Farzana Choudhury

Central and Peripheral Visual Impairment and the Risk of Falls and Falls with Injury

OBJECTIVE To evaluate whether central (CVI) and peripheral visual impairment (PVI) are independent risk factors for falls and falls with injury 4 years later. DESIGN Population-based, prospective cohort study. PARTICIPANTS A population-based sample of 3203 adult Latinos. METHODS Baseline presenting binocular central distance acuity was measured and impairment was classified as mild (20/40-20/63) or moderate/severe (<or=20/80). Peripheral visual impairment was classified as mild (-6 dB < mean deviation < -2 dB in worse eye), moderate/severe (mean deviation <or=-6 dB in worse eye). MAIN OUTCOME MEASURES Falls and falls with injury in the past 12 months were assessed by self-report at the 4-year follow-up visit. RESULTS Out of 3203 individuals, 19% reported falls and 10% falls with injury 4 years after the baseline examination; participants with falls were more likely to be >or=60 years of age, be female, report lower income, have >2 comorbidities, report alcohol use, report wearing bifocal glasses, and report obesity. Among those who reported falls, 7% had CVI (visual acuity >20/40) compared with 4% who did not report falls; and 49% had PVI (mean deviation < -2 dB) compared with 39% of those who did not report falls (both P<0.0001). After adjusting for confounders, moderate to severe CVI and PVI were associated with increased risk for falls (odds ratio [OR], 2.36; 95% confidence interval [CI], 1.02-5.45; P(trend) = 0.04; and OR, 1.42; 95% CI, 1.06-1.91l P(trend) = 0.01, respectively) and with falls with injury (OR, 2.76; 95% CI, 1.10-7.02; P(value) = 0.03; and OR, 1.40; 95% CI, 0.94-2.05 P(trend) = 0.04, respectively). CONCLUSIONS Both CVI and PVI were independently associated with increased risk for falls and falls with injury 4 years after the initial examination in a dose-response manner. Although vision-related interventions for preventing falls have mainly focused on correcting CVI, this study suggests that targeting both central and peripheral components may be necessary to effectively reduce rates of falls and falls with injury related to vision loss.

SEVERITY OF DIABETIC RETINOPATHY AND HEALTH-RELATED QUALITY OF LIFE: THE LOS ANGELES LATINO EYE STUDY

OBJECTIVE To assess the impact of diabetic retinopathy (DR) and its severity on health-related quality of life (HRQOL) in a population-based sample of Latinos with type 2 diabetes mellitus (DM). DESIGN Cross-sectional population-based study, the Los Angeles Latino Eye Study (LALES). PARTICIPANTS We included 1064 LALES participants with DM. METHODS We measured HRQOL by the 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25) and the Medical Outcomes Study 12-item Short Form Health Survey (SF-12). We assessed DR by masked standardized grading of stereoscopic photographs from 7 standard fields. Severity of DR in eyes was graded using a modified Airlie House classification. The severity scores from each eye were then concatenated to create a single per person grade ranging from 1 (no DR in either eye) to 15 (bilateral PDR). Multiple linear regression analyses were performed to determine the independent relationship between severity of DR and HRQOL after adjusting for covariates. MAIN OUTCOME MEASURES Scores on the NEI-VFQ-25 and SF-12. RESULTS More severe DR was associated with worse HRQOL scores on all of the NEI-VFQ-25 and SF-12 subscales (P<0.05). Individuals with DR from grade 2 (minimum nonproliferative diabetic retinopathy [NPDR]) through grade 8 (unilateral moderate NPDR) show a modest decline in HRQOL. However, the decline becomes significantly steeper between steps 8 (unilateral moderate NPDR) and 9-15 (bilateral moderate NPDR to bilateral PDR). The domains with the most significant impact were for vision-related daily activities, dependency, and mental health. CONCLUSIONS Greater severity of DR was associated with lower general and vision-specific HRQOL. Persons with bilateral moderate NPDR had the most substantial decrease in quality of life compared with those with less severe DR. The prevention of incident DR and, more important, its progression from unilateral to bilateral NPDR is likely to have a positive impact on a persons HRQOL and should be considered an important goal in management of individuals with DM.

