Simon P Kelly

Smoking and age-related macular degeneration: A review of association

PurposeAge-related macular degeneration (AMD) is the leading cause of severe and irreversible vision loss in the Western world. As there is no effective treatment for all types of AMD, identifying modifiable risk factors is of great importance. This review evaluates the epidemiological evidence associating smoking with AMD.MethodsSystematic review of published epidemiological studies evaluated against established criteria for evidence of a causal relationship.ResultsIn total, 17 studies (cross-sectional studies, prospective cohort studies, and case–control studies) were included in the review. A total of 13 studies found a statistically significant association between smoking and AMD with increased risk of AMD of two- to three-fold in current-smokers compared with never-smokers. Five studies found no association between smoking and AMD. There was also evidence of dose-response, a temporal relationship and reversibility of effect.ConclusionThe literature review confirmed a strong association between current smoking and AMD, which fulfilled established causality criteria. Cigarette smoking is likely to have toxic effects on the retina. In spite of the strength of this evidence, there appears to be a lack of awareness about the risks of developing eye disease from smoking among both healthcare professionals and the general public.

Cigarette smoking and thyroid eye disease : a systematic review

PurposeTo evaluate the epidemiological evidence for a causal association between tobacco smoking and thyroid eye disease (TED).MethodsSystematic review, including quality assessment, of published epidemiological studies and evaluation of the evidence using established causality criteria.ResultsFourteen papers describing 15 studies were included. There was a positive association between smoking and TED in four case–control studies when compared with control patients with Graves’ disease but no ophthalmopathy (odds ratio (OR) 1.94–10.1) and in seven case–control studies in which control subjects did not have thyroid disease (OR 1.22–20.2). Two cohort studies examined the occurrence of new cases of TED; one study found an increased incidence of TED with smoking. Four cohort studies investigated progression or outcome of treatment in patients with established TED, three finding an association between smoking and poorer outcome. The quality of the studies was variable, but the association with smoking was strong in the most methodologically rigorous studies. Other evidence supporting a causal link was a consistent association across studies, a dose–response effect, a reduced risk of TED in ex-smokers, and a temporal relationship.ConclusionThis systematic review provided strong evidence for a causal association between smoking and development of TED. Current-smokers were also more likely to experience disease progression or poorer outcome of treatment. Patients with Graves’ disease and the general public should be educated about the risk of smoking and TED. These findings suggest that patients with Graves’ disease or TED who are smokers should be given effective support to stop smoking.

Smoking and cataract: review of causal association.

&NA; Several risk factors for the development of cataract have been identified. This review evaluates epidemiologic literature that has examined tobacco smoking as a risk factor for cataract formation using established causality criteria. Twenty‐seven studies were included in this review. Evidence suggests that smoking has a 3‐fold increase on the risk for incident nuclear cataract development. There was also evidence of dose response, temporal relationship, and reversibility of effect. There was limited evidence of an association between smoking and posterior subcapsular cataract, but little or no association with cortical cataract. Thus, the literature review indicated a strong association between smoking and the development of cataract, particularly nuclear cataract. The association fulfills the established criteria for causality. The association between smoking and other types of cataract is less distinct and requires further evaluation.

Cigarette smoking and primary open angle glaucoma: a systematic review.

PurposeTo evaluate the epidemiologic evidence for a causal association between tobacco smoking and primary open angle glaucoma (POAG). MethodsSystematic review, including quality assessment, of published analytical epidemiologic studies and evaluation of the evidence using established causality criteria (strength, consistency, temporality, dose response, reversibility, and biologic plausibility). ResultsEleven papers describing 9 case-control studies, 1 prospective cohort study, and a paper describing a pooled analysis based on 2 prospective cohort studies were included in the review. The methodologic quality of most included studies was poor. The strongest studies methodologically were the cohort studies on which the pooled analysis was based. Neither the prospective cohort study (rate ratio not reported) nor the pooled analysis of 2 prospective cohort studies (adjusted rate ratio 0.9) found an association between smoking and POAG. There was a significant positive association between smoking and POAG in only 2 of the case-control studies (adjusted odds ratio 2.9 and 10.8). There was no evidence of a dose-response relationship with smoking or of reversibility of effect in the studies where this was assessed. ConclusionsThis systematic review provided little evidence for a causal association between smoking and development of POAG. Given the limited evidence from high quality studies, and the possibility that flaws in many of the studies reviewed biased the results toward the null, further high quality research to confirm our conclusions is needed. However, it remains important to warn ophthalmic patients of the dangers of smoking and provide cessation support owing to the clear evidence of links between smoking and other ocular and systemic diseases.

