Risk of high refractive error greatest among children with diabetic mothers

24th August 2021

An increased risk of high refractive error has been observed in children born to diabetic mothers, highlighting the need for early screening.

A refractive error represents a common eye disorder that prevents the eye from being able to focus images properly leading to blurred vision. There are several types of high refractive errors (HRE) including myopia (near-sightedness), hyperopia (far-sightedness), astigmatism (distorted vision) and presbyopia (difficulty in reading at arm’s length). The World Health Organisation has estimated that 153 million people worldwide have a visual impairment due to HRE. In children, the most common error is astigmatism, with one study finding a global prevalence of 14.9%. The cause of HRE remains uncertain although refractive changes are known to be associated changes in blood glucose levels and hence can be present in those with diabetes. In fact, there is some evidence that gestational diabetes can result in a three-fold increased probability of refractive errors compared to mothers without diabetes. In contrast, another study of refractive errors among diabetic and non-diabetic mothers found no significant differences in astigmatism between the two groups.

With some uncertainty over the relationship between HRE errors and diabetes, a team led by researchers from the Department of Clinical Epidemiology, Aarhus University, Denmark, undertook a population-based cohort study using Danish national registers. Mothers were considered to have diabetes if they were diagnosed either before or during their pregnancy. Their primary outcome of interest was high refractive errors in offspring and secondary outcomes were the specific types of refractive errors that developed over a 25-year follow-up period. The team used regression analysis to model the association between prenatal diabetes exposure and high refractive errors, adjusting for several factors including maternal age, smoking status, calendar period of delivery.

Findings
During the 25-year follow-up, there were 553 children of mothers with diabetes and 19,695 children of mothers without diabetes, diagnosed with a HRE. The children exposed to maternal had a 39% increased risk of having a HRE compared to those without diabetes (adjusted hazard ratio, aHR = 1.39, 95% CI 1.28 – 1.51, p < 0.001). This risk was significantly increased, compared to mothers without diabetes, for all forms of pre-gestational diabetes e.g., type 1 (aHR = 1.32), type 2 (aHR = 1.68) and gestational diabetes (aHR = 1.37). The risks for each type of HRE were also increased, e.g., hypermetropia (HR = 1.37), myopia (HR = 1.34) and astigmatism (HR = 1.58). In addition, the risks of HRE were higher in children of mothers who had at least one diabetic complications (aHR = 1.76) and higher still, in the presence of two or more complications (aHR = 2.24).
In trying to account for these elevated risks, the authors suggested the among diabetic mothers, it was possible that increased plasma glucose levels could result in foetal hyperglycaemia or that an increased oxidative stress and inflammatory response from the ensuing hyperglycaemia could have damaged the optical nerves. They concluded that given these finding, early ophthalmological screening should be undertaken in the children of mothers with diabetes.

Citation
Du J et al. Association of maternal diabetes during pregnancy with high refractive error in offspring: a nationwide population-based cohort study. Diabetologia 2021