Will be presented at : To the honorable :

CASE REPORT-1

A 14th years old Type 1 Diabetes girl with

Cataract

Presented By:
dr.

Tutors:

PEDIATRIC DEPARTMENT
FACULTY OF MEDICINE BRAWIJAYA UNIVERSITY
DR. SAIFUL ANWAR GENERAL HOSPITAL
December 2022
 A 14th years old Type 1 Diabetes girl with
Cataract : A case report
1 2 2
, ,
1
Pediatric Residency, Faculty of Medicine, Brawijaya University-Saiful Anwar Hospital Malang
2
Division of Nephrology, Pediatric Department, Brawijaya University-Saiful Anwar Hospital Malang

Abstract
Cataract is a rare manifestation of ocular complication at an early phase of T1DM in the
pediatric population. The pathophysiological mechanism of early diabetic cataract has not been
fully understood; however, there are many theories about the possible etiology including
osmotic damage, polyol pathway, and oxidative stress. We report a case of a 14-year old girl,
who presented blurr vision five years after the diagnosis of Type 1 Diabetes Mellitus (T1DM)
under antidiabetic oral therapy (Novorapid and Levemir). The HbA1c level was 8.8% and fasting
blood glucose was high (150 mg/dL). The patient underwent full ophthalmologic examination,
which was abnrmal. Her visual acuity was 2/60 in both eyes and the anterior segment was
cloudy and high opacity lens was found.

Keywords : pediatric; Type 1 Diabetes; Diabetic Cataract

Introduction Cataract is a rare manifestation of

Type 1 diabetes is an autoimmune
condition characterized by the destruction of
pancreatic beta cells and absolute insulin
1
deficiency. Onset of diabetes in childhood
and adolescence is associated
numerous complications, including diabetic
kidney disease, retinopathy, and peripheral
neuropathy, and has a substantial impact on
public health resources.2 Approximately half
a million children in the world today have
type 1 diabetes mellitus (T1DM) with an
estimation of 80,000 new cases every year.
T1DM principal is symptoms are elevated
thirst, exhaustion, and frequent urination.
Exogenous insulin therapy is the main
treatment.4
ocular complication at an early phase of
T1DM in the pediatric population. The
prevalence of early diabetic cataract in the
population of children and adolescents
with depending on the authors varies between
0.7 and 3.4%.5 The pathophysiological
mechanism of early diabetic cataract has
not been fully understood; however, there
are many theories about the possible
etiology including osmotic damage, polyol
pathway, and oxidative stress. The
3
occurrence of diabetic cataract in most
pediatric patients is the first sign of T1DM or
occurs within 6 months of diagnosis of
T1DM.5

