Race, macular degeneration, and the Macular Photocoagulation Study

Gene and cell therapy for age-related macular degeneration: A review

Age-related macular degeneration (AMD) is the most common cause of irreversible vision loss among the elderly in Western communities, with an estimated global prevalence of 10 - 20% in people older than 65 years. AMD leads to central vision loss due to degeneration of the photoreceptors, retinal pigment epithelium and the choriocapillaris. Beckman's classification for AMD, based upon color fundus photographs, divides the disease into early, intermediate, and late forms. The late, vision-threatening stage includes both neovascular AMD and geographic atrophy. Despite its high prevalence and impact on patients' quality of life, treatment options for AMD are limited. While neovascular AMD can be medically managed with anti-VEGF intravitreal injections, until very recently there has been no approved treatment options for atrophic AMD; however, in February 2023 the first treatment for geographic atrophy - pegcetacoplan - was approved by the US FDA. We describe the current landscape of potential gene and cell therapeutic strategies for late-stage AMD, with an emphasis on the therapeutic options that might become available in the next few years.

Bias and Non-Diversity of Big Data in Artificial Intelligence: Focus on Retinal Diseases

Artificial intelligence (AI) applications in healthcare will have a potentially far-reaching impact on patient care, however issues regarding algorithmic bias and fairness have recently surfaced. There is a recognized lack of diversity in the available ophthalmic datasets, with 45% of the global population having no readily accessible representative images, leading to potential misrepresentations of their unique anatomic features and ocular pathology. AI applications in retinal disease may show less accuracy with underrepresented populations that may further widen the gap of health inequality if left unaddressed. Beyond disease symptomatology, social determinants of health must be integrated into our current paradigms of disease understanding, with the goal of more personalized care. AI has the potential to decrease global healthcare inequality, but it will need to be based on a more diverse, transparent and responsible use of healthcare data.

[Epidemiological and clinical profile of age-related macular degeneration in Cameroon]

PURPOSE

To determine the epidemiological and clinical characteristics of age-related macular degeneration in patients in Yaoundé.

METHODOLOGY

A multicenter, analytical and cross-sectional study was carried out from March 2017 to June 2018 in four hospitals in the city of Yaoundé. Included were all consenting patients aged at least 40 years with an established diagnosis of AMD both clinically and by imaging. The data were analyzed with CSPro software version 7.0. Chi² and Student's "t" tests in univariate mode and logistic regression in multivariate mode were used with a significance of P≤5%.

RESULTS

Of the 9,989 patients who were seen during the 16-month study period, 38 met our inclusion criteria - a frequency of 0.4%. The sex ratio was 0.3, and the mean age was 68±11 years. As a function of geographic origin, AMD is more common in patients from the forest and mountain areas. The systemic comorbidities associated recorded were hypertension (47.4%) and diabetes (21.1%). After optical correction, 60 of 76 eyes (78.9%) had useful visual acuity according to WHO criteria, and the rate of blindness was 9.2%. Fundus examination revealed fewer lesions than optical coherence tomography, which demonstrated miliary drusen in 57 (75%) eyes, serous drusen in 27 (35.5%), retinal atrophy in 19 (25%) and neovascularization in 3 (3.9%). The clinical forms were dominated by age-related maculopathy, found in 45 eyes (69.2%), followed by atrophic AMD in 17 (26.2%) and finally by exudative AMD in 3 (4.6%), for a total of 65 out of 76 eyes. Age was related to the risk of MLA and atrophic AMD (P≤0.05).

CONCLUSION

AMD is an uncommon pathology in our setting, predominant in women over the age of 60 years.

Geographic distributions of age-related macular degeneration incidence: a systematic review and meta-analysis

PURPOSE

We performed a systematic review and meta-analysis to summarise the geographic distribution of age-related macular degeneration (AMD) incidence.

METHODS

Databases including PubMed, Embase and Web of Science were searched for publications of early and late AMD before September 2019. Studies were included if they applied a standardised photographic assessment and classification system. The proportion of participants with AMD in each eligible study was combined to obtain a pooled incidence from all studies using a random effects model. We also assessed sources of potential heterogeneity in the incidence of AMD using meta-regression analyses for both late and early AMD.

RESULTS

Twenty-four population-based studies (70 123 individuals aged 55 years or older) were included in the meta-analysis. The pooled global annual incidences of early and late AMD were 1.59% (95% CI 1.12% to 2.10%) and 0.19% (95% CI: 0.13% to 0.28%), respectively. Individuals of European descent had the highest annual incidence of both early (2.73%, 95% CI 1.63% to 4.57%) and late (0.36%, 95% CI 0.17% to 0.75%) AMD than other ethnic groups. Average age (p=0.001) at baseline, ethnicity (p=0.001), region (p=0.043) and gender (p=0.011) were predictors for incident late AMD, while only average age (p=0.01) at baseline and ethnicity (p=0.025) was associated with incidence of early AMD.

CONCLUSIONS

This meta-analysis offers an up-to-date overview of AMD globally, which may provide scientific guidance for the design and implementation of public health strategies such as screening programmes for AMD in both specific geographic locations and ethnic groups, as well as worldwide.

Prevalence of Age-Related Macular Degeneration in Australia: The Australian National Eye Health Survey

Importance

Age-related macular degeneration (AMD) is a leading cause of irreversible blindness among the elderly population globally. Currently, knowledge of the epidemiology of AMD in Australia remains scarce because of a paucity of recent population-based data.

Objective

To examine the prevalence of AMD in Australia.

Design, Setting, and Participants

In this population-based, cross-sectional survey performed from March 11, 2015, to April 18, 2016, a sample of 3098 nonindigenous Australians 50 years and older and 1738 indigenous Australians 40 years and older from 30 geographic areas across Australia were examined.

Main Outcomes and Measures

Any AMD, early AMD, intermediate AMD, and late AMD graded according to the Beckman clinical classification system.

