Susan C. Jensen

Risk factors for age-related macular degeneration: Pooled findings from three continents.

OBJECTIVE To assess the prevalence and potential risk factors for late age-related macular degeneration (AMD) in three racially similar populations from North America, Europe, and AUSTRALIA: DESIGN Combined analysis of population-based eye disease prevalence data. PARTICIPANTS There were 14,752 participants with gradable photographs from the Beaver Dam Eye Study (n = 4756), Rotterdam Study (n = 6411), and Blue Mountains Eye Study (n = 3585). MAIN OUTCOME MEASURES AMD diagnosis was made from masked grading of stereo macular photographs. Final classification of AMD cases was agreed by consensus between study investigators. RESULTS AMD prevalence was strongly age related. Overall, AMD was present in 0.2% of the combined population aged 55 to 64 years, rising to 13% of the population older than 85 years. Prevalence of neovascular AMD (NV) increased from 0.17% among subjects aged 55 to 64 years to 5.8% for those older than 85 years. Prevalence of pure geographic atrophy (GA) increased from 0.04% to 4.2% for these age groups. There were no significant gender differences in the prevalence of NV or GA. Subjects in the Rotterdam population had a significantly lower age-adjusted and smoking-adjusted risk of NV than subjects in the Beaver Dam and Blue Mountains populations. Apart from age, tobacco smoking was the only risk factor consistently associated with any form of AMD in all sites separately and in pooled analyses over the three sites. CONCLUSIONS These combined data from racially similar communities across three continents provide strong and consistent evidence that tobacco smoking is the principal known preventable exposure associated with any form of AMD.

The Five-year Incidence and Progression of Age-related Maculopathy

PURPOSE The aim of the study was to describe the incidence and progression of retinal drusen, retinal pigmentary abnormalities, and signs of late age-related maculopathy. POPULATION A population of 3583 adults (range, 43-86 years of age at baseline) living in Beaver Dam, Wisconsin, was studied during a 5-year period. METHODS Characteristics of drusen and other lesions typical of age-related maculopathy were determined by grading stereoscopic color fundus photographs using the Wisconsin Age-Related Maculopathy Grading System. RESULTS There was a statistically significant increased incidence of age-related maculopathy lesions with age (P < 0.05). Individuals 75 years of age or older had a significantly (P < 0.01) higher 5-year incidence of the following characteristics than people 43 to 54 years of age: larger sized drusen (125-249 microm, 17.6% vs. 2.1%; > or = 250 microm, 6.5% vs. 0.2%), soft indistinct drusen (16.3% vs. 1.8%), retinal pigment abnormalities (12.9% vs. 0.9%), exudative macular degeneration (1.8% vs. 0%), and pure geographic atrophy (1.7% vs. 0%). After adjusting for age, the incidence of early age-related maculopathy was 2.2 times (95% confidence interval 1.6, 3.2) as likely in women 75 years of age or older compared with men this age. At follow-up, late age-related macular degeneration was more likely to develop in eyes with soft indistinct drusen (6.5% vs. 0.1%) or retinal pigmentary abnormalities (7.1% vs. 0.1%) at baseline than in eyes without these lesions. CONCLUSIONS These population-based estimates document the high incidence of signs of age-related maculopathy in people 75 years of age or older, and in women compared with men that age. The findings demonstrate that the presence of soft drusen and pigmentary abnormalities significantly increases the risk for the development of geographic atrophy and exudative macular degeneration.

Open-angle Glaucoma and Older-onset Diabetes: The Beaver Dam Eye Study

PURPOSE To evaluate the relation of older-onset diabetes to open-angle glaucoma. METHODS During a population-based study of age-related eye disease (n = 4926), participants were evaluated for the presence of glaucoma. Glycosylated hemoglobin levels were measured, and a medical history was obtained. RESULTS Rates of persons meeting optic disc, visual field, and intraocular pressure criteria for definite glaucoma were more common in those with older-onset diabetes than in those without (4.2% versus 2.0%; P = 0.004). When persons with a history of treated glaucoma, despite whether they met the other criteria for glaucoma, were included, rates were 7.8% in those with diabetes compared with 3.9% in those without diabetes (P = 0.0005). CONCLUSIONS The presence of open-angle glaucoma is increased in people with older-onset diabetes.

Age-related maculopathy in a multiracial United States population: the National Health and Nutrition Examination Survey III.