2

Case report
A 14-year old girl presented with
blurred vision in both eyes. She also had
complained of weakness since the last few
days, accompanied by frequent feelings of
hunger and thirst. The patient
complained of numbness in both legs. While
the patient had a year-long history of
polydipsia and polyuria, without weight loss
or other discomforts, the vision symptoms
went unnoticed and untreated. The patient
was previously diagnosed with type 1
diabetes since 2017 and was
treatment for Novorapid 11-11-11
subcutaneous Levemir 0-0.13-0.
The patient was the first child and
was born to a mother with no history of
diabetes mellitus, she was born via sectio
caesare at 37-48 weeks of gestation, and
the birth weight was 2500 grams. There was
no cyanosis, tightness, and icteric at birth.
The basic immunization history
complete. Patients was also given complete
breast milk nutrition for 2 years. A family
history with diabetes mellitus type 2 was
found in her grandfather of the biological
maternal line. There is no family history with
the same complaints.
Physical examination: Weight 20 kg,
Height 129 cm, BMI 12.02 kg/m2. The
patient looks thin. Other physical
examinations are within normal limits.
Fasting blood glucose level
examination was found to be high at 150
mg/dl with an HbA1c level of 8.8%. Total
cholesterol levels increased by 207 mg/dL.
As for electrolyte levels, kidney function,
and liver function within normal limits. A
also routine urine test revealed that the urinary
glucose level was 1+, protein level 1+, while
the urinary ketone level was negative.
Patient's blood gas analysis was within
normal limit without acidosis or alkalosis.
An ophthalmiological examination
during the initial hospitalization revealed
given intermittent blurred vision. Her visual acuity
and was 2/60 in both eyes. On examination of
the anterior segment of the eye, a cloudy
and high opacity of lens is found. No anemic
conjunctiva is found. Examination of the
posterior segment shows results within
normal limits. The patient was conscious
with no headache, abdominal pain, or other
symptoms.
was During hospitalization, patients are
given medicamentous therapy including
Novorapid 15-15-15 and Levemir 0-0-20 to
control blood glucose levels, also given
simvastatin 1x10mg, Vit. B Complex 1x1
tab, Vit. A 1x5000 IU, Vit.C 1x100mg, Zinc
1x20mg, and Folic Acid 1x1 tab daily.
Discussion
The strongest predictor of diabetes
complications is glycaemic control and
achieving normal glycated haemoglobin
3
(HbA1c ≤ 7.0% or 53 mmol/mol) is The United Kingdom Prospective
considered the primary target in diabetes Diabetes Study highlighted the importance
management. However, data from type 1 of lowering HbA1c to reduce the risk of
diabetes registries across nineteen micro and macrovascular complications in
countries in Australasia, Europe and North patients with diabetes.6 The excessive use
America (n = 324,501) reported that 84% of of insulin that is often required to achieve
patients exhibited HbA1c above this target. glycaemic control in type 1 diabetes
It appears that current therapies are lacking increases susceptibility to severe
in effect and adjunctive strategies require hypoglycaemia and may lead to some
consideration.1 measure of hyperinsulinemia.
Juvenile diabetic cataract is Hyperinsulinemia is associated with;
morphologically similar to cataract in an excessive weight gain, development of the
older adult. Changes are often found toward metabolic syndrome, inflammation and
the rear and are subcapsular. Typically, atherosclerosis, Alzheimer’s Disease and
cloudy opacities such as vacuoles have cancer.1,8
been found. The risk factors for cataract Long-lasting hyperglycemia with
development are the duration of symptoms consequential ketoacidosis and dehydration
of type 1 diabetes mellitus prior to the certainly plays an important role in the
diagnosis, poor metabolic control, high development of early diabetic cataract.
glycosylated hemoglobin, diabetic Even though the majority of newly
ketoacidosis, genetic factors, and treatment diagnosed pediatric patients with T1DM
7
with glucocorticoids. have aforementioned symptoms, only a
The average age of patients with small number of patients develop early
cataract was 11.4 years and most (11 of 14) diabetic cataract.9
were female. Ehrlich et al. described a The activation of the polyol pathway
patient who developed cataract within 3 under the influence of hyperglycemia and
weeks of a type 1 diabetes mellitus other cofactors is the most widely accepted
diagnosis. Pakhetra et al. described bilateral hypothesis relating to the development of
cataract development at the time of early diabetic cataract. A crucial enzyme in
diagnosis of type 1 diabetes mellitus in a the cascade of polyol pathway is aldose
young girl and development of juvenile reductase, which catalyzes reduction of
diabetic cataract within a few months of type glucose into sorbitol using NADPH prior to
1 diabetes mellitus diagnosis in an another sorbitol reduction to fructose by sorbitol
7
patient. dehydrogenase with NAD+ as a cofactor.