Results

A total of 4836 individuals were examined, including 3098 nonindigenous Australian (64.1%; 58.9% female vs 41.1% male; age range, 40-92 years; mean [SD] age, 55.0 [10.0] years) and 1738 indigenous Australians (35.9%; 53.6% female vs 46.4% male; age range, 50-98 years; mean [SD] age, 66.6 [9.7] years). A total of 4589 (94.9%, 2946 nonindigenous and 1643 indigenous) participants had retinal photographs in at least 1 eye that were gradable for AMD. The weighted prevalence of early AMD was 14.8% (95% CI, 11.7%-18.6%) and of intermediate AMD was 10.5% (95% CI, 8.3%-13.1%) among nonindigenous Australians. In indigenous Australians, the weighted prevalence of early AMD was 13.8% (95% CI, 9.7%-19.3%) and of intermediate AMD was 5.7% (96% CI, 4.7%-7.0%). Late AMD was found in 0.96% (95% CI, 0.59%-1.55%) of nonindigenous participants (atrophic, 0.72%; neovascular, 0.24%). The prevalence of late AMD increased to 6.7% in participants 80 years or older and was higher in men (1.4% vs 0.61%, P = .02). Only 3 (0.17% [95% CI, 0.04%-0.63%]) indigenous participants had late (atrophic) AMD. Age-related macular degeneration was attributed as the main cause of vision loss (<6/12 in the better eye) in 23 of 208 nonindigenous Australians (11.1%) and 2 of 183 indigenous Australians (1.1%).

Conclusions and Relevance

In line with data from other white populations, AMD is a prominent cause of vision loss in the nonindigenous Australian population. An increased provision of low vision rehabilitation services may be required to cope with the projected increase in AMD in Australia.

Incidence of Age-Related Macular Degeneration in a Multi-Ethnic United States Population: The Multi-Ethnic Study of Atherosclerosis

PURPOSE

To describe the incidence of age-related macular degeneration (AMD) and associated risk factors in 4 racial/ethnic groups (white, black, Hispanic, and Chinese) residing in the United States.

DESIGN

Prospective cohort study.

PARTICIPANTS

A total of 3811 participants, aged 46 to 86 years, from the Multi-Ethnic Study of Atherosclerosis (MESA) cohort, with retinal data collected twice, on average, 8 years apart.

METHODS

Fundus images, taken using a digital camera through dark-adapted pupils using a standard protocol and the same equipment at both study visits, were graded centrally for early and late AMD on the basis of drusen size, type and area, increased retinal pigment, retinal pigment epithelial depigmentation, neovascular lesions, and geographic atrophy using the modified Wisconsin Age-Related Maculopathy Grading System. Demographic, clinical, and laboratory measures were included in multivariable regression models to determine their impact on the variation in AMD incidence among racial/ethnic groups.

MAIN OUTCOME MEASURES

Incident early and late AMD.

RESULTS

The overall 8-year age- and sex-standardized incidence of early and late AMD were 4.1% and 2.3%, respectively, with incidence of early and late AMD highest in whites (5.3% and 4.1%, respectively), intermediate in Chinese (4.5% and 2.2%, respectively) and Hispanics (3.3% and 0.8%, respectively), and lowest in blacks (1.6% and 0.4%, respectively). By adjusting for age and sex, blacks had a 70% lower risk of developing early AMD than whites, and this decreased only slightly to a 67% lower risk after multivariable adjustment. By adjusting for age, sex, and race/ethnicity, hyperopia was associated with early AMD (odds ratio [OR], 1.51; 95% confidence interval [CI], 1.04-2.20), as was astigmatism (OR, 1.47; 95% CI, 1.00-2.16), but not myopia (P = 0.29). Age, race/ethnicity, current smoking, hyperopia, and AMD-susceptibility genotypes Complement Factor H (CFH) RS1061170 and Age Related Maculopathy Susceptibility 2 (ARMS2) RS3793917 were independently associated with incident early AMD in multivariable models for the combined sample. However, the only statistically significant factor consistently associated with incident early AMD across the 4 racial/ethnic groups was increasing age. Risk factors for late AMD were not assessed because of its low incidence, particularly across racial/ethnic groups.

CONCLUSIONS

Variation in the incidence of early AMD exists among racial/ethnic groups in the United States and is not explained by the clinical, genetic, and environmental factors included in this study.

High-Resolution Imaging of the Optic Nerve and Retina in Optic Nerve Hypoplasia

PURPOSE

To investigate the optic nerve and macular morphology in patients with optic nerve hypoplasia (ONH) using spectral-domain optical coherence tomography (SD OCT).

DESIGN

Prospective, cross-sectional, observational study.

SUBJECTS

A total of 16 participants with ONH (10 female and 6 male; mean age, 17.2 years; 6 bilateral involvement) and 32 gender-, age-, ethnicity-, and refraction-matched healthy controls.

METHODS

High-resolution SD OCT (Copernicus [Optopol Technology S.A., Zawiercie, Poland], 3 μm resolution) and handheld SD OCT (Bioptigen Inc [Research Triangle Park, NC], 2.6 μm resolution) devices were used to acquire horizontal scans through the center of the optic disc and macula.

MAIN OUTCOME MEASURES

Horizontal optic disc/cup and rim diameters, cup depth, peripapillary retinal nerve fiber layer (RNFL), and thickness of individual retinal layers in participants with ONH and in controls.

