Optimal screening practices for diabetic retinopathy in children and adolescents with type 1 diabetes: a systematic review to inform global screening guidance

Observational and interventional studies involving individuals aged <20 years with T1D were eligible. Major databases were searched from 1995 to 2024 and risk of bias was assessed using Joanna Briggs Institute critical appraisal tools. Sixty-two studies met the inclusion criteria, involving more than 200,000 participants. No randomized trials or direct comparisons of screening strategies were identified. The mean study prevalence of diabetic retinopathy was 9.5%, with higher prevalence reported in low- and lower-middle-income countries. Most cases occurred after five years of diabetes duration and after 11 years of age, although rare cases were reported earlier. Higher HbA1c levels (≥9%) were associated with increased retinopathy prevalence. Mydriatic screening improved detection compared with non-mydriatic approaches (11.5% vs 4.4%). Only six studies reported screening intervals, all from high-income countries. Sight-threatening retinopathy was rare and largely confined to older adolescents with longer diabetes duration. Findings support current recommendations for screening initiation and highlight the need for prospective studies, particularly in low- and middle-income countries.