4
Sorbitol penetrates cell membranes poorly, guidelines for the prevention, diagnosis, and
accumulates in the lens, increases the treatment of T1DM, but did not include
osmotic pressure, and leads to lens about diagnostic and treatment for diabetic
vacuolization, lamellar separation, cataract.5 In the past two decades,
crystalline fiber damage, and ultimately phacoemulsification is the most common
cataract formation. A study revealed that technique of cataract extraction in the
T1D patients certainly had a higher risk of developed world. Types of surgery
developing cataracts because retinopathy is differentiate between younger and older
considered to take at least 5 years to children. Attributable to soft cataract in
develop after the onset of hyperglycemia. younger children, use of
The latest guideline of American Diabetes phacoemulsification is not mandatory,
Association suggests eye examination 3–5 whereas older children and adolescents
years after diabetic onset. Certain should proceed to phacoemulsification.12
predisposing factors might exist and Geloneck et al. reported that only 5
contribute to the rapid development. 10
out of 12 of their patients had visually
The occurrence of oxidative stress significant cataract and underwent cataract
also plays a major role in gradual diabetic surgery [3]. However, cataract surgery is not
cataract development. Reactive oxygen without complications, and it is especially
species (ROS) in diabetic patients are necessary to take into account the risks of
generated during oxidative stress in the long-term T1DM and the effects on growth
process of advanced glycation end-product and development of anterior eye segment.
(AGEs) formation, but also as a byproduct The most common complications after
of the polyol pathway due to accumulation cataract surgery are posterior capsular
of NADH and consequent NADH oxidase opacification (PCO), secondary glaucoma,
activity. The imbalance in antioxidant retinal detachment, amblyopia, and acute
capacity results in increased availability of complications (incision leakage, increased
free radicals, which can also be associated intraocular pressure, edema, and
with the possible formation of diabetic uveitis).13,14
cataract.11 Randomized controlled study in 27
American Diabetes Association children aged between 4 and 14 years who
(ADA) and the International Society for underwent the intervention of cataract
Pediatric and Adolescent Diabetes (ISPAD) surgery with or without PPC (primary
as two major associations of pediatric posterior capsulorhexis) and AV (anterior
diabetologists provide comprehensive vitrectomy) demonstrated better visual

5
acuity and significantly less PCO in the intraocular pressure reduction and
group that undergone cataract surgery with regression of neovascularization in the
PPC and AV. Elkin et al. revised the treatment of NVG. Cataract surgery after
incidence of PCO in all age groups of administering anti-VEGF agents should be
pediatric cataract patients who underwent done with or without vitrectomy as early as
cataract extraction followed by IOL possible to enable treatment of the posterior
implantation without PPC and AV and found segment.16 
occurrence of PCO up to 90%.5,15 A small number of studies have
Preoperative counseling is crucial for shown gradual regression and resolution of
diabetic patients. Before surgery, patients diabetic cataracts in the pediatric
should have good glycemic control and no population. Jin et al. reported two cases of
evidence of ocular or periocular infection. A reversible cataract that gradually
thorough and comprehensive disappeared over several months with good
ophthalmologic examination-including an glycemic control. Phillip et al. suggested
assessment of bestcorrected visual acuity that duration of T1DM symptoms prior to
(BCVA) and relative afferent pupillary therapy has a key role in the reversibility of
defect; using slitlamp biomicroscopy to diabetic cataract.5
assess the corneal health and
neovascularization of the iris (NVI); and Conclusion
using tonometry, dilated fundoscopy, and In summary, we recommend routine
gonioscopy for the evaluation of examination of the lens and retina for
neovascularization at the angle-is diabetic adolescents and children who have
mandatory. Bscan ultrasonography may be diabetic ketosis or high levels of HbA1c. For
helpful. Due to the range of diabetic anterior those patients with cataracts, postoperative
segment changes, an experienced surgeon retinoscopy should be routinely performed,
16
will perform better. and regular follow-up visits are advised. If
In patients who develop neovascular abnormalities are identified, it is encouraged
glaucoma (NVG), medical therapy is the first that patients are immediately referred to an
line of defense, however, it is usually ophthalmologist for further evaluation. 
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