Dovilė Venclovaitė1, Liucija Mažonaitė2
1Lithuanian University of Health Sciences, Faculty of Medicine, Kaunas, Lithuania
2Lithuanian University of Health Sciences Kaunas Clinics, Department of Ophthalmology, Kaunas, Lithuania
Abstract
Background. Type 1 diabetes mellitus is a disease in which relative or absolute insulin deficiency leads to the development of hyperglycaemia, which can cause microvascular complications such as diabetic retinopathy. Type 1 diabetes is the most common type of diabetes in children and adolescents worldwide. Diabetic retinopathy is a complication of diabetes, caused by hyperglycemia damaging small blood vessels of the retina, it can lead to blindness, which is why it is so important to diagnose the disease and to correct its risk factors such as hypertension, poor glycaemic control and obesity. Optical coherence tomography angiography is a new method of retinal imaging that can non-invasively diagnose the changes specific to diabetic retinopathy.
Methodology. Four scientific publications were selected from the „PubMed“ and „Science Direct“ databases based on keywords and inclusion and exclusion criteria.
Results. Four studies were analysed where children with type 1 diabetes mellitus and healthy children were examined using optical coherence tomography angiography. Statistically significant correlations were observed when comparing retinal capillary plexuses vessel densities between the study groups. Statistically significant correlations were also found between retinal capillary plexuses vessel densities and duration of the disease and glycated haemoglobin values.
Conclusions. The study found presence of microvascular changes in macula in children with type 1 diabetes mellitus and significant associations with both diabetes duration and glycated haemoglobin. Optical coherence tomography angiography can be used for the early detection of diabetic retinopathy in children.
Keywords: type 1 diabetes mellitus, macula, optical coherence tomography angiography, diabetic retinopathy.
https://doi.org/10.53453/ms.2023.5.8
Macular changes obtained with optical coherence tomography
angiography in children with type 1 diabetes mellitus: literature
review
Dovilė Venclovaitė
1
, Dovilė Buteikienė
2
1
Lithuanian University of Health Sciences, Faculty of Medicine, Kaunas, Lithuania
2
Lithuanian University of Health Sciences Kaunas Clinics, Department of Ophthalmology, Kaunas, Lithuania
Abstract
Background. Type 1 diabetes mellitus is a disease in which relative or absolute insulin deficiency leads to the
development of hyperglycaemia, which can cause microvascular complications such as diabetic retinopathy. Type
1 diabetes is the most common type of diabetes in children and adolescents worldwide. Diabetic retinopathy is a
complication of diabetes, caused by hyperglycemia damaging small blood vessels of the retina, it can lead to
blindness, which is why it is so important to diagnose the disease and to correct its risk factors such as
hypertension, poor glycaemic control and obesity. Optical coherence tomography angiography is a new method
of retinal imaging that can non-invasively diagnose the changes specific to diabetic retinopathy.
Methodology. Four scientific publications were selected from the „PubMed“ and „Science Direct“ databases
based on keywords and inclusion and exclusion criteria.
Results. Four studies were analysed where children with type 1 diabetes mellitus and healthy children were
examined using optical coherence tomography angiography. Statistically significant correlations were observed
when comparing retinal capillary plexuses vessel densities between the study groups. Statistically significant
correlations were also found between retinal capillary plexuses vessel densities and duration of the disease and
glycated haemoglobin values.
Conclusions. The study found presence of microvascular changes in macula in children with type 1 diabetes
mellitus and significant associations with both diabetes duration and glycated haemoglobin. Optical coherence
tomography angiography can be used for the early detection of diabetic retinopathy in children.
Keywords: type 1 diabetes mellitus, macula, optical coherence tomography angiography, diabetic retinopathy.