RESULTS

Patients with ONH had significantly smaller discs (P < 0.03 and P < 0.001 compared with unaffected eye and healthy controls, respectively), horizontal cup diameter (P < 0.02 for both), and cup depth (P < 0.02 and P < 0.01, respectively). In the macula, significantly thinner RNFL (nasally), ganglion cell layer (GCL) (nasally and temporally), inner plexiform layer (IPL) (nasally), outer nuclear layer (ONL) (nasally), and inner segment (centrally and temporally) were found in patients with ONH compared with the control group (P < 0.05 for all comparisons). Continuation of significantly thicker GCL, IPL, and outer plexiform layer in the central retinal area (i.e., foveal hypoplasia) was found in more than 80% of patients with ONH. Clinically unaffected fellow eyes of patients with ONH showed mild features of underdevelopment. Visual acuity and presence of septo-optic dysplasia were associated with changes in GCL and IPL. Sensitivity and specificity for the detection of ONH based on disc and retinal optical coherence tomography (OCT) parameters were >80%.

CONCLUSIONS

Our study provides evidence of retinal changes in ONH. In addition to thinning of retina layers mainly involving the RNFL and GCL, signs reminiscent of foveal hypoplasia were observed in patients with ONH. Optic nerve and foveal parameters measured using OCT showed high sensitivity and specificity for detecting ONH, demonstrating their useful for clinical diagnosis.

Iris color and associated pathological ocular complications: a review of epidemiologic studies

AIM

To elucidate the associations of iris color with major eye diseases.

METHODS

A systematic search on Medline with coverage up to August 2013 was conducted. Assessment of the quality of studies based on their levels of evidence was in accordance with the Centre for Evidence-Based Medicine, Oxford, United Kingdom.

RESULTS

A relationship between darker iris color and an increased risk of age-related cataract has been reported from cross-sectional studies and prospective cohort studies. There was no consistent evidence supporting a major role of iris color in the development or progression of age-related macular degeneration. The association of iris color with ocular uveal melanoma has been confirmed by a meta-analysis of observational studies previously. The etiologic synergism between light iris color and environmental exposure such as UV the exposure of UV radiation was found. There were no studies evaluating the refractive associations with iris color but there may be a possible link between iris color and myopia.

CONCLUSION

Darker iris color is associated with an increased risk of cataract and a reduced risk of ocular uveal melanoma. The association of iris color with age-related macular degeneration is not confirmed. Ophthalmologists should be aware that the risk of ocular disorders appears to vary by differences in iris color.

Normal macular structure measured with optical coherence tomography across ethnicity

OBJECTIVE

The difference in prevalence of various retinal pathologies in people of different ethnicity is well established. Optical coherence tomography (OCT) is a widely used technique that allows quantitative analysis of macular structure. In this study, we investigated macular layer morphology in healthy subjects using high-resolution spectral domain (SD) OCT across ethnicities comparing Asian (ie, Indian subcontinent) and Caucasian individuals.

METHODS

133 healthy volunteers (67-Asian, 66-Caucasian) were examined using SD-OCT. Average retinal and nerve fibre layer thickness were measured in a semiautomated way. Analysis of the measurements of each retinal layer at the macula was quantified using tomograms obtained by SD-OCT.

RESULTS

In this study, we find significant difference in macular structure in Asian and Caucasian participants. Caucasian subjects have thicker inner segment (p=0.015 in the central region), outer segment (p=0.04 in the temporal region) and outer nuclear (p=0.021 and p=0.03 for the central and temporal regions, respectively) layers, while Asians demonstrate thicker retinal pigment epithelial layer (p=0.004 for the temporal region).

CONCLUSIONS

Differences in macular morphology due to ethnicity should be considered in determining control values for diagnostic purposes, and can be used to guide future studies in risk and prognosis for macular pathologies.

Automated segmentation of intraretinal cystoid fluid in optical coherence tomography

Cystoid macular edema (CME) is observed in a variety of ocular disorders and is strongly associated with vision loss. Optical coherence tomography (OCT) provides excellent visualization of cystoid fluid, and can assist clinicians in monitoring the progression of CME. Quantitative tools for assessing CME may lead to better metrics for choosing treatment protocols. To address this need, this paper presents a fully automated retinal cyst segmentation technique for OCT image stacks acquired from a commercial scanner. The proposed method includes a computationally fast bilateral filter for speckle denoising while maintaining CME boundaries. The proposed technique was evaluated in images from 16 patients with vitreoretinal disease and three controls. The average sensitivity and specificity for the classification of cystoid regions in CME patients were found to be 91% and 96%, respectively, and the retinal volume occupied by cystoid fluid obtained by the algorithm was found to be accurate within a mean and median volume fraction of 1.9% and 0.8%, respectively.

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.

Comparison of diabetic retinopathy phenotype between Latinos and Blacks

OBJECTIVE

The objective of this study was to delineate the difference in the phenotype of diabetic retinopathy (DR) in Latinos versus Blacks using characteristics shown on fundus photography (FP) and fluorescein angiography (FA).

RESEARCH DESIGN AND METHODS

This was a retrospective chart review of 203 adult Black and Latino diabetic patients from the King-Drew Medical Center eye clinic from January 1998 to March 2005. Systemic risk factors such as HbA(1c) and kidney function data were collected. FP and FA were analyzed and graded according to Early Treatment of Diabetic Retinopathy Study criteria. Statistical analysis was performed to determine whether a given lesion type was more characteristic of a particular racial group.

RESULTS

Gender, age, median microalbumin-to-creatinine ratio (ACR), and average HbA(1c) values were not significantly different between the groups. The presence of clinically significant macular edema (CSME), focal or diffuse, was very high in both groups (44% in Latinos and 46% in Blacks), and the overall DR grades were similar. However, upon individual lesion analysis, the Latinos were noted to have more prevalent intraretinal hemorrhages involving a greater area of the retina (P=.046).

CONCLUSIONS

Although Latinos and Blacks of comparable age and glycemic control are equally at risk for CSME and proliferative retinopathy, Latinos may be at greater risk for a specific phenotype of DR characterized by extravasation of intraretinal hemorrhages, which is associated with poor prognosis. Further prospective studies may uncover racial differences that may have implications for prognosis and therapy.