Risk Factors for Cortical, Nuclear, Posterior Subcapsular, and Mixed Lens Opacities: The Los Angeles Latino Eye Study

PURPOSE To identify sociodemographic and biological risk factors associated with having cortical, nuclear, posterior subcapsular (PSC), and mixed lens opacities. DESIGN Population-based, cross-sectional study. PARTICIPANTS A total of 5945 Latinos aged ≥ 40 years from 6 census tracts in Los Angeles, California. METHODS Participants underwent an interview and detailed eye examination, including best-corrected visual acuity and slit-lamp assessment of lens opacities using the Lens Opacities Classification System II. Univariate and stepwise logistic regression analyses were used to identify independent risk factors associated with each type of lens opacity. MAIN OUTCOME MEASURES Odds ratios for sociodemographic and biological risk factors associated with cortical only, nuclear only, PSC only, and mixed lens opacities. RESULTS Of the 5945 participants with gradable lenses, 468 had cortical only lens opacities, 217 had nuclear only lens opacities, 27 had PSC only opacities, and 364 had mixed lens opacities. Older age, higher hemoglobin A(1c), and history of diabetes mellitus were independent risk factors for cortical only lens opacities. Older age, smoking, and myopic refractive error were independent risk factors for nuclear only lens opacities. Higher systolic blood pressure and history of diabetes were independent risk factors for PSC lens opacities. Older age, myopic refractive error, history of diabetes, higher systolic blood pressure, female gender, and presence of large drusen were independent risk factors for mixed lens opacities. CONCLUSIONS The modifiable and non-modifiable risk factors identified in this study provide insight into the mechanisms related to the development of lens opacification. Improved glycemic control, smoking cessation and prevention, and blood pressure control may help to reduce the risk of having lens opacities and their associated vision loss.

Four-Year Incidence and Progression of Diabetic Retinopathy and Macular Edema: The Los Angeles Latino Eye Study

PURPOSE To estimate the 4-year incidence and progression of diabetic retinopathy, macular edema (ME) and clinically significant macular edema (CSME) among adult Latinos with diabetes mellitus. DESIGN A population-based, longitudinal study of 4658 self-identified Latinos (primarily Mexican Americans), residing in Los Angeles, examined at baseline (2000-2003) and at 4 years (2004-2008). METHODS Participants underwent a standardized ophthalmic examination. Diabetic retinopathy (DR) and CSME were detected by grading of stereoscopic fundus photographs using the modified Airlie House classification scheme. chi(2) and trend tests were used to assess differences in incidence when stratifying by age and duration of diabetes. RESULTS The 4-year incidence of DR, ME, and CSME was 34.0% (182/535), 5.4% (38/699), and 7.2% (50/699) respectively. Younger persons and those with longer duration of diabetes mellitus had a higher incidence of DR compared to those who were older and had shorter duration of diabetes mellitus. A higher incidence of ME was associated with longer duration of diabetes mellitus (P = .004). Worsening/progression of any DR was found in 38.9% (126/324) and improvement occurred in 14.0% (37/265) of participants. Progression from nonproliferative DR (NPDR) to proliferative DR (PDR) and from NPDR to PDR with high-risk characteristics occurred in 5.3% and 1.9% of participants. CONCLUSIONS The 4-year incidence and progression of DR and the incidence of ME and CSME among Latinos are high compared to non-Hispanic whites. These findings support the need to identify and modify risk factors associated with these long-term complications.