Perceptions of blindness related to smoking: a hospital-based cross-sectional study

AimsSmoking is associated with several serious eye diseases. Awareness of smoking and blindness, and its potential to act, as a stimulus to assist stopping smoking has not been investigated.MethodsA cross-sectional survey using a structured interview of adult patients attending district general hospital ophthalmology, general surgery, and orthopaedic clinics. The interview investigated the awareness and fear of blindness for three established smoking-related diseases, and a distractor condition (deafness), and the likelihood that smokers would quit on developing early signs of each condition.ResultsResponse was 89.1% (358/402). In all, 183 (51.1%) of responders were male and 175 (48.9%) female. Only 9.5% of patients believed that smoking was definitely or probably a cause of blindness, compared with 92.2% for lung cancer, 87.6% for heart disease, and 70.6% for stroke. Patients ranked their fear of each of the five conditions, scoring five for the most feared and one for the least feared. Patients were significantly (P<0.01) less fearful of blindness (mean score 2.80) than lung cancer (3.89), heart disease (3.58), and stroke (3.35). About one-half of smokers stated that they would definitely or probably quit smoking if they developed early signs of blindness or the three established smoking-related conditions, with no significant differences in proportions for these four conditions.ConclusionThe findings suggest that awareness of the risk of blindness from smoking is low, but that the fear of blindness is as compelling a motivation to quit as fear of lung cancer, heart disease, and stroke. The link between smoking and eye disease should be publicised to help reduce smoking prevalence.

Teenagers’ perceptions of blindness related to smoking: a novel message to a vulnerable group

Background: Cigarette smoking often starts in teenage years. It is not known whether teenagers are aware of the association of smoking with eye disease and blindness. Aim: To explore the knowledge of the link between smoking, and eye diseases and blindness, and the likely impact of this knowledge among teenagers in UK. Methods: A cross-sectional survey, using a structured interview of teenagers attending four organised social events, was conducted. Awareness and fear of blindness, and of three smoking-related diseases (lung cancer, heart disease and stroke) and a distractor condition (deafness) was investigated. The likelihood of smokers quitting on developing early signs of each condition was determined. Results: A 92% “opt in” response rate was achieved. Out of 260 teenagers (16–18 years), 15%, 27% and 81% believed that smoking caused stroke, heart disease and lung cancer, respectively. Only 5% believed smoking caused blindness. Subjects ranked their fear of each of the five conditions, scoring five for the most feared and one for the least feared. Subjects were significantly (p<0.01) more fearful (mean scores in brackets) of blindness (4.2) than of lung cancer (3.4), heart disease (2.3) and deafness (1.2). More teenagers (p<0.01) said they would stop smoking on developing early signs of blindness compared with early signs of lung or heart disease. Conclusions: Awareness of the risk of blindness from smoking is low among teenagers, but fear of blindness may be more likely to motivate teenagers to stop smoking than fear of lung or heart disease. Teenagers should be made more aware of the ocular risks of cigarette smoking as a novel public health measure.