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Medical Sciences 2023 Vol. 11 (4), p. 72-76, https://doi.org/10.53453/ms.2023.5.8
72
1. Introduction
Type 1 diabetes mellitus (T1DM) is a disease
characterised by elevated blood glucose levels due
to relative or absolute insulin deficiency caused by
autoimmune destruction of pancreatic β-cells or
genetic factors (1). The International Diabetes
Federation (IDF) has estimated that in 2021, the
approximate number of children and adolescents
with T1DM worldwide was 1.2 million, with around
149 500 new cases diagnosed each year (2). T1DM
can lead to microvascular complications, including
diabetic retinopathy (DR), in which persistent
hyperglycaemia damages the small blood vessels of
the retina and can lead to blindness (1,3). DR can be
divided into two stages: non-proliferative and
proliferative. The first signs of non-proliferative DR
are microaneurysms, retinal haemorrhages and hard
exudates. Proliferative DR is a stage of advanced
DR that develops as retinal ischaemia progresses,
resulting in the formation of new pathological blood
vessels (neovascularisation) that can cause
haemorrhages or retinal detachment. At any stage of
DR, diabetic macular edema may occur,
characterised by increased vascular permeability
and the accumulation of fluid in the retina (4).
Children and adolescents with T1DM may be at risk
of developing DR at a young age due to a long
duration of T1DM, poor glycaemic control,
hypertension, hyperlipidaemia, obesity, and a family
history of T1DM or its complications (5,6). The
American Academy of Ophthalmology (AAO)
guidelines recommend annual DR screening for all
patients with T1DM 5 years after the diagnosis of
diabetes mellitus, and the American Academy of
Paediatrics (AAP) guidelines recommend annual
DR screening 3 – 5 years after the diagnosis of
diabetes mellitus, or at 9 years of age, whichever is
later. However, the prevalence of DR in children is
not well established and there is a lack of
information in the literature on its manifestation,
which is why it is very important to diagnose the
disease in time to prevent visual impairment in the
future (7,8).
One of the branches of the ophthalmic artery is the
central retinal artery, which divides and forms
different retinal capillary plexuses that cover the
entire retina except for the foveal avascular zone
(FAZ) of the macula and the periphery (9). The
number of retinal capillary plexuses depends on the
eccentricity and varies from one to four: radial
peripapillary capillary plexus, superficial capillary
plexus (SCP), intermediate capillary plexus, and
deep capillary plexus (DCP) (10).
Optical coherence tomography angiography
(OCTA) is a new, fast, non-invasive imaging
technique based on optical coherence tomography
technology that captures images of retinal and
choroidal layers capillary blood flow within a few
seconds and allows quantitatively measure the
density of capillary plexuses, assess enlargement of
the FAZ, identify microaneurysms, retinal perfusion
impairment, degree of neovascularisation (11,12).
FAZ is a region of the macula that has no blood flow
and is supplied by choroidal choriocapillaries. The
analysis of the FAZ is very important as its changes
are directly related to a number of important clinical
conditions, such as the severity of the disease and
visual acuity in patients with DR (13).One of the
main advantages of OCTA is the ability to examine
different retinal vascular layers and to separate SCP
and DCP, allowing precise identification of the
damaged area (14).
2. Materials and Methods
The literature search was done in the „PubMed“ and
„Science Direct“ databases using the following
keywords: type 1 diabetes mellitus in children,
optical coherence tomography angiography, foveal
avascular zone, retinal capillary plexus. Studies
were included if they met the following criteria:
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studies with participants younger than 18 years
diagnosed with T1DM, studies published within the
past 10 years, and written in English. Articles not
written in English were excluded. Studies that did
not use OCTA for imaging the retina were also
excluded.
3. Results
Four articles were included in the study:
Gołębiewska J. et al. 2017 (15), Mameli C. et al.
2019 (16), Inanc M. et al. 2019 (3), Wysocka –
Mincewicz M. et al. 2021 (17). In all included
studies, the eyes of subjects (diabetic (DM+)) and
controls (non-diabetic (DM–)) were examined by
OCTA, and the duration of the T1DM and the
glycated haemoglobin (HbA1c) value of the study
group were reported (Table 1).
Table 1. Characteristics of the study and control group
*mean ± standart deviation (SD); ** median (min-max)
Gołębiewska J. et al. did a study in Poland that
involved 130 children (94 in the study group and 36
in the control group). FAZ, foveal SCP vessel
density, DCP vessel density, parafoveal SCP and
DCP vessel densities were assessed by OCTA. The
mean duration of T1DM in the study group was 6.4
( ± SD = 3.3) years, and the mean HbA1c was 8.1 (
± SD = 1.1) %. The authors did not determine
statistically significant difference between SCP,
DCP vessel densities and FAZ region in children
with T1DM compared with the control group. On
the other hand, a statistically significant negative
correlation was observed between an increased
HbA1c and decreased parafoveal SCP vessel density
in the study group (r = -0.17, p = 0.039), whereas
parafoveal DCP vessel density decreased when
T1DM duration increased (p = 0.014) (15).