Longitudinal Changes in Visual Acuity and Health-related Quality of Life: The Los Angeles Latino Eye Study

PURPOSE To examine the association between longitudinal changes in visual acuity (VA) and health-related quality of life (HRQOL) in a population-based sample of adult Latinos. DESIGN A population-based cohort study of eye disease in Latinos. PARTICIPANTS We included 3169 adult Latino participants who live in the city of La Puente, California. METHODS Data for these analyses were collected for the Los Angeles Latino Eye Study (LALES). Distance VA was measured during a detailed ophthalmologic examination using the standard Early Treatment Diabetic Retinopathy Study protocol at baseline and a 4-year follow-up examination. We assessed HRQOL by the National Eye Institute Visual Function Questionnaire (NEI-VFQ-25) and the Medical Outcomes Study 12-Item Short-Form Health Survey version 1 (SF-12). MAIN OUTCOME MEASURES Mean differences in HRQOL composite and subscale scores between baseline and follow-up were calculated for 3169 participants with complete clinical examination and HRQOL data at both time points. Mean differences and effect sizes (ES) for NEI-VFQ and SF-12 scores were calculated for 3 categories of VA change over the 4-year follow-up period (VA improved ≥ 2 lines, no change in VA or -2 < VA < 2, VA loss ≥ 2 lines). RESULTS For participants with a 2-line loss in VA, we noted an approximate 5-point loss in the NEI-VFQ-25 composite score, with the greatest score changes found for the driving difficulties, vision-related mental health, and vision-related dependency subscales (-12.7, -11.5, and -11.3, respectively). For participants with a 2-line improvement in VA, we also noted an approximate 5-point gain in the NEI-VFQ-25 composite score. The greatest change (ES = 0.80) was observed for the driving difficulties subscale. No measurable differences in HRQOL were observed for individuals without change in VA from baseline to follow-up. CONCLUSIONS Clinically important, longitudinal changes in VA (≥ 2-line changes) were associated with significant changes in self-reported visual function and well-being. Both the size and direction of VA change influenced change in HRQOL scores.

Risk Factors for Four-Year Incidence and Progression of Age-Related Macular Degeneration: The Los Angeles Latino Eye Study

PURPOSE To identify risk factors for 4-year incidence and progression of age-related macular degeneration (AMD) in adult Latinos. DESIGN Population-based prospective cohort study. METHODS Participants, aged 40 or older, from The Los Angeles Latino Eye Study (LALES) underwent standardized comprehensive ophthalmologic examinations at baseline and at 4 years of follow-up. Age-related macular degeneration was detected by grading 30-degree stereoscopic fundus photographs using the modified Wisconsin Age-Related Maculopathy Grading System. Multivariate stepwise logistic regression was used to examine the independent association of incidence and progression of AMD and baseline sociodemographic, behavioral, clinical, and ocular characteristics. RESULTS Multivariate analyses revealed that older age (OR per decade of age: 1.52; 95% CI: 1.29, 1.85) and higher pulse pressure (OR per 10 mm Hg: 2.54; 95% CI: 1.36, 4.76) were independently associated with the incidence of any AMD. The same factors were associated with early AMD, soft indistinct drusen, and retinal pigmentary abnormalities. Additionally, presence of clinically diagnosed diabetes mellitus was independently associated with increased retinal pigment (OR: 1.66; 95% CI: 1.01, 2.85), and male gender was associated with retinal pigment epithelial depigmentation (OR 2.50; 95% CI: 1.48, 4.23). Older age (OR per decade of age: 2.20; 95% CI: 1.82, 2.67) and current smoking (OR: 2.85; 95% CI: 1.66, 4.90) were independently associated with progression of AMD. CONCLUSIONS Several modifiable risk factors were associated with 4-year incidence and progression of AMD in Latinos. The results suggest that interventions aimed at reducing pulse pressure and promoting smoking cessation may reduce incidence and progression of AMD, respectively.