OBJECTIVE To investigate the prevalence of and risk factors for age-related maculopathy (ARM) in three racial/ethnic groups: non-Hispanic whites, non-Hispanic blacks, and Mexican-Americans. DESIGN A nationally representative population-based, cross-sectional study. PARTICIPANTS A total of 8270 persons 40 years of age or older, a sample of the Third National Health and Nutrition Examination Survey. MAIN OUTCOME MEASURES Age-related maculopathy was determined by the grading of fundus photographs using a standardized protocol. RESULTS The prevalence of any ARM in the civilian noninstitutionalized United States population including those 40 years of age or older was 9.4% (95% confidence interval [CI], 8.2, 10.6) as estimated from the sample. After adjusting for age, there was no difference in the prevalence of early ARM (defined largely by the presence of soft drusen) by ethnic/racial group. However, for the less frequent component lesions of early ARM (increased retinal pigment and retinal pigment epithelial depigmentation), the odds ratios (95% CIs) comparing non-Hispanic blacks to non-Hispanic whites were 0.47 (0.31, 0.74) and 0.59 (0.33, 1.04), respectively, and for comparing Mexican-Americans to non-Hispanic whites, they were 0.41 (0.21, 0.81) and 0.72 (0.44, 1.19), respectively. For late ARM, the odds ratio (95% CI) for non-Hispanic blacks compared to non-Hispanic whites was 0.34 (0.10, 1.18) and for Mexican-Americans compared to non-Hispanic whites, it was 0.25 (0.07, 0.90). Other than age, none of the personal, medical, or physiologic variables studied were statistically significantly associated with any of the ARM endpoints in any of the three races/ethnic groups. CONCLUSION Overall, rates of any ARM (including all early and late lesions) are not significantly different among non-Hispanic blacks, Mexican-Americans, and non-Hispanic whites. However, the rates of individual lesions suggest that non-Hispanic whites and Mexican-Americans may be protected against retinal pigment abnormalities and lesions associated with late ARM. There appears to be little influence of personal, medical, and environmental factors studied on these results. Further studies in larger populations of older persons in these ethnic groups would likely clarify these relations.

The Relation of Cardiovascular Disease and Its Risk Factors to the 5-year Incidence of Age-related Maculopathy: The Beaver Dam Eye Study

OBJECTIVE The purpose of the study is to examine the association between cardiovascular disease and its risk factors and the incidence of age-related maculopathy. PARTICIPANTS A population of 3583 adults (range, 43-86 years of age at baseline) living in Beaver Dam, Wisconsin, was studied at baseline and 5 years later. METHODS Standardized protocols for physical examination, blood collection, administration of a questionnaire, and stereoscopic color fundus photography to determine age-related maculopathy were used. Standard univariate and multivariate analyses were performed. MAIN OUTCOME MEASURES Incidence and progression of age-related maculopathy were measured. RESULTS After controlling for age and gender, the authors found both higher systolic blood pressure (odds ratio [OR] per 10 mmHg, 1.16; 95% confidence interval [CI] 1.05, 1.27) and uncontrolled treated hypertension (OR 1.98, 95% CI 1.00, 3.94) were related to the incidence of retinal pigment epithelial depigmentation. After controlling for age and gender, the authors found that both blood pressure and uncontrolled treated hypertension were not significantly associated with an increased risk of having exudative macular degeneration develop (for systolic blood pressure, OR 1.18, 95% CI 0.95, 1.45; for uncontrolled treated hypertension, OR 2.10, 95% CI 0.54, 8.11). After controlling for age and gender, the authors found higher pulse pressure was significantly associated with increased incidence of retinal pigment epithelial depigmentation (OR per 10 mmHg 1.27, 95% CI 1.14, 1.42) and exudative macular degeneration (OR per 10 mmHg 1.29, 95% CI 1.02, 1.65). These relations remained significant after controlling for other risk factors in multivariable analyses. CONCLUSIONS These findings indicate modest relations between higher pulse pressure (a presumed indicator of atherosclerotic vascular disease) and uncontrolled hypertension with increased 5-year incidence of retinal pigment epithelial depigmentation. Overall, however, data from this study show neither consistent nor strong relations between cardiovascular disease and most of its risk factors with the incidence of lesions associated with age-related maculopathy.

Measures of obesity and age-related eye diseases.