Mameli C. et al. did a study in Italy and used OCTA
to examine both eyes of 53 children with T1DM and
both eyes of 48 healthy children. Fovea SCP and
DCP vessel densities, parafoveal SCP vessel
density, parafoveal temporal superficial capillary
plexus (TSCP) vessel density, parafoveal superior
superficial capillary plexus (SSCP) vessel density,
parafoveal nasal superficial capillary plexus (NSCP)
vessel density, parafoveal inferior superficial
capillary plexus (ISCP) vessel density, parafoveal
DCP vessel density, parafoveal temporal deep
capillary plexus (TDCP) vessel density, parafoveal
superior deep capillary plexus (SDCP) vessel
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density, parafoveal nasal deep capillary plexus
(NDCP) vessel density, parafoveal inferior deep
capillary plexus (IDCP) vessel density was assessed
and compared between the two groups. The authors
did not find any significant changes while
comparing these parameters. The FAZ zone was not
assessed in the study. The most significant
difference among the two groups was observed
between parafoveal TSCP vessel density
(p = < 0.001), parafoveal SSCP vessel density
(p = 0.0028) and parafoveal TDCP vessel density
(p = <0.001). These parameters were significantly
lower in the T1DM group. The median duration of
T1DM in the study group was 6.0 (3.3; 10.3) years,
and the median HbA1c value was 7.6 (6.9; 8.1) %,
but no correlation was observed between these
parameters and vessel densities of retinal capillary
plexuses (16).
Inanc M et al. did a study in Turkey in which 57
healthy children and 60 children with T1DM were
examined using OCTA. The authors assessed the
patients' FAZ, foveal SCP and DCP vessel densities
as well as parafoveal SCP, TSCP, SSCP, NSCP,
ISCP, DCP, TDCP, SDCP, NDCP, and IDCP vessel
densities and found a statistically significant
decrease in the parafoveal TDCP (p = 0.015) and
parafoveal SDCP (p = 0.005) vessel densities in the
study group while comparing with the control group.
Inanc M et al. did not find a significant correlation
between the mean duration of T1DM (6.54 (± SD =
3.86) years), mean HbA1c (6.42 (± SD = 1.12 ) %),
and FAZ as well as capillary plexuses vessel
densities of the study group (3).
The study by Wysocka-Mincewicz M et al. in
Poland included 71 children: 50 in the study group
and 21 in the control group. Patients were examined
using OCTA. FAZ, foveal, as well as parafoveal
SCP and DCP vessel densities were assessed. A
statistically significant correlation among the two
groups was found between parafoveal SCP vessel
densities (p = <0.005); it was lower in the T1DM
group. Also, the authors found a correlation between
the duration of T1DM (6.88 (± SD = 4.34) years) and
FAZ (r = 0.29, p < 0.05). No significant correlation
was found when comparing FAZ and capillary
plexuses vessel densities with mean HbA1c in
children with T1DM (17).
After analysing 4 studies, it was found that Mameli
C. et al. and Inanc M. et al. determined a statistically
significant decrease in vessel density in the
parafoveal TDCP area, while Mameli C. et al. and
Wysocka-Mincewicz M. et al. determined a
statistically significant decrease in vessel density in
the parafoveal SCP area when comparing the study
group with the control group. Only Wysocka-
Mincewicz M. et al. found a significant positive
correlation between FAZ and the duration of the
disease in the study group. Gołębiewska J. et al.
observed a significant negative correlation of the
parafoveal DCP vessel density with the mean
duration of T1DM as well as a statistically
significant negative correlation between the
parafoveal SCP vessel density and the mean value of
HbA1c.
4. Conclusions
In conclusion, the study found presence of
microvascular changes in macula in children with
T1DM and significant associations with both
diabetes duration and HbA1c. OCTA can be used for
the early detection of DR in children.
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