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Prof. Somashekhar Nimbalkar
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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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On Aug 2018




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Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


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Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
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Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : June | Volume : 16 | Issue : 6 | Page : NC11 - NC14 Full Version

Early Cataract and Surgical Recovery in Young Type 1 Diabetics: Experiences from a Single Centre in Northern India


Published: June 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/52927.16451
Rishi Shukla, Sangeeta Shukla, Neha Agarwal, Anurag Bajpai, Mohit Khattri

1. Consultant, Department of Endocrinology, Regency Hospital, Kanpur, Uttar Pradesh, India. 2. Consultant, Department of Ophthalmology, Regency Hospital, Kanpur, Uttar Pradesh, India. 3. Assistant Professor, Department of Paediatrics, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India. 4. Consultant, Department of Endocrinology, Regency Hospital, Kanpur, Uttar Pradesh, India. 5. Consultant, Department of Ophthalmology, Regency Hospital, Kanpur, Uttar Pradesh, India.

Correspondence Address :
Neha Agarwal,
House No 264, Lane No17, Golden Green Park Colony, Bareilly, Uttar Pradesh, India.
E-mail: nagarwal88@yahoo.com

Abstract

Introduction: Cataract, a non-retinal ophthalmic complication, is the leading cause of visual impairment in adults living with Type 1 Diabetes (T1D). Unfortunately, there is a dearth of data on diabetic cataract in the paediatric population, particularly from developing countries. To the best of our knowledge, the current study is the first and the largest observational study reporting the characteristics, and surgical recovery of early cataract among Indian children and adolescents living with T1D.

Aim: To report the patient characteristics and surgical outcome of early cataract in young type 1 diabetics.

Materials and Methods: The present study was a retrospective observational study (January 2005-December 2020), conducted at Regency Hospital Pvt. Ltd., Kanpur, Uttar Pradesh, India. Medical records of Children and adolescents (n=150) aged 1-18 years with T1D in the last 15 years, and who developed cataract during follow-up were included in the study and reviewed from January 2021 to March 2021 , for the socio-demographic details, age at which diabetes was diagnosed, presence or absence of ketoacidosis at the time of diagnosis of diabetes, age at which cataract was diagnosed, glycaemic control, morphology and laterality of cataract, history of retinopathy before cataract surgery, presence or absence of concomitant nephropathy, visual acuity at the time of cataract diagnosis, type of surgical intervention done and visual acuity following surgery.

Results: Out of 150 T1D patients, a total of ten patients (five boys; 19 eyes) were diagnosed with cataract, before the age of 18 years. The mean age at diagnosis of T1D was 8.6±3.2 years (range, 3-12 years) and cataract was 13.2±4.1 years (range, 6-18 years). Mean HbA1c at the time of cataract diagnosis was 7.99±0.98%. The past history of diabetic ketoacidosis was documented in six patients (60%). Nearly 70% (n=7) patients belonged to the lower socio-economic strata. Cortical cataract (12/19 eyes; 63%) was the most common morphology identified. These patients were operated after a mean duration of 0.5±0.7 years of cataract diagnosis. The corrected visual acuity remained good after a mean follow-up duration of 3.2±2.7 years (range 0-8 years), post cataract extraction.

Conclusion: The experiences gained from this study reinforce the need for early cataract screening in the paediatric diabetic population, especially in those, belonging to lower socio-economic strata, and/or with history of diabetic ketoacidosis. Cortical cataract was the most common form identified. Vision can be preserved with timely surgical intervention.

Keywords

Cataract Surgery, Cortical cataract, Diabetic ketoacidosis, Paediatric diabetes

Type 1 diabetes (T1D) and its associated complications is one of the leading public health problems contributing to morbidity and mortality, later in life. Cataract, retinopathy, strabismus, glaucoma, refractive changes, macular oedema, and papillopathy are some of the ocular complications, known to be associated with diabetes (1),(2). Cataract, a non-retinal ophthalmic complication, is a known leading cause of visual impairment in adults with T1D. Unfortunately, only limited data in the form of case reports are available that describe early diabetic cataract and its outcomes among children and adolescents (3).

Based on the limited data available, diabetic cataract is believed to occur more frequently in those with a longer duration of symptoms prior to the diagnosis of diabetes, or in those with poor metabolic control (4). However, since all children and adolescents with T1D do not develop cataract, other factors, such as genetic predisposition, nutrition, and the use of offending drugs (e.g., steroids) might also be considered in the pathogenesis of early diabetic cataract (4). Despite being an important preventable cause of permanent visual impairment, definite recommendations for the screening of early diabetic cataract in children and adolescents living with diabetes is lacking (5),(6).

Although surgical intervention remains the gold standard for the management of cataract (7), it is not without complications. Apart from acute complications like incision leakage, oedema, increased intra ocular pressure, and uveitis; other common complications associated with cataract surgery include, Posterior Capsular Opacification (PCO), secondary glaucoma, retinal detachment, and amblyopia (8). Long-term T1D and growth and development of the anterior eye chamber accounts for the occurrence of these complications (9). Extended follow-up of patients is therefore advocated to understand the possible influence of surgery on ophthalmologic complications. However, majority of this data is available from developed countries (3), whose findings cannot be extrapolated to the developing nations.