Visual Impairment and Blindness in Adults in the United States: Demographic and Geographic Variations From 2015 to 2050

IMPORTANCE The number of individuals with visual impairment (VI) and blindness is increasing in the United States and around the globe as a result of shifting demographics and aging populations. Tracking the number and characteristics of individuals with VI and blindness is especially important given the negative effect of these conditions on physical and mental health. OBJECTIVES To determine the demographic and geographic variations in VI and blindness in adults in the US population in 2015 and to estimate the projected prevalence through 2050. DESIGN, SETTING, AND PARTICIPANTS In this population-based, cross-sectional study, data were pooled from adults 40 years and older from 6 major population-based studies on VI and blindness in the United States. Prevalence of VI and blindness were reported by age, sex, race/ethnicity, and per capita prevalence by state using the US Census projections (January 1, 2015, through December 31, 2050). MAIN OUTCOMES AND MEASURES Prevalence of VI and blindness. RESULTS In 2015, a total of 1.02 million people were blind, and approximately 3.22 million people in the United States had VI (best-corrected visual acuity in the better-seeing eye), whereas up to 8.2 million people had VI due to uncorrected refractive error. By 2050, the numbers of these conditions are projected to double to approximately 2.01 million people with blindness, 6.95 million people with VI, and 16.4 million with VI due to uncorrected refractive error. The highest numbers of these conditions in 2015 were among non-Hispanic white individuals (2.28 million), women (1.84 million), and older adults (1.61 million), and these groups will remain the most affected through 2050. However, African American individuals experience the highest prevalence of visual impairment and blindness. By 2050, the highest prevalence of VI among minorities will shift from African American individuals (15.2% in 2015 to 16.3% in 2050) to Hispanic individuals (9.9% in 2015 to 20.3% in 2050). From 2015 to 2050, the states projected to have the highest per capita prevalence of VI are Florida (2.56% in 2015 to 3.98% in 2050) and Hawaii (2.35% in 2015 and 3.93% in 2050), and the states projected to have the highest projected per capita prevalence of blindness are Mississippi (0.83% in 2015 to 1.25% in 2050) and Louisiana (0.79% in 2015 to 1.20% in 2050). CONCLUSIONS AND RELEVANCE These data suggest that vision screening for refractive error and early eye disease may reduce or prevent a high proportion of individuals from experiencing unnecessary vision loss and blindness, decrease associated costs to the US economy for medical services and lost productivity, and contribute to better quality of life. Targeted education and screening programs for non-Hispanic white women and minorities should become increasingly important because of the projected growth of these populations and their relative contribution to the overall numbers of these conditions.

Harmonizing the classification of age-related macular degeneration in the three-continent AMD consortium

Abstract Purpose: To describe methods to harmonize the classification of age-related macular degeneration (AMD) phenotypes across four population-based cohort studies: the Beaver Dam Eye Study (BDES), the Blue Mountains Eye Study (BMES), the Los Angeles Latino Eye Study (LALES), and the Rotterdam Study (RS). Methods: AMD grading protocols, definitions of categories, and grading forms from each study were compared to determine whether there were systematic differences in AMD severity definitions and lesion categorization among the three grading centers. Each center graded the same set of 60 images using their respective systems to determine presence and severity of AMD lesions. A common 5-step AMD severity scale and definitions of lesion measurement cutpoints and early and late AMD were developed from this exercise. Results: Applying this severity scale changed the age-sex adjusted prevalence of early AMD from 18.7% to 20.3% in BDES, from 4.7% to 14.4% in BMES, from 14.1% to 15.8% in LALES, and from 7.5% to 17.1% in RS. Age-sex adjusted prevalences of late AMD remained unchanged. Comparison of each center’s grades of the 60 images converted to the consortium scale showed that exact agreement of AMD severity among centers varied from 61.0–81.4%, and one-step agreement varied from 84.7–98.3%. Conclusion: Harmonization of AMD classification reduced categorical differences in phenotypic definitions across the studies, resulted in a new 5-step AMD severity scale, and enhanced similarity of AMD prevalence among the four cohorts. Despite harmonization it may still be difficult to remove systematic differences in grading, if present.

