A prospective longitudinal study of 182 children and adolescents with diabetes revealed that during a follow-up of 2.5 +/- 0.5 years the prevalence of retinopathy increased from 10.8% to 28.0%, corresponding to an annual increase of 7%. Retinopathy was diagnosed at a mean age of 15.3 years (95% CI, 14.8-15.8 years) after a mean duration of diabetes of 8.9 years (95% CI, 8.0-9.7 years). Prepubertal years of diabetes contributed to the risk of developing retinopathy. The initial signs of retinopathy were microaneurysm(s) in 56%, microaneurysm(s) and haemorrhage(s) in 30%, and haemorrhage(s) in 10%. A combination of microaneurysm, haemorrhage and cotton-wool spot was observed in 2%, and microaneurysms, haemorrhage and an IRMA lesion were seen in 2%. Most of the initial lesions disappeared during the follow-up period, but at the same time new lesions developed elsewhere in the retina in all but 2 cases. In 8 patients (15% of patients with retinopathy) aged 13.7-19.8 years and having had diabetes for 3.7-14.8 years, retinal changes progressed from mild to a more advanced background retinopathy. A higher glycated haemoglobin level during puberty was the only factor which differentiated these patients from control patients matched for sex, age, puberty and duration of diabetes.