Yury L. Stanislavsky

The Epidemiology of Dry Eye in Melbourne, Australia

OBJECTIVE To describe the epidemiology of dry eye in the adult population of Melbourne, Australia. DESIGN A cross-sectional prevalence study. PARTICIPANTS Participants were recruited by a household census from two of nine clusters of the Melbourne Visual Impairment Project, a population-based study of age-related eye disease in the 40 and older age group of Melbourne, Australia. Nine hundred and twenty-six (82.3% of eligible) people participated; 433 (46.8%) were male. They ranged in age from 40 to 97 years, with a mean of 59.2 years. MAIN OUTCOME MEASURES Self-reported symptoms of dry eye were elicited by an interviewer-administered questionnaire. Four objective assessments of dry eye were made: Schirmers test, tear film breakup time, rose bengal staining, and fluorescein corneal staining. A standardized clinical slit-lamp examination was performed on all participants. Dry eye for the individual signs or symptoms was defined as: rose bengal > 3, Schirmers < 8, tear film breakup time < 8, > 1/3 fluorescein staining, and severe symptoms (3 on a scale of 0 to 3). RESULTS Dry eye was diagnosed as follows: 10.8% by rose bengal, 16.3% by Schirmers test, 8.6% by tear film breakup time, 1.5% by fluorescein staining, 7.4% with two or more signs, and 5.5% with any severe symptom not attributed to hay fever. Women were more likely to report severe symptoms of dry eye (odds ratio [OR] = 1.85; 95% confidence limits [CL] = 1.01, 3.41). Risk factors for two or more signs of dry eye include age (OR = 1.04; 95% CL = 1.01, 1.06), and self-report of arthritis (OR = 3.27; 95% CL = 1.74, 6.17). These results were not changed after excluding the 21 people (2.27%) who wore contact lenses. CONCLUSIONS These are the first reported population-based data of dry eye in Australia. The prevalence of dry eye varies by sign and symptom.

The prevalence of glaucoma in the Melbourne Visual Impairment Project

PURPOSE The purpose of the study was to determine the prevalence of glaucoma in Melbourne, Australia. METHODS All subjects were participants in the Melbourne Visual Impairment Project (Melbourne VIP), a population-based prevalence study of eye disease that included residential and nursing home populations. Each participant underwent a standardized eye examination, which included a Humphrey Visual Field test, applanation tonometry, fundus examination including fundal photographs, and a medical history interview. Glaucoma status was determined by a masked assessment and consensus adjudication of visual fields, optic disc photographs, intraocular pressure, and glaucoma history. RESULTS A total of 3271 persons (83% response rate) participated in the residential Melbourne VIP. The overall prevalence rate of definite primary open-angle glaucoma in the residential population was 1.7% (95% confidence limits = 1.21, 2.21). Of these, 50% had not been diagnosed previously. Only two persons (0.1%) had primary angle-closure glaucoma and six persons (0.2%) had secondary glaucoma. The prevalence of glaucoma increased steadily with age from 0.1% at ages 40 to 49 years to 9.7% in persons aged 80 to 89 years. There was no relationship with gender. The authors examined 403 (90.2% response rate) nursing home residents. The age standardized rate for this component was 2.36% (95% confidence limits = 0, 4.88). CONCLUSION The rate of glaucoma in Melbourne rises significantly with age. With only half of patients being diagnosed, glaucoma is a major eye health problem and will become increasingly important as the population ages.

Visual Impairment in Australia: Distance Visual Acuity, Near Vision, and Visual Field Findings of the Melbourne Visual Impairment Project

PURPOSE To describe the age-specific and gender-specific rates of blindness and visual impairment in urban adults aged 40 years and older. METHODS A population-based sample of residents was recruited. Presenting and best-corrected distance visual acuities were assessed. Functional near vision was measured at each participants preferred distance. Visual field examination was performed with a Humphrey Field Analyzer (HFA); those unable to perform the field analyzer test attempted a Bjerrum screen or confrontation field. RESULTS The study population comprised 3,271 residents (83% of eligible) from ages 40 to 98 years; 54% were women. Overall, 56% of the study population wore distance correction; this was significantly lower in men but higher in the older age groups. Age-adjusted rates of blindness were 0.066% in men and 0.170% in women. Vision with current correction improved after refraction by gender and age. Direct age-standardized rates of functional near vision did not vary significantly by gender. Forty-six people had significant visual field loss in their better eye. The proportion of participants with constriction of the visual field to within 20 degrees of fixation was similar for men and women when controlled for age (odds ratio, 0.81; 95% confidence interval, 0.44 to 1.49) but increased significantly with age controlled for gender. Visual field abnormalities were detected in 548 right eyes (17%) and 533 left eyes (16%). CONCLUSIONS Although overall rates of blindness because of visual acuity loss were relatively low, nearly three times more people had visual impairment because of visual field loss than visual acuity loss. These results highlight the need to target blindness prevention programs to the aging population, with a special emphasis on women.

Methods for a population-based study of eye disease: the Melbourne Visual Impairment Project.