Risk Factors for Incident Cortical, Nuclear, Posterior Subcapsular, and Mixed Lens Opacities

PURPOSE To identify sociodemographic and biological risk factors associated with the 4-year incidence of nuclear, cortical, posterior subcapsular (PSC), and mixed lens opacities. DESIGN Population-based, longitudinal study. PARTICIPANTS We included 4658 Latinos ≥40 years from 6 census tracts in Los Angeles, California. METHODS Participants underwent an interview and detailed eye examination, including best-corrected visual acuity and slit-lamp assessment of lens opacities using the Lens Opacities Classification System II (LOCS II) at baseline and again 4 years later. Each opacity type was defined in persons with a LOCS II score of ≥2. Univariate and forward stepwise logistic regression analyses were used to identify independent baseline risk factors associated with 4-year incidence of nuclear only, cortical only, PSC only, and mixed (when >1 opacity type developed in a person) lens opacities. These comprised 4 mutually exclusive groups, and were based on person rather than eye. MAIN OUTCOME MEASURES Odds ratios for independent risk factors associated with 4-year incidence of nuclear-only, cortical-only, PSC-only, and mixed lens opacities. RESULTS Of the 3471 participants with gradable lenses in the same eye at baseline and 4-year follow-up, 200 (5.8%) had incident nuclear-only opacities, 151 (4.1%) had incident cortical-only opacities, 16 (0.5%) had incident PSC-only lens opacities, and 88 (2.5%) had mixed lens opacities. Independent baseline risk factors for incident nuclear-only lens opacities included older age, current smoking, and presence of diabetes. Independent risk factors for incident cortical-only lens opacities included older age and having diabetes at baseline. Female gender was an independent risk factor for incident PSC-only lens opacities. Older age and presence of diabetes at baseline examination were independent risk factors for incident mixed lens opacities. Specifically, in diabetics, higher levels of hemoglobin A1c was associated with greater risk for 4-year incident nuclear-only, cortical-only and mixed lens opacities. CONCLUSIONS Improved diabetic control and smoking prevention may reduce the risk of developing lens opacities. Understanding both modifiable and nonmodifiable risk factors provides insight into the development of lens opacification.

Ocular Risk Factors for Age-Related Macular Degeneration: The Los Angeles Latino Eye Study

PURPOSE To assess the association between ocular factors and age-related macular degeneration (AMD) in Latinos. DESIGN Population-based, cross-sectional study of 6357 self-identified Latinos aged 40 years and older. METHODS Ophthalmic examination included subjective refraction, measurement of axial length, evaluation of iris color, Lens Opacities Classification System II (LOCS II) grading of cataracts, and stereoscopic macular photographs for AMD lesions. Generalized estimating equation analysis incorporated data from both eyes to estimate odds ratios (OR) adjusted for covariates. RESULTS After controlling for confounders (age, gender, and smoking), prior cataract surgery was associated with advanced AMD (OR, 2.8; 95% CI, 1.01, 7.8), increased retinal pigment (OR, 1.6; 95% CI, 1.02, 1.5), and retinal pigment epithelial depigmentation (OR, 2.2; 95% CI, 1.1, 4.4). The presence of any lens opacity was associated with soft drusen (OR, 1.2; 95% CI, 1.002, 1.5). Longer axial length (per mm) was associated with decreased odds of soft drusen, increased retinal pigment, and geographic atrophy (GA) (ORs, 0.8 [95% CI, 0.7, 0.9], 0.8 [95% CI, 0.7, 0.9], 0.7 [95% CI, 0.5, 0.9], respectively). Myopia was inversely associated with soft drusen (OR, 0.8; 95% CI, 0.7, 0.99). Lighter-colored irises were associated with GA (OR, 5.0; 95% CI, 1.0, 25.3). CONCLUSIONS Cross-sectional associations of ocular factors such as cataract, cataract surgery, and refractive errors with early AMD lesions found in Latinos are consistent with those in non-Hispanic Whites. Additionally, prior cataract surgery was associated with advanced AMD.