Smoking and blindness

Strong evidence for the link, but public awareness lags While most people and many patients attending eye clinics recognise many adverse health hazards of tobacco smoking, they remain largely unaware of its link with blindness. Although smoking is associated with several eye diseases, including nuclear cataractw1 w2 and thyroid eye disease,w3 the most common cause of smoking related blindness is age related macular degeneration, which results in severe irreversible loss of central vision. Current treatment options are of only partial benefit to selected patients. Identifying modifiable risk factors to inform efforts for prevention is a priority. A risk factor is generally judged to be a cause of disease if certain causality criteria are fulfilled.w4 Applying commonly used criteriaw4 to available evidence provides strong evidence of a causal link between tobacco smoking and age related macular degeneration. The strength of association is confirmed in a pooled analysis of data from three cross sectional studies, totalling 12 468 participants, in which current smokers had a significant threefold to fourfold increased age adjusted risk of age related macular degeneration compared with never smokers.1 By way of comparison, although the relative risks associated …

Incidence and baseline clinical characteristics of treated neovascular age-related macular degeneration in a well-defined region of the UK

Aims To analyse the incidence and baseline clinical characteristics of patients with neovascular age-related macular degeneration (nAMD) treated with intravitreal anti-vascular endothelial growth factor (VEGF) injections in a defined UK region. Methods A standardised dataset was collected prospectively using an electronic medical record (EMR) system from 1 January 2008 to 21 June 2012 for all patients living in Gloucestershire who received intravitreal anti-VEGF injections for nAMD. Results Over the study period, 1207 eyes from 1033 patients began intravitreal anti-VEGF injections for nAMD. The annual incidence in the years after National Institute for Health and Care Excellence (NICE) technology appraisal 155 implementation was stable at 120 (95% CI 110 to 138) eyes or 100 (89 to 115) people per 100 000 population. The most common indication was occult choroidal neovascularisation (51%). Median baseline visual acuity (VA) was significantly higher for second treated than first treated eyes (66 and 56 letters, respectively; p<0.0001). Median baseline VA of fellow eyes increased from 47 (2008) to 67 letters (2012; p<0.005). The proportion of patients with baseline VA in the better eye ≥70 letters increased from 27.6% (2008) to 51.4% (2012; p<0.0001), while the proportion eligible at baseline for full or partial certificate of visual impairment decreased from 13.8% (2008) to 7.1% (2012; p<0.05). Conclusions The incidence of patients undergoing anti-VEGF therapy for nAMD increased substantially following NICE approval of ranibizumab (August 2008), and has been stable since 2009. This equates to an annual UK incidence of 26 850 (21 320 to 32 440) eyes, similar to NICE estimates. Patients eligible for blindness certification before treatment decreased by half from 2008–2012. Prospective data collection using an EMR system is invaluable for efficient monitoring of real-world clinical care.

Attitudes of community optometrists to smoking cessation: an untapped opportunity overlooked?

Aim:  To assess community optometrists’ attitudes and current behaviour regarding provision of smoking cessation advice in their practice.

Attitudes and behaviour of ophthalmologists to smoking cessation.

AimsGrowing evidence suggests a causal association between smoking and eye disease. This study explores the current beliefs and practice among UK consultant ophthalmologists towards delivering smoking cessation advice to eye clinic attenders.MethodsA cross-sectional survey using a postal questionnaire of all UK NHS hospital based consultant ophthalmologists was conducted. The questionnaire explored whether: ophthalmologists identify the smoking status of their patients, advise about the increased risk of eye diseases among smokers, and deliver smoking cessation advice. The availability of departmental smoking cessation resources was also ascertained.ResultsThe response rate was 55% (485/886). Of the responders 79% were males. Only 35% of responders asked about smoking status every time or most times for new patients and 5% for follow-up patients. In all, 40% claimed to always or usually advise patients to quit smoking and 61% claimed to always or usually mention eye disease as a reason to quit. Only 14% assessed motivation to quit and 22% provided advice and assistance about how to stop smoking to smokers who wished to quit. Female ophthalmologists were more likely to undertake most aspects of smoking assessment and intervention. Only 18% of responders stated that their departments provide information about smoking for patients and 6% stated that support is available for patients wanting to quit smoking.ConclusionThe assessment of smoking status and provision of targeted support for smokers to quit could be substantially improved in UK ophthalmology departments. There is a need to introduce smoking cessation support into routine ophthalmic practice and provide the resources to support this.