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Emily K Deschler, Kristen Hock, Paolo Sandico Silva, Jerry Cavallerano, Jennifer K Sun, Morella M Grossmann, Andreina Millan, Lloyd M Aiello, Lloyd P Aiello, Joslin Vision Network Research Team; Pediatric Teleophthalmology Diabetes Eye Care Program in Caracas, Venezuela: Joslin Vision Network 7 Year Experience. Invest. Ophthalmol. Vis. Sci. 2014;55(13):2289.
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To assess the presence, onset and progression of diabetic retinopathy (DR) in a type 1 pediatric diabetes population in Caracas, Venezuela as evaluated in the Joslin Vision Network (JVN) teleophthalmology diabetes eye care program.
Stereoscopic nonmydriatic digital retinal imaging (3x45° fields, 2x30° fields & external image of each eye) was obtained from patients presenting for routine care at the pediatric endocrinology clinic at the Hospital de Niños, Caracas, Venezuela. Image grading for clinical level of DR and diabetic macular edema (DME) was performed remotely by certified graders using the previously validated JVN protocol.
From 11/2006 to 10/2013, 480 patients ≤ 18 years of age with type 1 DM were imaged. At initial imaging, (mean±SD) age was 10.6±3.7 years, DM duration 2.7±3.4 years, age at DM diagnosis 7.9±3.8 years and 54.4% were female. Baseline A1C was obtained in 66.3% (N=318). Mean A1C was 9.8±2.5% (range 4.4-17.7%) and was >8.0% in 74.5% (237). This program was the patient’s first exposure to eye care in 44.2% (212). DR was present at baseline in 5.2% (23 patients with mild nonproliferative DR (NPDR), 1 moderate NPDR, and 1 proliferative DR). Images were ungradable in 1.3% (6). Follow-up imaging was performed for 283 (59.0%) patients over an average of 2.6±1.9 imaging sessions and follow-up of 1.15±0.67 years. A ≥ 2 step DR progression was observed in 5.2% (29/558) of eyes with gradable images. Among the 264 (93.3%) patients with no DR on initial imaging, 37 (14.0%) developed DR and 2 (0.8%) developed proliferative DR during followup. Age >12 years (OR 4.1, 95% CI 1.7-9.7, p=0.001), DM duration > 5 years (2.8, 1.2-6.5, p=0.019) and DM onset <12 years (5.9, 1.5-23.7, p=0.013) were associated with an increased risk for onset and progression of DR.
Retinal imaging can be effectively obtained (99% gradable) in an underserved pediatric population and readily identifies a substantial amount of DR. In this cohort, DR was present in over 5% at baseline. Remarkably, over a mean followup of less than 14 months, 14% developed new onset DR and over 5% had ≥ 2 step DR progression. These data reinforce the critical need for medical and ophthalmic care and education to reduce the risk of DR progression, and suggest that teleophthalmology programs may serve a useful role in assessing and following DR in pediatric diabetes populations.
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