Prevalence of age-related macular degeneration in 4 racial/ethnic groups in the multi-ethnic study of atherosclerosis

OBJECTIVE

To describe the prevalence of age-related macular degeneration (AMD) in 4 racial/ethnic groups (white, black, Hispanic, and Chinese) that participated in the second examination of the Multi-ethnic Study of Atherosclerosis (MESA).

DESIGN

Prospective cohort study.

PARTICIPANTS

Six thousand one hundred seventy-six 45- to 85-year-old subjects selected from 6 United States communities.

METHODS

Fundus images were taken using a 45 degrees digital camera through dark-adapted pupils and were graded for drusen size, type, area, increased retinal pigment, retinal pigment epithelial depigmentation, neovascular lesions, and geographic atrophy using the modified Wisconsin Age-Related Maculopathy Grading System.

MAIN OUTCOME MEASURE

Age-related macular degeneration.

RESULTS

Prevalences of AMD were 2.4% (black), 4.2% (Hispanic), 4.6% (Chinese), to 5.4% (white) (P<0.001 for any differences among groups). The highest prevalence of any AMD occurred in those 75 to 84 years old, varying from 7.4% in blacks to 15.8% in whites and Chinese (P = 0.03). Estimated prevalences of late AMD were 0.3% (black), 0.2% (Hispanic), 0.6% (white), and 1.0% (Chinese). These differences were marginally significant (age and gender adjusted, P = 0.08). The frequency of exudative AMD was highest in Chinese (age- and gender-adjusted odds ratio, 4.30; 95% confidence interval, 1.30-14.27) compared with whites. Differences in age, gender, pupil size, body mass index, smoking, alcohol drinking history, diabetes, and hypertension status did not explain the variability among the 4 racial/ethnic groups.

CONCLUSIONS

Low prevalences of AMD were found in the MESA cohort in all groups. A lower prevalence of AMD was found in blacks compared with whites. The higher prevalence of exudative AMD in Chinese needs further study.

Nine-Year Incidence of Age-Related Macular Degeneration in the Barbados Eye Studies

OBJECTIVE

To provide 9-year incidence estimates of age-related macular degeneration (AMD) in a population of African descent.

DESIGN

Population-based cohort study.

PARTICIPANTS

Two thousand seven hundred ninety-three participants (81% of eligible) after 9 years' follow-up.

MAIN OUTCOME MEASURES

Nine-year incidence of AMD-related features, based on fundus photographic gradings and/or clinical examinations.

RESULTS

The overall incidence rate of early AMD was 12.6% (95% confidence interval [CI], 11.0%-14.1%), and that of late AMD was 0.7% (95% CI, 0.4%-1.1%). Both increased with age (P<0.05). For early AMD, incidence ranged from 10.7% at 40 to 49 years of age to 16.8% at > or =70 years. For late AMD, incidence increased from 0.1% to 2.3% in the same age groups. Late AMD was more likely to develop in eyes with pigment changes (risk ratio [RR], 5.8; 95% CI, 2.0-16.8) and retinal pigment epithelial atrophy (RR, 5.4; 95% CI, 1.9-15.8) at baseline. Crude RRs indicated significant associations of late AMD to elevated systolic blood pressure and diabetes history, but only the diabetes relationship was suggested after adjusting for age, with borderline statistical significance (age-adjusted RR, 2.7; P = 0.054).

CONCLUSIONS

Nine-year data on natural history indicate that early AMD is common in this population of African origin, although late AMD is infrequent. These long-term observations provide further evidence for the lower AMD risk in black populations compared with white populations.

Risk factors for the incidence of Advanced Age-Related Macular Degeneration in the Age-Related Eye Disease Study (AREDS) AREDS report no. 19

PURPOSE

To describe the association of demographic, behavioral, medical, and nonretinal ocular factors with the incidence of neovascular age-related macular degeneration (AMD) and central geographic atrophy (CGA) in the Age-Related Eye Disease Study (AREDS), a randomized trial of antioxidants and zinc supplementation prophylaxis for development of advanced AMD.

DESIGN

Clinic-based prospective cohort study.

PARTICIPANTS

Of individuals with early or intermediate AMD at baseline with a median follow-up of 6.3 years, 788 were at risk of developing advanced AMD in one eye (the fellow eye had advanced AMD), and 2506 were at risk in both eyes.

METHODS

The incidence of neovascular AMD and CGA was assessed from stereoscopic color fundus photographs taken at baseline and at annual visits beginning at year 2.

MAIN OUTCOME MEASURES

Neovascular AMD was defined as photocoagulation for choroidal neovascularization, or photographic documentation at the reading center of any of the following: nondrusenoid retinal pigment epithelial detachment, serous or hemorrhagic retinal detachment, hemorrhage under the retina or the retinal pigment epithelium, and subretinal fibrosis. Central geographic atrophy was defined as geographic atrophy involving the center of the macula.

RESULTS

In multivariable models, in persons at risk of advanced AMD in both eyes, while controlling for age, gender, and AREDS treatment group, the following variables were statistically significantly associated with the incidence of neovascular AMD: race (odds ratio [OR], white vs. black, 6.77; 95% confidence interval [CI], 1.24-36.9) and larger amount smoked (OR, >10 vs. < or =10 pack-years [a pack-year is an average of 1 pack of cigarette smoked per day for a year], 1.55; 95% CI, 1.15-2.09). The following were statistically significantly associated with the incidence of CGA: less education (OR, high school graduate or less vs. college graduate, 1.75; 95% CI, 1.10-2.78), greater body mass index (BMI) (OR, obese vs. nonobese, 1.93; 95% CI, 1.25-2.65), larger amount smoked (OR, >10 pack-years vs. < or =10 pack-years, 1.82; 95% CI, 1.25-2.65), and antacid use (OR, 0.29; 95% CI, 0.09-0.91). In persons at risk of developing advanced AMD in one eye, the incidence of neovascular AMD was associated with diabetes (OR, 1.88; 95% CI, 1.07-3.31), and the incidence of CGA was associated with use of antiinflammatory medications (OR, 0.22; 95% CI, 0.08-0.59).

