case report

1. A FOURTEEN YEARS OLD GIRL WITH TYPE 1
DIABETES MELLITUS WITH CATARACT
PRESENTED BY:
Kirnia Tri Wulandari, MD
SUPERVISOR:
Harjoedi Aji Cahyono, MD, PAED (C), Ph.D
Irfan Agus Salim, MD, PAED, M.Biomed
Fadilah Mutaqin, MD, PAED, M.Biomed
PEDIATRIC DEPARTMENT
FACULTY OF MEDICINE BRAWIJAYA UNIVERSITY, DR. SAIFUL ANWAR MALANG GENERAL HOSPITAL
C A S E R E P O R T

2. LIST OF ABBREVIATIONS
T1DM : Type 1 Diabetes Mellitus
BMI : Body Mass Index
HbA1c : Hemoglobin A1c
NADPH : Nikotinamid Adenin Dinukleotida Phosfat
NADH : Nicotinamide Adenine Dinucleotide (NAD) + hydrogen (H)
ROS : Reactive oxygen species
IOL : Intra Ocular Lens
ADA : American Diabetes Association
ISPAD : International Society for Pediatric and Adolescent Diabetes
NVG : Neo Vascular Glaucoma
anti-VEGF: Anti-Vascular Endothelial Growth Factor
PEDIATRIC DEPARTMENT
FACULTY OF MEDICINE BRAWIJAYA UNIVERSITY, DR. SAIFUL ANWAR MALANG GENERAL HOSPITAL

3. Introduction
In the world
Half a million children have type 1 diabetes
mellitus (T1DM)
With an estimation of 80,000 new cases
every year
In the pediatric population
Cataract is a rare manifestation of ocular
complication at an early phase of T1DM
The prevalence of early diabetic cataract
varies between 0.7 and 3.4%
The pathophysiological mechanism of early
diabetic cataract has not been fully
understood
There are many theories about the possible
etiology including osmotic damage, polyol
pathway, and oxidative stress
PEDIATRIC DEPARTMENT
FACULTY OF MEDICINE BRAWIJAYA UNIVERSITY, DR. SAIFUL ANWAR MALANG GENERAL HOSPITAL
M. M. Geloneck, B. J. Forbes, J. Shaffer, G. Ying, and G. Binenbaum, “Ocular complications in children with diabetes mellitus,” Ophthalmology, vol. 122, no. 12, pp. 2457–2464, 2020
M. E. Wilson, A. V. Levin, R. H. Trivedi et al., “Cataract associated with type-1 diabetes mellitus in the pediatric population,” Journal of American Association for Pediatric Ophthalmology and Strabismus, vol. 11, no. 2, pp. 162–165, 2020

4. CASE REPORT

5. Chief Complaint
Blurred foggy vision in the both eyes since 2 years ago
History of Present Illness
- Weakness since the last few days
- Feelings of hunger and thirst
- Numbness in both legs
Past Medical History
- A year-long history of polydipsia and polyuria
- Diagnosed with type 1 diabetes since 2017
D/Girl/14 years old/38 kg

6. Family History
Diabetes mellitus type 2 was found in her grandfather of the biological maternal line
History of Immunization
The patient completed the immunization
History of growth & development
Growth and developemnt was in accordance to the age
History of Childbirth
- She was born via sectio caesare at 37-48 weeks of gestation
- The birth weight was 2100 grams
- There was no cyanosis, tightness, and icteric at birth

7. History of Treatment
Novorapid 11-11-11
Levemir 0-0.13-0
History of Surgical
The patient underwent a surgical treatment for her catarract of the right eye in
Islamic Hospital at September 15th 2022
History of nutrition
Complete breast milk nutrition for 2 years
History of Social
The patient was the first child

8. • Weight 38 kg (P5)
• Height 149 cm (<P5) ~ 11
years old
• Head Circumference 50 cm
(-2SD to Mean)
• Mid-Upper Arm
Circumference 18 cm (P5-
P10)
• BMI 17,1 kg/m2 (P10-P25)
Antropometric
status

9. PHYSICAL EXAMINATION
General Appearance : Looked mild ill, compos mentis , spontaneous breathing
Vital Sign
HR : 110 times/ minute RR : 20 times/ minute
Axillary Temperature : 36,7º C SaO2 : 99% with room air
Head/Neck :
Normocephal, lymph node enlargement (-)
Anemia -/-, Ikterus -/-, Cyanosis-/-, conjunctival injection -/-, pericorneal injection -/-
Thorax:
Symmetrical, deep subcostal retraction (-), abdominal breathing
Heart/ single S1, normal S2, murmur (-), gallop (-)
Lung/ ves/ves, Rh -/-, Wh -/-
Abdomen:
Slightly distended (-), meteorismus (-), normal Bowel Sound (+), tenderness (-)
Liver and Spleen are not palpable
Extremities :
Warm acrals, CRT <2”, edema (-)