To the best of the author’s knowledge, this is the first and the largest study reporting the characteristics, and surgical recovery of early cataract among Indian children and adolescents living with T1D.

Results

Out of 150 T1D patient’s pool, a total of 10 (five boys) patients were diagnosed with cataract before the age of 18 years. Remaining 140 patients (who did not develop cataract) were excluded from the analyses. The mean age at the diagnosis of T1D was 8.6±3.2 years (range 3-12 years) and the mean age at the diagnosis of cataract was 13.2±4.1 years (range 6-18 years). The mean interval between the two was 4.6±1.8 years (range 2-8 years). Mean HbA1C at the time of cataract diagnosis was 7.99±0.98%. Nearly 70% (n=7) patients belonged to the lower socio-economic status as per the modified Kuppuswamy classification (11). A past history of diabetic ketoacidosis was documented in six patients; two patients had concomitant nephropathy while none of them had diabetic retinopathy.

Among these, only one patient had unilateral cataract (OD, right eye cataract) while the other nine patients had bilateral cataract (OU). These patients underwent cataract extraction after a mean duration of 0.5±0.7 years of cataract diagnosis, and were followed-up for a mean duration of 3.2±2.7 years (range 0-8 years), post cataract extraction. The clinical characteristics of all the ten patients are summarised in (Table/Fig 1). Cortical cataract (12/19 eyes; 63%) was the most common morphology identified, followed by posterior polar (5/19 eyes; 26.3%) and hyper-mature cataract (2/19 eyes; 10.5%).

Phacoemulsification (PE) was done in five patients (10 eyes), small-incision cataract surgery in four patients (seven eyes), and micro-incision cataract surgery in one patient (two eyes). Implantation of Intra-ocular Lens (IOL) was performed in all the patients (rigid poly methyl methacrylate in two, foldable hydrophilic in six, foldable hydrophobic in seven, heparin-coated in two and multi-focal in two eyes). No intra-operative or immediate post-operative complication was observed.

Following surgery, improvement in the visual acuity was seen in 1-2 weeks. The best corrected visual acuity was 6/6 or 6/6 (partial) in all patients except one (patient 3), as this patient was amblyopic preoperatively (V/A 6/24, left eye amblyopia). Visual acuity remained good after a mean follow-up duration of 3.2±2.7 years (range 0 to 8 years), post cataract surgery. One patient (patient 5) showed a decline in visual acuity which was attributed to the development of non-proliferative diabetic retinopathy in the peri-macular area. Three patients developed non-proliferative retinopathy during follow-up, after a mean diabetes duration of 8.9±1.3 years (7-10 years). The PCO was not observed in patients who underwent hydrophobic, heparin-coated and multi-focal IOL implantation. Nd:YAG capsulotomy was performed in the 8 eyes that developed PCO.

Discussion

Cataract is an important preventable cause of visual impairment among those living with T1D (1),(2). Past studies have reported variable relationship between the glycemic control and development of cataract. Garcia E et al., have reported cataract development in patients with strictly controlled blood glucose levels (3). Exact pathogenesis and risk factors for the cataract development in diabetic patients is still unclear.

Findings of the present study highlight that cataract formation is not an uncommon complication of T1D in the paediatric population. Unfortunately, no clear recommendations exist regarding cataract screening in the paediatric diabetic population. The diagnosis of T1D and cataract are both very important for school-going children.

Interestingly, the majority of the patients had a history of ketoacidosis at the time of diabetes diagnosis, and/or belonged to lower socio-economic status. Since 70% (n =7) of the patients belonged to the poor socio-economic strata, lack of good nutrition could be a plausible explanation. Being an indirect evidence, this needs further exploration in future studies. Further, six of our patients had diabetic ketoacidosis at the time of diagnosis of T1D. Extreme high blood sugar and ketoacidosis at the time of diabetes presentation might play a role in the development of early cataract in the present study patients. The association between cataract and ketoacidosis has been reported in the past (12). This highlights the importance of cataract screening in individuals presenting with a high HbA1C level and diabetic ketoacidosis.

Previous studies report significant variability in the level of HbA1C, both at the time of diagnosis of T1D and diabetic cataract (2), (4). Importantly, majority of the patients had optimal metabolic control (7.5% to 8.5%), with only three patients having HbA1C more than 8.5% at the time of diagnosis of cataract. This highlights the role of factors like the time in range, genetic predisposition, and nutrition in the development of early diabetic cataract. Data regarding time in range were not available for the present study patients and hence could not be reported.

Similar to a previous report by Iafusco D et al., (12), an equal gender distribution was observed in the present study. In contradiction to this, a few authors have reported female preponderance in their studies (13),(14). Most patients with early diabetic cataract reported in the literature were adolescents (15), with the youngest case being reported in a 5-year-old patient (16).