CONCLUSIONS

Results suggest that, among persons with early or intermediate AMD, smoking and BMI are modifiable factors associated with progression to advanced AMD, and suggest other associations (e.g., use of antacids and antiinflammatory medications) that warrant further study. This article contains additional online-only material available at http://www.ophsource.org/periodicals/ophtha. .

Surgery for subfoveal choroidal neovascularization in age-related macular degeneration: ophthalmic findings: SST report no. 11

PURPOSE

To present visual acuity (VA) and related findings from patients enrolled in one of the Submacular Surgery Trials (SST) evaluating surgical removal versus observation of subfoveal choroidal neovascularization secondary to age-related macular degeneration (SST Group N Trial).

DESIGN

Randomized clinical trial.

PARTICIPANTS

Eligible patients had age-related macular degeneration with subfoveal choroidal neovascularization, some with a classic pattern on fluorescein angiography, and best-corrected VA (BCVA) of 20/100 to 20/800 in one eye (study eye) that had received no treatment in the macula. Any contiguous blood had to account for <50% of the total area occupied by the subfoveal lesion (maximum size, 9.0 disc areas [22.9 mm2]).

METHODS

Randomization was stratified by VA and by clinical center. All patients were scheduled for study examinations at 3, 6, 12, and 24 months after enrollment for assessment of study outcomes.

MAIN OUTCOME MEASURE

A successful outcome was defined a priori to be either improvement of BCVA or VA no more than 1 line (7 letters) worse than baseline at the 24-month examination.

RESULTS

Of 454 patients enrolled, 228 study eyes were assigned to observation and 226 to surgery. The percentages of eyes that had successful outcomes were similar in the 2 arms: 44% assigned to observation and 41% assigned to surgery. Median VA losses from baseline to the 24-month examination were 2.1 lines (10.5 letters) in the observation arm and 2.0 lines (10 letters) in the surgery arm. Median VA declined from 20/100 at baseline to 20/400 at 24 months in both arms. No subgroup of patients was identified in which submacular surgery led to better VA outcomes. In the surgery arm, 55 (39%) of 142 initially phakic eyes had cataract surgery by the 24-month examination, compared with 6 (5%) of 133 eyes in the observation arm. Rhegmatogenous retinal detachment occurred in 12 surgery eyes (5%) and 1 observation eye.

CONCLUSIONS

Submacular surgery, as performed in this clinical trial, did not improve or preserve VA for 24 months in more eyes than observation and is not recommended for patients with similar lesions. This article contains additional online-only material available at http://www.ophsource.com/periodicals/ophtha.

Dietary analysis and patterns of nutritional supplement use in normal and age-related macular disease affected subjects: a prospective cross-sectional study

Background

Poor diet is thought to be a risk factor for many diseases, including age-related macular disease (ARMD), which is the leading cause of blind registration in those aged over 60 years in the developed world. The aims of this study were 1) to evaluate the dietary food intake of three subject groups: participants under the age of 50 years without ARMD (U50), participants over the age of 50 years without ARMD (O50), and participants with ARMD (AMD), and 2) to obtain information on nutritional supplement usage.

Methods

A prospective cross-sectional study designed in a clinical practice setting. Seventy-four participants were divided into three groups: U50; 20 participants aged < 50 years, from 21 to 40 (mean ± SD, 37.7 ± 10.1 years), O50; 27 participants aged > 50 years, from 52 to 77 (62.7 ± 6.8 years), and ARMD; 27 participants aged > 50 years with ARMD, from 55 to 79 (66.0 ± 5.8 years). Participants were issued with a three-day food diary, and were also asked to provide details of any daily nutritional supplements. The diaries were analysed using FoodBase 2000 software. Data were input by one investigator and statistically analysed using Microsoft Excel for Microsoft Windows XP software, employing unpaired t-tests.

Results

Group O50 consumed significantly more vitamin C (t = 3.049, p = 0.005) and significantly more fibre (t = 2.107, p = 0.041) than group U50. Group ARMD consumed significantly more protein (t = 3.487, p = 0.001) and zinc (t = 2.252, p = 0.029) than group O50. The ARMD group consumed the highest percentage of specific ocular health supplements and the U50 group consumed the most multivitamins.

Conclusions

We did not detect a deficiency of any specific nutrient in the diets of those with ARMD compared with age- and gender-matched controls. ARMD patients may be aware of research into use of nutritional supplementation to prevent progression of their condition.

Baseline characteristics, the 25-Item National Eye Institute Visual Functioning Questionnaire, and their associations in the Complications of Age-Related Macular Degeneration Prevention Trial (CAPT)

OBJECTIVE

To describe characteristics of participants in the Complications of Age-Related Macular Degeneration Prevention Trial (CAPT) at baseline and to investigate associations among visual function, fundus features, and vision-related quality of life.

DESIGN

Cross-sectional study.

PARTICIPANTS

The 1052 participants in CAPT, a multicenter, randomized clinical trial. Eligibility criteria for CAPT included > or =10 large drusen and visual acuity > or =20/40 in each eye.

METHODS

At baseline, the visual acuity, contrast sensitivity, and critical print size for each eye were measured, color stereo photographs of the disc and macula of each eye were taken, and the 25-item National Eye Institute Visual Functioning Questionnaire (NEI-VFQ-25) was self-administered. Graders from a central photograph reading center evaluated the photographs for drusen characteristics and focal hyperpigmentation. All procedures were performed using standardized protocols. Associations among characteristics were assessed by Spearman correlation coefficients and multiple linear regression.