The methodology of the Melbourne Visual Impairment Project, a major population-based survey of eye disease on 3,500 randomly selected individuals aged 40 years of age and over in the Melbourne metropolitan region, is presented. The aims of the study are to determine the distribution and determinants of eye disease in an urban population; the impact of eye disease on visual function and the activities of daily living; and the accessibility of eye health care services in the community. All procedures are conducted according to a standardised protocol to allow for comparison with other population-based studies, both in Australia and overseas. Information collected from this study will be employed in the development of recommendations related to eye health care service delivery and establishment of priorities for future public education programmes and health research.

Use of eye care services by people with diabetes: the Melbourne Visual Impairment Project

AIM The use of eye care services by people with and without diabetes was investigated in the Melbourne Visual Impairment Project (VIP), a population based study of eye disease in a representative sample of Melbourne residents 40 years of age and older. METHODS A comprehensive interview was employed to elicit information on history of diabetes, medication use, most recent visit to an ophthalmologist and optometrist, and basic demographic details. Presence and extent of diabetic retinopathy was determined by dilated fundus examination. RESULTS The Melbourne VIP comprised 3271 people who ranged in age from 40 to 98 years; 46.2% of them were male. Of 3189 people who had the fundus examination and knew their diabetes status, 162 (5.1%) reported having been previously diagnosed with diabetes and, of these, 37 (22.2%) were found to have diabetic retinopathy. Seven people (4.3%) had developed diabetes before age 30. The mean duration of diabetes was 9.2 years. People with diabetes were significantly more likely to have visited an ophthalmologist ever or in the past 2 years than people without diabetes. However, 31.8% of people with diabetes had never visited an ophthalmologist. The proportion of people who had never seen an ophthalmologist was 47.1% for people without diabetes, 34.2% for people with diabetes but without diabetic retinopathy, and 25% for people with diabetic retinopathy. Sixty one per cent of people with diabetic retinopathy had seen an ophthalmologist in the past year and a further 3% within the past 2 years. People with diabetes were not significantly more likely to have visited an optometrist than people without diabetes (p=0.51). Overall, 37.7% of people with diabetes and 32.9% of people without diabetes had visited an optometrist within the past year (χ2=2.25, 1 df, p=0.13). Information concerning retinal examinations was available for 135 individuals (83.3% of people with diabetes). Only 74 (54.8%) could recall ever having a dilated fundus examination; 10 (14%) by an optometrist, 62 (86%) by an ophthalmologist, and five (7%) by a general practitioner. Of those 68 people who had seen an ophthalmologist in the past 2 years, 48 (71%) reported a dilated fundus examination during that time. This compares with 28 (43%) reported dilated fundus examinations in the 65 people who had seen an optometrist in the past 2 years. This finding is statistically significant (χ2=10.2, 1 df, p<0.005). CONCLUSION These results indicate that nearly half of people with diabetes in Melbourne are not receiving adequate screening or follow up for diabetic retinopathy, despite universal health care.

A population-based estimate of cataract prevalence: the Melbourne Visual Impairment Project experience

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Schizophrenia, psychotropic medication, and cataract

OBJECTIVE To compare the distribution of cataract types between psychiatric patients diagnosed with schizophrenia and the general population not exposed to psychotropic medication, and to compare cataract prevalence between users and nonusers of various psychotropic medications in the general community. DESIGN Case-control. PARTICIPANTS A total of 151 (93%) eligible patients from a community mental health service and 3271 (83%) eligible residents from the Melbourne Visual Impairment Project (VIP) were examined. MAIN OUTCOME MEASURES All patients 40 years of age and older from a community mental health service and residents of nine randomly selected areas of Melbourne were eligible. Best-corrected distance visual acuity was determined using a 4-m logarithm of the minimum angle of resolution (LogMAR) chart. The presence of cataract was determined by photographs or slit-lamp examination using direct and indirect retroillumination. Anterior, cortical, nuclear, and posterior subcapsular cataracts were measured. Participants from the Melbourne VIP were classified as to whether they had taken benzodiazepams, phenothiazines, thioxanthenes, butyrophenols, tricyclic antidepressants, or monoamine oxidase inhibitors for at least 12 months during their lifetime. RESULTS The distribution of cataract type varied between persons with and without schizophrenia. Anterior subcapsular (ASC) cataract was significantly more prevalent (26%) in participants with schizophrenia from the community mental health service than Melbourne VIP participants (0.2%) not exposed to psychotropic medication (chi-square, 1 degree of freedom = 605.5, P = 0.001). This remained significant after controlling for age (odds ratios = 250, 95% confidence interval = 83.3, 1000). The distribution of the age-related cataract was similar across all groups of psychotropic medication users with the exception of the phenothiazine users. They had less of all types of the age-related cataracts, despite being slightly older than the control group (mean age, 60.0 vs. 58.4, t test = 0.85, P = 0.40). However, only cortical cataract in the phenothiazine group was statistically lower (chi-square, 1 degree of freedom = 3.96, P = 0.047). CONCLUSION This study has identified the need to investigate whether other newer agents, especially high-potency medications, cause ASC opacities if a certain threshold of exposure to psychotropic medications must be attained to develop cataract, or if schizophrenia itself is associated with cataract formation.