum profile was adjusted for, the level of somatomedin associated with the small carrier complex was normal whereas that associated with the large carrier complex was reduced by almost 60% in Type 1 diabetic patients with retinopathy. It is proposed that the total circulating somatomedin level is low in advanced diabetic retinopathy.(ABSTRACT TRUNCATED AT 250 WORDS)

Intraocular infestation by the reindeer warble fly larva: an unusual indication for acute vitrectomy.

A case of ophthalmomyiasis interna posterior (OIP) caused by the larva of the Reindeer warble fly is reported. The larva was initially found intraretinally in the inferior parts of the fundus. From this position it moved into the macula lutea within two days, causing decreased visual acuity. Acute vitrectomy was performed and the larva was removed through a retinotomy. About two months afterwards a small retinal detachment appeared near the ora serrata, where the larva had entered the eye. The retina was reattached with a scleral buckling procedure. The patient regained most of his vision postoperatively. Pars plana vitrectomy is a safe procedure and we consider that in any case of OIP, with a living larva in the eye, acute vitrectomy should be considered, since the larva may damage vital parts of the eye. Furthermore, the site of entrance should be treated with photocoagulation to prevent retinal detachment.

Residual insulin production, glycaemic control and prevalence of microvascular lesions and polyneuropathy in long-term type 1 (insulin-dependent) diabetes mellitus.

The aim of the present study was to evaluate the role of residual insulin production in long-term Type 1 (insulin-dependent) diabetes mellitus. Ninety-seven patients with a disease duration of 9-16 years and onset before the age of 30 years were studied. C-peptide excretion in 24-h urine samples was measured as an indicator of residual insulin production. Thirty-five patients (36%) excreted C-peptide (greater than or equal to 0.2 nmol); as many as possible of them were carefully matched with a non-excretor patient with regard to age at onset of diabetes and disease duration. Twenty-nine pairs were obtained, and 22 of them agreed to participate in further investigations of glycaemic control and microangiopathic lesions. The patients who excreted C-peptide had significantly lower HbA1c than the non-excretor group, 6.9 +/- 0.3% vs 7.9 +/- 0.3%, (p less than 0.025). Moderate-to-advanced background retinopathy was found in 2 patients in the excretor group and in 7 patients in the non-excretor group. Microalbuminuria [ratio of albumin: creatinine (mg/l:mmol/l) greater than or equal to 5] was found in 1 and in 5 patients, respectively, while proteinuria [ratio of protein: creatinine (mg/l:mmol/l X 10) greater than or equal to 136] was found in 0 and in 4 patients, respectively. Microalbuminuria and/or proteinuria was found in 7 of the non-excretor group as compared to 1 in the excretor group (p = 0.046).(ABSTRACT TRUNCATED AT 250 WORDS)

Electrodes for electroretinography. A comparison of four different types.

Electroretinograms of 11 healthy eyes were recorded on two occasions. Four different electrodes were used, and the B-wave amplitudes were compared. The Lovac contact lens electrode produced higher amplitudes than did the ERG-Jet lens electrode or the Burian-Allen lens electrode. The gold foil electrode gave the lowest amplitudes, but was superior in comfort.

Effect on intraocular pressure of retrobular injection of xylocaine with and without adrenaline.

The changes in IOP were registered in two groups, each comprising 30 patients, after a retrobulbar injection of Xylocaine and Xylocaine-adrenaline respectively. No significant difference between the mean values of the initial pressures and the IOP during the following ten min could be proved in either of the groups, but in several individual cases there was a considerable and unpredictable change in IOP following the injection. After ten min this effect was still often present but less pronounced. The change in IOP was significantly greater when adrenaline was used. As a result of these findings the authors have been inclined to cease using adrenaline in retrobulbar anaesthesia for intraocular surgery of short duration.