RESULTS

Among CAPT participants at baseline, the mean age was 71.0 years, 60.6% were women, and 99.3% were white. The median visual acuity of the better eye was 20/20 and of the worse eye 20/25. In approximately one third of eyes, drusen covered > or =10% of the retina within 3000 microm of the foveal center, and 67.7% of eyes had focal hyperpigmentation. Drusen area and focal hyperpigmentation were weakly correlated (r = -0.08 to -0.18) with the measures of visual function. The measures of visual function were weakly associated with the NEI-VFQ-25 scores. An association of fundus features with NEI-VFQ-25 scores was not found.

CONCLUSION

At baseline, CAPT participants had good visual function and several risk factors for progression to neovascular age-related macular degeneration. Scores on the NEI-VFQ-25 indicated that participants perceived some problems with their vision. Within this relatively homogeneous group of participants, measures of visual function were only weakly associated with the measures of vision-related quality of life.

The epidemiology of age-related macular degeneration

PURPOSE

To review the epidemiology of age-related macular degeneration (AMD).

DESIGN

Evidence from epidemiologic data regarding the natural history of AMD and its risk factors are presented.

RESULTS

Large, soft drusen associated with pigmentary abnormalities increase the risk of progression to advanced AMD. Large soft drusen may fade over time. Advanced AMD is more likely to be present in whites than blacks, despite the similar prevalence of soft drusen in both groups. Neovascular AMD is more frequent than geographic atrophy in most population-based studies in whites in America, Australia, and the Netherlands than in similar population-based studies in Iceland and Norway. After age and family history, there are few consistent relationships of risk factors to AMD. Of these, the relationship of smoking, hypertension, and cataract surgery to advanced AMD have been most consistent.

CONCLUSIONS

Long-term epidemiologic studies have provided information on the distribution and the natural history of AMD and its associated risk factors. It is not known what effect reduction of blood pressure and the cessation of smoking might have on the incidence and progression of AMD.

Iris colour, ethnic origin and progression of age-related macular degeneration

AIM

To investigate the relationship between iris colour, ethnic origin and the progression of age-related macular degeneration (AMD).

METHODS

Participants were recruited from the population-based Melbourne Visual Impairment Project or the prospective, randomized, double-masked Vitamin E, Cataract and Age-Related Macular Degeneration study. From these two cohorts, 171 participants aged between 52 and 93 years who were identified as having early AMD features at their baseline examination (1992-1995) were followed for an average of 6.8 years (until 2001) to determine the progression rate of early AMD. The participants' iris colour was categorized as light, intermediate or dark. Ethnic origin was categorized as Anglo-Saxon or non-Anglo-Saxon, according to the participants' grandparents' country of birth.

RESULTS

In total, 53 (31%) of the 171 participants showed signs of AMD progression. Participants with light iris colour had twofold the risk of AMD progression of those with dark or intermediate iris colours, although the age-adjusted and multivariate-adjusted associations were not significant (both P = 0.13). Age-adjusted and multivariate comparisons of Anglo-Saxon ethnic origin to non-Anglo-Saxon ethnic origin showed a noticeable but non-significant association with progression of AMD (P= 0.22 and P= 0.14, respectively).

CONCLUSION

Individuals with light iris colour or of Anglo-Saxon ethnic origin had a strong tendency to greater progression of AMD. A larger sample is required to confirm these clinically important, but statistically non-significant, associations.

Epidemiology of age-related maculopathy: a review

Age-related maculopathy (ARM) is a degenerative disease of the retina and the leading cause of incurable blindness and visual impairment in industrialized countries. By definition, ARM is confined to the age-category above 50 years. The aetiology of ARM is still unknown, despite intensive research on many fronts. In this paper, we provide a review of the epidemiology of ARM. The most prominent findings were an exponential increase in frequency with age, a significant familial and genetic component, and a strong association with smoking. Other risk factors that were found less consistently were atherosclerosis, low intake of antioxidant nutrients, and cataract extraction. Future studies, both observational and experimental, will hopefully identify more risk factors that are amenable to prevention.

A randomised controlled trial investigating the effect of nutritional supplementation on visual function in normal, and age-related macular disease affected eyes: design and methodology [ISRCTN78467674]

BACKGROUND

Age-related macular disease is the leading cause of blind registration in the developed world. One aetiological hypothesis involves oxidation, and the intrinsic vulnerability of the retina to damage via this process. This has prompted interest in the role of antioxidants, particularly the carotenoids lutein and zeaxanthin, in the prevention and treatment of this eye disease.

METHODS

The aim of this randomised controlled trial is to determine the effect of a nutritional supplement containing lutein, vitamins A, C and E, zinc, and copper on measures of visual function in people with and without age-related macular disease. Outcome measures are distance and near visual acuity, contrast sensitivity, colour vision, macular visual field, glare recovery, and fundus photography. Randomisation is achieved via a random number generator, and masking achieved by third party coding of the active and placebo containers. Data collection will take place at nine and 18 months, and statistical analysis will employ Student's t test.

DISCUSSION

A paucity of treatment modalities for age-related macular disease has prompted research into the development of prevention strategies. A positive effect on normals may be indicative of a role of nutritional supplementation in preventing or delaying onset of the condition. An observed benefit in the age-related macular disease group may indicate a potential role of supplementation in prevention of progression, or even a degree reversal of the visual effects caused by this condition.

The relationship between iris color, hair color, and skin sun sensitivity and the 10-year incidence of age-related maculopathy: the Beaver Dam Eye Study

PURPOSE

To examine the association between iris color, hair color, and skin sun sensitivity and the 10-year incidence of age-related maculopathy (ARM).

DESIGN

Population-based cohort study.

PARTICIPANTS

A population of 4926 adults (range, 43-86 years of age at baseline) living in Beaver Dam, Wisconsin, was studied at baseline (1988-1990); of these, 3684 and 2764 subjects, respectively, participated in 5-year and 10-year follow-up examinations.