OBJECTIVE. To compare body mass index with waist-to-hip ratio as correlates of age-related eye disease. DESIGN. Population-based cross-sectional study. PARTICIPANTS. Participants of the Beaver Dam Eye Study at 5-year follow-up examinations. METHODS. Body mass index was computed from weight and height, and waist-to-hip ratio was computed from measurements all done at the 5-year examination. Presence of ocular lesions was based on gradings of standard photographs of the retina and lens. MAIN OUTCOME MEASURES. Presence of early and late age-related maculopathy and nuclear, cortical, and posterior subcapsular cataracts. RESULTS. In women, early age-related maculopathy was significantly associated with both body mass index and waist-to-hip ratio. The relationship between waist-to-hip ratio and late age-related maculopathy was of borderline significance. When analyzed as continuous measures, waist-to-hip ratio was more strongly associated with nearly every outcome compared to body mass index. In men, there was little difference between body mass index and waist-to-hip ratio as correlates of age-related eye diseases. The reason for differences between men and women is not clear, but is unlikely to be due to current exposure to estrogen. CONCLUSIONS. In women in our analyses, waist-to-hip ratio is more strongly associated with age-related eye disease than is body mass index. When adiposity is considered as a risk factor itself, or as a confounder of risk factors for age-related ocular disease, waist-to-hip ratio may be the better measure to use in women.

Hypertension and Lens Opacities From the Beaver Dam Eye Study

PURPOSE To examine the relationship between hypertension and lens opacities, and the use of antihypertensive agents. METHODS A total of 4,926 adults, 43 to 84 years of age, living in Beaver Dam, Wisconsin, at the time of a private census, were invited to participate in a study that included a medical interview and an examination that included ocular photography. All study procedures and photographic grading were done according to standard protocols. RESULTS According to analysis with the Liang-Zeger multiple logistic regression model, people with hypertension were more likely to have posterior subcapsular opacities than people without hypertension (odds ratio, 1.39; 95% confidence interval, 1.05, 1.84). Specific medications for hypertension did not meaningfully affect the risk. Hypertension was associated with increased risk in both those with and without diabetes. CONCLUSIONS Hypertension is associated with increased risk of posterior subcapsular opacities. The pathophysiologic mechanisms that may explain the relationship are unknown. Incidence data will give a better indication of temporal relationship between hypertension, medications to lower blood pressure, and lens opacities.

Alcohol Use and Age-related Maculopathy in the Beaver Dam Eye Study

PURPOSE Because there are few epidemiologic data examining the relationship between alcohol use and age-related maculopathy, we investigated this relationship via the population-based Beaver Dam Eye Study. METHODS Alcohol consumption in the year before examination was determined by a standardized questionnaire. Age-related maculopathy status was determined by grading stereoscopic color fundus photographs. RESULTS While controlling for other factors, consumption of beer in the past year was related to greater odds of increased retinal pigment degeneration (odds ratio, 1.13; 95% confidence interval, 1.02, 1.25) and exudative macular degeneration (odds ratio, 1.41; 95% confidence interval, 1.05, 1.88). Current consumption of neither wine nor liquor was related to early or late age-related maculopathy. CONCLUSIONS These data suggest a relationship between beer consumption and greater odds of having exudative macular degeneration. Whether this is from a toxic effect specific to beer or from other unknown confounders cannot be determined.

The relation of socioeconomic factors to the incidence of proliferative diabetic retinopathy and loss of vision

PURPOSE To investigate the relations between socioeconomic factors and the incidence of proliferative retinopathy and loss of vision. METHODS A population-based sample of younger-onset persons with diabetes 25 years of age or older (n = 334) and older-onset persons with diabetes (n = 906) was followed over a 4-year period. Education, occupational status, employment status, and marital status were measured at baseline and follow-up. Main outcome measures were incidence of proliferative retinopathy and loss of vision measured using standard protocols. RESULTS Proliferative retinopathy was more likely to develop in younger-onset women with less education than in those with more education; no relation was found in the older-onset group. Education was associated inversely with incidence of loss of vision in younger-onset women and older-onset men. CONCLUSION These data suggest that education is associated with the development of loss of vision, independent of other risk factors. The associations vary between men and women and between younger-onset and older-onset people with diabetes. Further understanding of these relationships may lead to interventions to prevent loss of vision in people with diabetes.

The relation of socioeconomic factors to the incidence of early age-related maculopathy : The Beaver Dam Eye Study

PURPOSE To investigate the relationship between socioeconomic factors and the 5-year incidence of age-related maculopathy. METHODS The Beaver Dam Eye Study, a population-based cohort study, examined 3681 adults (range, 43-86 years of age at baseline) living in Beaver Dam, Wisconsin, at baseline and 5 years later. Standardized protocols for physical examination, including administration of a questionnaire that included questions regarding income, education level, and status and type of employment, and fundus photography to determine age-related maculopathy, were performed. RESULTS While controlling for age and sex, less education, and being in a service-related occupation compared with a white collar professional occupation, was associated (P <.05) with the incidence of early age-related maculopathy. CONCLUSION These data show an association of education and occupation but not income with the incidence of early age-related maculopathy that appears independent of smoking or vitamin supplement use status.