10. Normal Chest X-ray of the patient

11. Laboratoric examination
Hemoglobin 12.7 g/dL
Level of insulis 17.8
Vitamin D serum 7.43 ng/L
Fasting blood glucose level 150 mg/dl
HbA1c 8.8%
Total cholesterol 207 mg/dL
Urinary glucose level 1+
Protein level 1+
Urinary ketone level Negatif
Electrolyte levels
Normal
Kidney function
Liver function
Blood gas analysis Normal without acidosis or alkalosis

12. Ophthalmiological examination
Intermittent blurred vision
Visual acuity was more than 2/60 in both eyes
No anemic conjunctiva is found
The posterior segment shows results within normal limits
An intraocular lens (IOL on place) in the right eye as she got cataract
surgical treatment previously
The lens of left eye was coudy uneven
The intraocular pressure was found higher on the both eye as 17.3
mmHg

13. Figure. The Funduscopy examination.
A. there was a redness in the right eye; B. There was an
intraocular lens (IOL on place) in the right eye as she
got cataract surgical treatment previously; C. The lens of
left eye was coudy uneven.
A B
Figure. The clinical appearance of patient eyes.
A. there was a redness in the right eye; B. There was an
intraocular lens (IOL on place) in the right eye as she
got cataract surgical treatment previously; C. The lens of
left eye was coudy uneven.
B
A
C

14. Funduscopy examination
Funduscopy Right eye Left eye
FR + +
FR media Clear Clear
PN II Round shape with orange
coulour
Round shape with orange
coulour
C/D ratio of PN II 0.3 0.3
SV of PN II >7 >7
Vasa A/V 2, No scle, no Cross 3. No scle, no Cross
Retina No exudate, no
haemmorhage
No exudate, no
haemmorhage
RF of Macula + +

15. Diagnosis & Therapy
Diagnosis Therapy
- Type 1 Diabetes mellitus
- cataract of the left eye
• Novorapid 15-15-15
• Levemir 0-0-20
• Vitamin D 5000 IU once daily
• Vitamin B Complex once daily
• A drop of Levocin Eye drop
• Vosama Eye Drop six time a day on
the right eye

16. Discussion

17. According report data from type 1
diabetes registries across nineteen
countries in Australasia, Europe
and North America (n = 324,501)
reported that 84% of patients
exhibited HbA1c above target
The laboratorium result in
this patient, fasting
blood glucose level
examination was found to
be high at 150 mg/dL
with an HbA1c level of
8.8%.
Glycaemic control and
achieving normal
glycated haemoglobin
(HbA1c ≤ 7.0% or 53
mmol/mol)
M. Craig, C. Jefferies, D. Dabelea et al., “Definition, epidemiology, and classification of diabetes in children and adolescents,” Pediatric Diabetes, vol. 15, no. S20, pp. 4–17, 2020
Type 1 Diabetes Mellitus

18. The risk factors for cataract
development are the duration
of symptoms of type 1 diabetes
mellitus prior to the diagnosis,
poor metabolic control, high
glycosylated hemoglobin,
diabetic ketoacidosis, genetic
factors, and treatment with
glucocorticoids
In this patient we found blurred
foggy vision in the both eyes since
2 years ago. There were not pain
and redness in the eyes. She had 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
M. Phillip, D. Ludwick, K. Armour, and M. Preslan, “Transient subcapsular cataract formation in a child with diabetes,” Clinical Pediatrics, vol. 32, no. 11, pp. 684-685, 2021
Type 1 Diabetes Mellitus with Cataract Diabeticum

19. Ehrlich et al. described a patient
who developed cataract within 3
weeks of a type 1 diabetes mellitus
diagnosis
Pakhetra et al. described bilateral cataract
development at the time of diagnosis of type
1 diabetes mellitus in a young girl and
development of juvenile diabetic cataract
within a few months of type 1 diabetes
mellitus diagnosis in an another patient
In this patient a 14-year old girl presented with
blurred foggy vision in the both eyes since 2 years
ago. The patient was previously diagnosed with
type 1 diabetes since 2017
E. L. Montgomery and J. A. Batch, “Cataracts in insulindependent diabetes
mellitus: sixteen years’ experience in children and adolescents,”Journal of
Paediatrics and Child Health, vol. 34, no. 2, pp. 179–182, 2022