METHODS

Data on hair color at age 15 years and skin responsiveness to sun exposure were obtained from a standardized questionnaire administered at the baseline examination. Iris color was determined with penlight illumination during the baseline examination by using photographic standards. Age-related maculopathy status was determined by grading stereoscopic color fundus photos with the Wisconsin Age-Related Maculopathy Grading System.

MAIN OUTCOME MEASURES

Incidence and progression of ARM.

RESULTS

When controlling for age and gender, people with brown eyes were significantly more likely to develop soft indistinct drusen (risk ratio [RR], 1.53; 95% confidence interval [CI], 1.19-1.97; P < 0.01) than were people with blue eyes. However, people with brown eyes were significantly less likely to develop retinal pigment epithelial depigmentation (RR, 0.58; 95% CI, 0.41-0.82; P < 0.01) than were people with blue eyes. When compared with persons with blond hair, persons with brown hair were at decreased risk of developing pigmentary abnormalities (RR, 0.73; 95% CI, 0.53-1.00; P = 0.05). Iris color, hair color, and skin sun sensitivity were not associated with the development of late ARM.

CONCLUSION

Iris color and hair color were found to be associated with the 10-year incidence of pigmentary abnormalities. Iris color seems to be inconsistently related to the 10-year incidence of early ARM lesions and the progression of ARM.

Early age-related maculopathy in the cardiovascular health study

OBJECTIVE

To describe the prevalence of early age-related maculopathy (ARM) and its relation to atherosclerosis, lipids, hypertension, and inflammatory factors in a population studied for cardiovascular disease risk factors and outcomes.

DESIGN

Population-based cohort study.

PARTICIPANTS

A biracial population of 2361 adults (ranging from 69-97 years of age; 1998 whites and 363 blacks) living in four US counties (Allegheny County, Pennsylvania; Forsyth County, North Carolina; Sacramento County, California; and Washington County, Maryland) were examined during the interval from 1997 to 1998.

METHODS

Drusen and other lesions typical of ARM were identified by examining a 45 degrees color fundus photograph of one eye of each participant and classified by means of a modification of the Wisconsin Age-Related Maculopathy Grading System.

MAIN OUTCOME MEASURES

Early ARM.

RESULTS

Early ARM was present in 15.5% and late ARM in 1.3% of the cohort. The overall prevalence of any ARM was lower in blacks (9.1%) compared with whites (18.2%). While controlling for age, race, gender, and total calories consumed in the diet, factors associated with ARM were cerebral white matter disease as detected by magnetic resonance imaging (odds ratio [OR], 1.50; 95% confidence interval [CI], 1.05, 2.16, P = 0.027), and lower serum total cholesterol (OR, per 10 mg/dl increase 0.95; 95% CI, 0.91, 0.98, P = 0.02). There were no associations between hypertension, blood pressure, common carotid artery plaque, or any systemic inflammatory factors studied and early ARM.

CONCLUSIONS

This population-based study documents the higher prevalence of ARM in whites compared with blacks. Although an association was found between signs of white matter disease and early ARM, there was no evidence of an association of ARM with either hypertension or inflammatory factors.

Risk factors for age-related macular degeneration: an update

Age-related macular degeneration (AMD) is the leading cause of irreversible vision loss in the United States and other western nations. Limited treatment is available, and there are no established means of prevention. The detection of modifiable risk factors is important to suggest preventive behaviors that can reduce disease occurrence or prevent the progression to the late stages of AMD. Results of recent studies suggest that the etiology and pathogenesis of AMD are a complex interaction of genetic and external factors. Although a number of factors seem promising, only age and cigarette smoking are confirmed as increasing AMD risk. Other factors that most likely play a significant role in AMD are nutritional factors, e.g., antioxidants, and hypertension or other underlying atherosclerotic disease processes. The results of the Age-Related Eye Disease Study suggest a moderate beneficial effect of antioxidant, vitamin, and zinc supplementation in reducing progression to severe AMD.

Lutein and zeaxanthin in the diet and serum and their relation to age-related maculopathy in the third national health and nutrition examination survey

Relations of the carotenoids lutein and zeaxanthin in the diet and serum to photographic evidence of early and late age-related maculopathy (ARM) among persons over age 40 years (n = 8,222) were examined. Inverse relations of these carotenoids in the diet or serum to any form of ARM were not observed overall. There was a direct relation of dietary levels to one type of early ARM (soft drusen). However, relations differed by age and race. In the youngest age groups who were at risk for developing early (ages 40-59 years) or late (ages 60-79 years) ARM, higher levels of lutein and zeaxanthin in the diet were related to lower odds for pigmentary abnormalities, one sign of early ARM (odds ratio among persons in high vs. low quintiles = 0.1, 95 percent confidence interval: 0.1, 0.3) and of late ARM (odds ratio = 0.1, 95 percent confidence interval: 0.0, 0.9) after adjustment for age, gender, alcohol use, hypertension, smoking, and body mass index. Relations of these carotenoids to ARM may be influenced by age and race and require further evaluation in separate populations and in prospective studies.

Risk factors for age-related macular degeneration

There is an increasing body of evidence as to the risk factors for age-related macular degeneration. Age and genetic make-up are the most important risk factors identified to date. Over the next decade, the different genes that are involved in the development of age-related macular degeneration will be identified. There is reasonably consistent evidence that smoking cigarettes results in increased risk of the disease. The question as to whether antioxidant vitamin and mineral supplementation prevents or delays the development of the disease will be resolved as the results of large ongoing trials become available in the next few years. Currently, there is conflicting evidence as to their benefits and some indication as to possible harm. Other risk factors such as alcohol consumption, oestrogen replacement and lifetime light exposure require further study. The study of the epidemiology of age-related macular degeneration would be facilitated by a greater standardization of methods. Studies with large numbers of late stage disease are needed in order to provide the power to investigate moderate risks. This may either be achieved by adding on macular degeneration studies to large cohort studies already in place, or by pooling data from smaller studies.

