Bilateral cataract in a teenage girl with type 1 diabetes (T1D): case report

¹Abass Ndao Hospital, Cheikh Anta Diop University Dakar, Dakar, Senegal, ²De la Paix Hospital, Assane Seck University Ziguinchor, Ziguinchor, Senegal, ³Diamniadio Children Hospital, Iba Der Thiam University Thies, Thies, Senegal, ⁴Ophthalmology Practice Fann résidence Dakar, Dakar, Senegal, ⁵Regional Hospital Center, Gaston Berger University Saint Louis, Saint Louis, Senegal

^&Corresponding author
Djibril Boiro, Abass Ndao Hospital, Cheikh Anta Diop University Dakar, Dakar, Senegal

Introduction    

A cataract is a rare ocular complication of T1D among pediatric patients with an estimated prevalence of 0.7% to 3.4% [1]. It can go up to 16% in Haitian or African patients [2]. The pathophysiological mechanisms of cataract formation at the onset of T1D have not been fully elucidated. The most widely accepted theory is the activation of the polyol pathway, osmotic damage, and oxidative stress due to hyperglycemia leading to clouding of the lens in diabetic patients [3]. Surgical treatment remains the gold standard [4]. We describe the case of a teenage girl who suddenly presented a severe decline of the visual acuity.

Patient and observation     

Patient and observation: it was an 18-year-old teenage girl with type 1 diabetes discovered during ketoacidosis in 2014 and followed in our department since 2018. Her mother has type 2 diabetes, there is no parental consanguinity and no history of familial cataract. She had menstruated at the age of 13 and is currently in high school. She was on insulin with three injections per day with a premixed (Rapid-NPH) 30/70 in the morning and evening as well as a rapid at noon, for a total 0.7IU/kg day. She ate three meals and snacks often in between meals. Blood sugar control is rare. She practices physical activity (gymnastics) for 5 hours per week. She had several hospitalizations for ketoacidosis. Her average glycated hemoglobin over the past year was at 10.6%. She complained of bilateral eye pain with reduced visual acuity for several months.

Clinical findings: on examination: weight: 55kg, height: 177cm, BMI: 17.57kg/m², PA100/70mmHg. The general condition was maintained, and the rest of physical examination was within normal limits. The search for microalbuminuria was negative; an ophthalmic consultation with fundus examination was requested.

Diagnosis:at diagnosis, the ophthalmologic examination (Table 1) found a visual acuity of 1/10 on the right and just a light perception on the left. Examination of the lens of both eyes revealed cataracts (Figure 1) and an inaccessible fundus. The diagnosis of secondary bilateral cataract to poorly balanced diabetes was made.

Therapeutic interventions: two cataract surgeries 15 days apart were performed after strict glycemic control and ocular echobiometry. We performed an extra capsular extraction (Figure 2) with the placement of a posterior chamber implant under sub-tenonian anesthesia.

Follow-up and outcome of interventions: the postoperative course was normal for both eyes. The stitches were removed 60 days after surgery for each eye. We noted secondary capsulosis in the right eye which prompted a needle capsulotomy under local anesthesia. At the control examination (Table 2), visual acuity was normalized to 8/10 for both eyes. Bilateral pseudophakia was noted (Figure 3) and the retinograph (Figure 4) was normal on both sides.

Discussion     

A cataract may be the first sign of T1D or it occurs within 6 months of a diagnosis of T1D in most pediatric patients [5]. For our patient, the diagnosis was made 6 years after the diagnosis of diabetes. It appears to be a late onset or delayed diagnosis in the absence of an ophthalmologic consultation. Authors have diagnosed cases of cataracts one month before the diagnosis of diabetes. Some cases was diagnosed one month before the diagnosis of diabetes [5]. The diagnosis age varies. Wilson et al. reported the average age of diagnosis at 11.7 years. The youngest patients described in the literature with early diabetic cataracts were 5 years old, but many patients were adolescents as in our case [6,7]. Most authors have reported that cataracts were significantly associated with female patients [8,9]. However, lafusco et al. reported an equal gender distribution in the pediatric population with T1D [7]. Our patient had several hospitalizations for ketoacidosis. Her average glycated hemoglobin over the past year was 10.6%. High blood sugar and hemoglobin A1c levels at the time of diagnosis are associated with an increased risk of developing cataracts [7,10]. Lafisco et al. showed in their study that for each percentage point of 12.8 to 14.1% of the level of HbA1c, the appearance of early diabetic cataract increased by 3.6 times [7]. Currently, there are many experimental therapies for the treatment of diabetic cataracts, but cataract surgery remains the gold standard in the treatment of diabetic cataracts [11]. The postoperative course is generally favorable with good recovery of the visual acuity. According to Wilson et al. nineteen out of twenty-three operated eyes had better postoperative visual acuity corrected at 20/40 or better [5].

Conclusion     

Although rare, cataracts in young diabetics must be screened as well as other complications of type 1 diabetes. Surgery is essential but is not without risk, hence the importance of emphasizing prevention by improving the patients' glycemic control.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Djibril Boiro; final draft. Lamine Thiam; bibliographic search. Idrissa Basse; formatting first draft. Mar Ndiaye; drafting of the ophthalmology section. Aliou A. Ndongo, Ndiogou Seck, Amadou Sow, Babacar Niang, Demba Diedhiou, Modou Gueye, Ousmane Ndiaye; corrections and contributions. All the authors have read and agreed to the final manuscript.

Tables and figures     

Table 1: results of the ophthalmological examination

Table 2: results of the ophthalmologic examination after surgery

Figure 1: examination of the lens of both eyes revealed cataracts and an inaccessible fundus (A: right eye, B: left eye)

Figure 2: lens after extra capsular extraction

Figure 3: eyes after cataract extraction (A: right eye, B: left eye)

Figure 4: normal retinography on both sides (A:right eye, B: left eye)

References