20. American Diabetes Association
(ADA) and the International Society
for Pediatric and Adolescent
Diabetes (ISPAD) as two major
associations of pediatric
diabetologists. Phacoemulsification is
the most common technique of
cataract extraction in the developed
world. Types of surgery differentiate
between younger and older children.
Attributable to soft cataract in
younger children, use of
phacoemulsification is not mandatory
In this patient, at September 15th 2022,
the patient underwent a surgical treatment
for her catarract of the right eye in Islamic
Hospital.
Y. Y. Jin, K. Huang, C. C. Zou, L. Liang, X. M. Wang, and J. Jin, “Reversible cataract as the presenting sign of diabetes mellitus : report of two cases and
literature review,” Iranian Journal of Pediatrics, vol. 22, no. 1, pp. 125–128, 2019.
A. Falck and L. Laatikainen, “Diabetic cataract in children,” Acta Ophthalmologica Scandinavica, vol. 76, no. 2, pp. 238– 240, 2021
Surgical treatment

21. She found an ophthalmiological
examination during the initial
hospitalization revealed intermittent
blurred vision. Her visual acuity was
more than 2/60 in both eyes. No
anemic conjunctiva is found.
Examination of the posterior segment
shows results within normal limits.
There was an intraocular lens (IOL on
place) in the right eye. While the lens
of left eye was cloudy uneven. The
intraocular pressure was found higher
on the both eye as 17.3 mmHg The
patient was conscious with no
headache, abdominal pain, or other
symptoms.
Randomized controlled study in 27
children aged between 4 and 14 years
who underwent the intervention of
cataract surgery with or without PPC
(primary posterior capsulorhexis) and
AV (anterior vitrectomy) demonstrated
better visual acuity and significantly
less PCO in the group that undergone
cataract surgery with PPC and AV.
Elkin et al. revised the incidence of
PCO in all age groups of pediatric
cataract patients who underwent
cataract extraction followed by IOL
implantation without PPC and AV and
found occurrence of PCO up to 90%.
C. Costagliola, G. Iuliano, M. Menzione, A. Nesti, F. Simonelli, and E. Rinaldi, “Systemic human diseases as oxidative risk factors in cataractogenesis. I. Diabetes,” Ophthalmic Research, vol. 20, no. 5, pp. 308–316, 2021.
I. G. Obrosova, S. S. Chung, and P. F. Kador, “Diabetic cataracts: mechanisms and management,” Diabetes/Metabolism Research and Reviews, vol. 26, no. 3, pp. 172–180, 2020.
POST SURGICAL

22. Treatment for intraoperative and
postoperative complications
In patients with neovascular
glaucoma (NVG)  Anti-
VEGF agents such as
bevacizumab  intraocular
pressure reduction and
regression of
neovascularization
Cataract surgery after
administering anti-VEGF
agents should be done with or
without vitrectomy as early as
possible to enable treatment
of the posterior segment
M. C. Ventura, V. V. Sampaio, B. V. Ventura, L. O. Ventura, and W. Nosé, “Congenital cataract surgery with intraocular lens implantation in microphthalmic eyes: visual outcomes and complications,” Arquivos Brasileiros de Oftalmologia, vol. 76, no. 4, pp. 240–243, 2018
S. K. Khokhar, G. Pillay, E. Agarwal, and M. Mahabir, “Innovations in pediatric cataract surgery,” Indian Journal of Ophthalmology, vol. 65, no. 3, pp. 210–216, 2019

23. Jin et al. reported two cases of
reversible cataract that gradually
disappeared over several months with
good glycemic control.
Prognosis
Y. Y. Jin, K. Huang, C. C. Zou, L. Liang, X. M. Wang, and J. Jin, “Reversible cataract as the
presenting sign of diabetes mellitus : report of two cases and literature review,” Iranian Journal of
Pediatrics, vol. 22, no. 1, pp. 125–128, 2019.

24. Conclusion
 Routine examination of the lens and retina for diabetic adolescents and
children who have diabetic ketosis or high levels of HbA1c
 The patient with cataract, postoperative retinoscopy should be routinely
performed, and regular follow-up visits are advised
 If abnormalities are identified, it is encouraged that patients are immediately
referred to an ophthalmologist for further evaluation

25. THANK YOU