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.

Racial differences in the prevalence of age-related macular degeneration: the Baltimore Eye Survey

OBJECTIVE

To determine the prevalence of age-related macular degeneration (AMD) and signs of age-related maculopathy in a population-based sample of blacks and whites 40 years of age or older from East Baltimore.

DESIGN

Cross-sectional population-based study.

PARTICIPANTS

A total of 5308 black and white subjects received a screening eye examination that included fundus photography.

MAIN OUTCOME MEASURES

Stereoscopic color fundus photographs were graded for the presence and severity of drusen, pigmentary abnormalities, geographic atrophy, and choroidal neovascularization in the macula.

RESULTS

Drusen > or = 64 microm were identified in about 20% of individuals in both groups, but large drusen (>125 microm) were more common among older whites (15% for whites versus 9% for blacks over 70). Pigmentary abnormalities were also more common among older whites (7.9% for whites versus 0.4% for blacks over 70). Age-related macular degeneration was more prevalent among whites than blacks. The prevalence of AMD was 2.1 % among whites over 70 years of age. No cases of AMD were detected among 243 black subjects in this age group. Logistic regression adjusting for age, sex and smoking (current, former, or never) detected an odds ratio of 4.4 (95% confidence interval: 1.5-12.4) for whites with AMD compared with blacks.

CONCLUSION

Although drusen are common in both blacks and whites over the age of 40, more severe forms of age-related maculopathy and late AMD are more prevalent in older whites.

The prevalence of age-related maculopathy by geographic region and ethnicity

The prevalence of age-related maculopathy (ARM) varies considerably in different locations and racial/ethnic groups around the world. At present there are insufficient data to determine whether it is likely that these differences in prevalence, especially for the early forms of ARM are due to variations in genetic and environmental factors or due to variations in age of the cohorts and methods used to ascertain and define ARM. In three population-based studies of whites living in Beaver Dam, Wisconsin, Blue Mountains, Australia, and Rotterdam, The Netherlands, in which similar methods of ascertainment and classification were used to detect and define ARM, late ARM was present in 1.2%, 1.4%, and 1.2% of the population less than 86 years of age, respectively. While data from clinical studies suggest that late ARM associated with choroidal neovascularization is rare in blacks compared with whites, some epidemiological studies suggest that late ARM may be similar in blacks and whites. There are still too few data from various ethnic/racial groups around the world and too few population-based data in older Hispanic and Asian populations to make meaningful comparisons. There is a need for further research into the distribution of ARM and its possible causes using similar methodologies to ascertain and define the disease. Further insights will be gained when genotypes associated with ARM are discovered.

Age-related macular degeneration

Macular degeneration is now responsible for approximately 95% of blindness and partial sighted registrations in the UK. This review has been written specifically to make the general medical community of the UK aware of the prevalence and clinical manifestations of aged-related macular degeneration. The review encompasses the risk factors, the disabilities and problems experienced by suffers of the condition and current therapeutic options. Age related macular degeneration increases in prevalence in our community from 0% among people under 55 years old to 18.5% among those 85 years or older. There is a marked female preponderance. The exudative form of the disorder is commoner. Treatment remains supportive for most patients with macular degeneration although a minority will benefit from macular laser photocoagulation.

Racial/ethnic differences in age-related maculopathy. Third National Health and Nutrition Examination Survey

PURPOSE

To investigate the prevalence of age-related maculopathy in three racial/ethnic groups, non-Hispanic whites, non-Hispanic blacks, and Mexican Americans.

METHODS

People 40 years of age or older who participated in a nationally representative population-based sample of the Third National Health and Nutrition Examination Survey were examined from 1988 to 1991. Age-related maculopathy was determined by grading of fundus photographs using a standardized protocol for a sample of 4007 persons.

RESULTS

The prevalence of any age-related maculopathy in the civilian noninstitutionalized United States population including those 40 years of age or older was 9.2% as estimated from the sample. Prevalence was higher in non-Hispanic whites (9.3%) compared with non-Hispanic blacks (7.4%) and Mexican Americans (7.1%). Before 60 years of age, Mexican Americans (odds ratio [OR], 1.53; 95% confidence interval [CI] 1.0-2.35) and non-Hispanic blacks (OR, 1.59; 95% CI, 0.86-2.95) had a greater chance of having any maculopathy than non-Hispanic whites; thereafter, Mexican Americans (OR, 0.63; 95% CI, 0.44-0.90) and non-Hispanic blacks (OR, 0.50; 95% CI, 0.37-0.68) had a lesser chance than non-Hispanic whites.

CONCLUSION

These survey data indicate that age-related maculopathy is prevalent in all groups studied. Differences among the racial/ethnic groups vary by age and sex.

Racial differences in the prevalence of atrophic-appearing macular lesions between black and white patients with retinitis pigmentosa

We compared the prevalence of atrophic-appearing macular lesions between black and white patients with isolated or various genetic types of retinitis pigmentosa to determine if an appreciable difference existed between these two groups. The study included 720 patients of whom 138 (19.2%) were black patients from 115 families and 582 (80.8%) were white patients from 478 families. A logistic regression analysis combining isolated and all genetic types but randomly selecting one patient per family showed a statistically significant difference in the prevalence of atrophic-appearing macular lesions between black and white patients for the right eye (P = .0012) and left eye (P = .002). When considering either all patients or one patient per family, the estimated odds ratios were approximately 2.0 for blacks relative to whites. Our findings indicate that black patients with retinitis pigmentosa are approximately twice as likely as white patients to develop an atrophic-appearing macular lesion. This observation has implications for the prognosis of central visual function in such patients.