In the present study, there was a mean interval of 4.6±1.8 years between the diagnosis of diabetes and the detection of cataract. However, cataract has been reported to occur as early as six months after the onset of diabetes and in a few instances, is even the first sign of T1D (17). Ehrlich RM et al., emphasised that T1D should be considered in all children with acquired cataract of unknown aetiology (18).

As far as the morphology is concerned, posterior sub-capsular cataract is reported to be the most common type of diabetic cataract in the paediatric population (18),(19). In contrast to this, we observed cortical cataract to be the most common type in the present study patients.

The type of surgical technique employed depends on the age of the patient. Phacoemulsification is preferred in older children and adults while it is not mandatory in younger children owing to soft cataract (7). Similar to the trend observed in developed countries, phacoemulsification was the most common technique used in the present study. Nevertheless, cataract surgery is not without complications. In addition, long standing T1D and growth and development of anterior eye segment further increases the risk of complications (8), (9). We found development of PCO in eight eyes (40%), which is much lower than that reported in a study by Piluek WJ and Fredrick D, who noted PCO in up to 90% of paediatric cataract patients (20). Moreover, onset and progression of retinopathy is reported to be influenced by cataract surgery (1),(19). Falck A and Laatikainen L observed retinopathy in 8 out of 11 eyes in paediatric patients who underwent surgery for early diabetic cataract (16). We also observed mild non-diabetic proliferative retinopathy in three patients (8/19 eyes, 42.10%) not at the time of surgery, but after a mean diabetes duration of 8.9±1.3 years (7-10 years). Consequently, long-term follow-up is needed to explore the possible impact of surgical interventions on the development of ocular complications.

Limitation(s)

The retrospective study design constitutes a limitation of the present study. However, meticulous record maintenance and protocolised management of the patients by the same clinical leads throughout the study period ascertained the availability and reliability of the data. Studies with a long term follow up are needed to observe the complications developed after the surgery.

Conclusion

Cortical cataract was the most common form identified in the present study. There is a need for early cataract screening in the paediatric diabetic population, especially in those, belonging to lower socio-economic strata, and/or with history of diabetic ketoacidosis. With timely surgical intervention, vision can be preserved.

References

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Sayin N, Kara N, Pekel G. Ocular complications of diabetes mellitus. World journal of diabetes. 2015;6:92. [crossref] [PubMed]
2.
Geloneck MM, Forbes BJ, Shaffer J, Ying GS, Binenbaum G. Ocular Complications in Children with Diabetes Mellitus. Ophthalmology. 2015;122:2457-64. [crossref] [PubMed]
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García E, García Robles E. Cataract: A forgotten early complication of diabetes in children and adolescents. Endocrinol Diabetes Nutr. 2017;64:58-59. [crossref]
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Montgomery EL, Batch JA. Cataracts in insulin-dependent diabetes mellitus: sixteen years’ experience in children and adolescents. J Paediatr Child Health. 1998;34:179-82. [crossref] [PubMed]
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Donaghue KC, Marcovecchio ML, Wadwa RP, Chew EY, Wong TY, Calliari LE, et al. ISPAD Clinical Practice Consensus Guidelines 2018: Microvascular and macrovascular complications in children and adolescents. Pediatr Diabetes. 2018;19:262-74. [crossref] [PubMed]
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American Diabetes Association. Standards of Medical Care in Diabetes-2019 Abridged for Primary Care Providers. Clin Diabetes. 2019;37:11-34. [crossref] [PubMed]
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de Silva SR, Riaz Y, Evans JR. Phacoemulsification with posterior chamber intraocular lens versus extracapsular cataract extraction (ECCE) with posterior chamber intraocular lens for age-related cataract. Cochrane Database Syst Rev. 2014;(1):CD008812. [crossref] [PubMed]
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Gasper C, Trivedi RH, Wilson ME. Complications of Pediatric Cataract Surgery. Dev Ophthalmol. 2016;57:69-84. [crossref] [PubMed]
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Chen D, Gong XH, Xie H, Zhu XN, Li J, Zhao YE. The long-term anterior segment configuration after pediatric cataract surgery and the association with secondary glaucoma. Scientific reports. 2017;7:1-9. [crossref] [PubMed]
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American Diabetes Association. 6. Glycemic Targets: Standards of Medical Care in Diabetes-2020. Diabetes Care. 2020;43:S66-S76. [crossref] [PubMed]
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Tables and Figures
[Table / Fig - 1]
DOI and Others

DOI: 10.7860/JCDR/2022/52927.16451

Date of Submission: Oct 19, 2021
Date of Peer Review: Dec 15, 2021
Date of Acceptance: Feb 01, 2022
Date of Publishing: Jun 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Oct 21, 2021
• Manual Googling: Dec 14, 2021
• iThenticate Software: Jan 31, 2022 (8%)

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